Vasectomy reversal is a term used for surgical procedures that reconnect the male reproductive tract after interruption by a vasectomy. Two procedures are possible at the time of vasectomy reversal: vasovasostomy (vas deferens to vas deferens connection) and vasoepididymostomy (epididymis to vas deferens connection). Although vasectomy is considered a permanent form of contraception, advances in microsurgery have improved the success of vasectomy reversal procedures. The procedures remain technically demanding and may not restore the pre-vasectomy condition.
Procedure
Preparation A general or regional anesthetic is most commonly used, as this offers the least interruption by patient movement for microsurgery. Local anesthesia, with or without sedation, can also be used. The procedure is generally done on a “come and go” basis. The actual operating time can range from 1–4 hours, depending on the anatomical complexity, skill of the surgeon and the kind of procedure performed.
Assessing biology After anesthesia and scrubbing the scrotum with soap and water, the vas deferens is exposed through a small, 1–2 cm incision in the upper scrotum on each side. The vas deferens is cut sharply in half, both above and below the vasectomy site. A special bipolar microcautery is used to judiciously control any bleeding. One end of the vas deferens, termed the abdominal end, is inspected and flushed with salt solution to ensure that it is not blocked as it courses from the scrotum to the prostate (a “saline vasogram”). In order to assess for the presence of possible obstruction above the vasectomy site, the testicular end of the vas deferens can be compressed and inspected for fluid. This fluid is examined with a microscope for color, for consistency, and for sperm. This information is used by some surgeons to decide whether or not a secondary epididymal obstruction is present (see Table below).
{| class="wikitable" border="1" |- ! Grade ! Vasal Fluid Findings ! Procedure Suggested |- | 1 | Normal appearing sperm with motility | Vasovasostomy |- | 2 | Mostly normal appearing, nonmotile | Vasovasostomy |- | 3 | Mostly sperm heads without tails, nonmotile | Vasovasostomy |- | 4 | Only sperm heads | Vasovasostomy |- | 5 | No sperm, creamy fluid | Vasoepididymostomy |- | 6 | No fluid | Vasoepididymostomy |- | 7 | Clear fluid, no sperm | It depends
If sperm are found at the testicular end of the vas deferens, then it is assumed that a secondary epididymal obstruction has not occurred and a vas deferens-to-vas deferens reconnection (vasovasostomy) is planned. If sperm are not found, then some surgeon consider this to be prime facie evidence that an epididymal obstruction is present and that an epididymis to vas deferens connection (vasoepididymostomy) should be considered to restore sperm flow. Other, more subtle findings that can be observed in the fluid—including the presence of sperm fragments and clear, good quality fluid without any sperm—require surgical decision-making to successfully treat. There are however, no large randomised prospective controlled trials comparing patency or pregnancy rates following the decision to perform either microsurgical vasovasostomy to microsurgical vasoepididymosty as determined by this paradigm.
Vasovasostomy
For a vasovasostomy, two microsurgical approaches are most commonly used. Neither has proven superior to the other. What has been shown to be important, however, is that the surgeon use optical magnification to perform the vasectomy reversal. One approach is the modified 1-layer vasovasostomy and the other is a formal, 2-layer vasovasostomy.
Vasoepididymostomy
A vasoepididymostomy involves a connection of the vas deferens to the epididymis. This is necessary when there is no sperm present in the vas deferens.
Success rates
Success rates: patency
With vasectomy reversal surgery, there are two typical measures of success: patency rate, or return of some moving sperm to the ejaculate after vasectomy reversal, and pregnancy rates. In one study 95% of men with a vasovasostomy were found to have motile sperm in the ejaculate within 1 year after vasectomy reversal. Almost 80% of these men achieved sperm motility within 3 months of vasectomy reversal. The case for vasoepididymostomy is different. Fewer men will eventually achieve motile sperm counts and the time to achieve motile sperm counts is longer.
Additional information: The age of the patient at the time of vasectomy reversal does not appear to matter. Using different age cut-offs, including <35, 36-45, and > 45 years old, no differences in patency rates were detected in a recent vasectomy reversal series. The patency rates after vasovasostomy appear equivalent when performed in the straight or convoluted segments of the vas deferens
Another issue to consider is the likelihood of vasoepididymostomy at the time of vasectomy reversal, as this technique is generally associated with lower patency and pregnancy rates than vasovasostomy. Web-based, computer models and calculations have been proposed and published that described the chance of needing an vasoepididymostomy at reversal surgery.
Success rates: pregnancy The pregnancy rate is often seen as a more reliable way of measuring the success of a vasectomy reversal than the patency rates, as they measure the real-life success of whether the man succeeds in the aim of having a new child.
It is important to appreciate that female age is the single most powerful factor determining the pregnancy rate following any fertility treatment and vasectomy reversal is no exception. No large studies have stratified the results of vasectomy reversal by female age and hence assessing outcomes is confounded by this issue.
Pregnancy rates range widely in published series, with a large study in 1991 observing the best outcome of 76% pregnancy success rate with vasectomy reversals performed within 3 years or less of the original vasectomy, dropping to 53% for reversals 3–8 years out from the vasectomy, 44% for reversals 9–14 years out from the vasectomy, and 30% for reversals 15 or more years after the vasectomy. BPAS cites the average pregnancy success rate of a vasectomy reversal is around 55% if performed within 10 years, and drops to 25% if performed over 10 years. Higher success rates are found with reversal of vasovasostomy than those with a vasoepididymostomy, and factors such as antisperm antibodies and epididymal dysfunction are also implicated in success rates.Schwarzer, JU "Vasectomy Reversal using a micro-surgical three layer technique: one surgeon's experience over 18 years with 1300 patients" in International Journal of Andrology April 20, 2012
Failure and complications
Failure
The current measure of success in vasectomy reversal surgery is achievement of a pregnancy. There are several reasons why a vasectomy reversal may fail to achieve this:
A pregnancy involves two partners. Although the count and quality of sperm may be sufficiently high after vasectomy reversal surgery, female fertility factors may play an indirect role in pregnancy success. If the female partner’s age is >35 years old, the couple should consider a female factor evaluation to determine if they have adequate reproductive potential before a vasectomy reversal is undertaken. This evaluation can be done by a gynecologist and should include a cycle day 3 FSH and estradiol levels, an assessment of menstrual cycle regularity, and a hysterosalpingogram to evaluate for fibroids. Approximately 50%-80% of men who have had vasectomies develop a reaction against their own sperm (i.e., antisperm antibodies). High levels of these proteins directed against sperm may impair fertility, either by making it hard for sperm to swim to the egg or by interrupting the way the sperm must interact with the egg. Sperm-bound antibodies are usually assessed >6 months after the vasectomy reversal if no pregnancy has ensued. Treatment options include steroid treatment, intrauterine insemination (IUI) and in vitro fertilization (IVF) techniques. Occasionally, scar tissue develops at the site where the vas deferens is reconnected, causing a blockage. Depending on the physician, this occurs in 5-10% of vasovasostomies and up to 35% of vasoepididymostomies. Depending on when it occurs, it may be treated with anti-inflammatory medication or could necessitate repeat vasectomy reversal surgery. If an epididymal blowout has occurred and is not discovered at the time of vasectomy reversal surgery, the vasectomy reversal will probably fail. In this case, a vasoepididymostomy would need to be performed. When the vas deferens has been blocked for a long time, the epididymis is adversely affected by elevated pressure. As sperm are nurtured to maturity within the normal epididymis, sperm counts may be sufficiently high to achieve a pregnancy, but sperm movement may be poor. Antioxidants, vitamins (A, C and E), or other supplements are recommended by some centers after vasectomy reversal for this reason. Some patients gradually recover from this epididymal dysfunction. Those patients whose sperm continue to have problems may require IVF to achieve a pregnancy.
Complications In general, vasectomy reversal is a safe procedure and complication rates are low. There are small chances of infection or bleeding, the latter of which can result in a hematoma or blood clot in the scrotum that needs surgical drainage. If there is significant scar tissue encountered during the vasectomy reversal, fluid other than blood (seroma) can also accumulate in a small number of cases. Painful granulomas, caused by leaking sperm, can develop near the surgical site in some cases. Very rare complications include compartment syndrome or deep venous thrombosis from prolonged positioning, testis atrophy due to damaged blood supply, and reactions to anesthesia.
Alternatives: assisted reproduction Assisted reproduction uses “test tube baby” technology (also called in vitro fertilization, IVF) for the female partner along with sperm retrieval techniques for the male partner to help build a family. This technology, including intracytoplasmic sperm injection (ICSI), has been available since 1992 and became available as an alternative to vasectomy reversal soon after. This alternative should be discussed with couples during a consultation for vasectomy reversal.
Procedure to extract sperm for IVF include percutaneous epididymal sperm aspiration (PESA procedure), testicular sperm extraction (TESE procedure) and open testicular biopsy. Needle aspiration in a PESA procedure invariably causes trauma to the epididymal tubule and TESE procedures may damage the intra testicular collecting system (rete testis). Both potentially compromise the prospect of successful vasectomy reversal. Conversely, because in most circumstances vasectomy reversal leads to the restoration of sperm in the semen, it reduces the need for sperm retrieval procedures in association with IVF.