Reverse vasectomy
Encyclopedia
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 expensive, and usually do not restore the pre-vasectomy condition.
over the past 100 years. As a discipline, microsurgery was first performed by Carl Nylen in Sweden for middle ear surgery in 1910, but grew most rapidly as a discipline in the 20th century stimulated by its success in microvascular reconstruction of war-injured soldiers. The first microsurgical vasectomy reversal was performed by Earl Owen in 1971.
worldwide, with an estimated 40-60 million individuals having the procedure and 5-10% of couples choosing it as a birth control
method. In the U.S., about 5% of men who have had a vasectomy will change their minds and have a vasectomy reversal afterwards. The most common reason for a reversal is remarriage and a desire for more children. Other men in long-standing relationships have changed their minds and would like more children. There are occasional unfortunate individuals who have lost children and want to have more children. Vasectomy reversals are also performed in attempts to relieve post-vasectomy pain syndrome
.
are produced in the male sex gland or testicle
. From there they travel through tubes (efferent tubules), exit the testes and enter a “storage site” or epididymis
. The epididymis is a single, 18 feet (5.5 m), tightly coiled, small tube, within which sperm mature to the point where they can move, swim and fertilize eggs. Testicular sperm are not able to fertilize eggs naturally (but can if they are injected directly into the egg in the laboratory), as the ability to fertilize eggs is developed slowly over several months of storage in the epididymis. From the epididymis, a 14-inch, 3 mm-thick muscular tube called the vas deferens
carries the sperm to the urethra
near the base of the penis. The urethra then carries the sperm through the penis
during ejaculation
. A vasectomy interrupts sperm flow within the vas deferens. After a vasectomy, the testes still make sperm, but because the exit is blocked, the sperm die and eventually are reabsorbed by the body.
A problem in the delicate tubes of epididymis can develop over time after vasectomy. The longer the time since the vasectomy, the greater the “back-pressure” behind the vasectomy. This “back-pressure” may cause a “blowout” in the delicate epididymal tubule, the weakest point in the system. The blowout may or may not cause symptoms, but will probably scar the epididymal tubule, thus blocking sperm flow at second point. To summarize, with time, a man with a vasectomy can develop a second obstruction deeper in the reproductive tract that can make the vasectomy more difficult to reverse. Having the skill to detect and fix this problem during vasectomy reversal is the essence of a skilled surgeon. If the surgeon simply reconnects the two freshened ends of the vas deferens without examining for a second, deeper obstruction, then the procedure can fail, as sperm-containing fluids are still unable to flow to the place of the connection. In this case, the vas deferens must be connected to the epididymis in front of the second blockage, to bypass both blockages and allow the sperm to reenter the urethra in the ejaculate. Since the epididymal tubule is much smaller (0.3 mm diameter) than the vas deferens (3 mm diameter, 10-fold larger), epididymal surgery is far more complicated and precise than the simple vas deferens-to-vas deferens connection.
, 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.
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”). If a blockage is suspect above the vasectomy site, then this must be dealt with as well, if sperm is to return to the ejaculate after surgery. The testicle end of the vas deferens is then compressed and inspected for fluid. This fluid is examined with a microscope for color, consistency and for sperm. This information is used to decide whether or not a secondary epididymal obstruction is present (see Table below).
If sperm are found at the testis 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 an epididymis to vas deferens connection (vasoepididymostomy) is needed 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.
, 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.
involves a connection of the vas deferens
to the epididymis
. This is necessary when there is no sperm present in the vas deferens.
rates. In a recently published report 95% of men with a vasovasostomy had motile sperm in the ejaculate within 1 year after vasectomy reversal. Interestingly, 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.
What has also been published is that:
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.
after vasectomy reversal depends not only on the patency rate, but also on known or unknown female factor issues. Pregnancy rates range widely in published series, anywhere from 30-76%, and depend on many factors. Some of these include female age, female reproductive potential, female uterine and ovulatory issues. There are also male specific reasons for variations in pregnancy rates, including antisperm antibodies and epididymal dysfunction and other reasons listed below. However, in general, pregnancy rates with vasovasostomy are higher than those with vasoepididymostomy.
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
.
(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.
Published research attempts to identify the issues that matter most as couples decide between IVF-ICSI and vasectomy reversal, two very different approaches to family building. This research has generally taken the form of cost-effectiveness or cost-benefit analyses and decision analyses and Markov modeling. Since it is difficult to perform randomized, blinded prospective trials on couples in this situation, analytic modeling can help uncover what variables affect outcomes the most. From this body of work, it has been observed that vasectomy reversal can be the most cost effective way to build a family if: (a) the female partner is reproductively healthy, and (b) the surgeon can achieve good vasectomy reversal outcomes. If the surgeon can achieve high “patency” rates (moving sperm in the ejaculate) after vasectomy reversal, then vasectomy reversal is competitive with IVF-ICSI. In the special instance of couples with advanced maternal age
(defined as a female partner > 38 years old), case series’ have reported that pregnancy rates with vasectomy reversal are competitive with IVF-ICSI. When Markov modeling was applied to probe the issue of pregnancy rates after reversal surgery in more depth, the results revealed that female reproductive health is far more important than: (a) the age of the vasectomy, (b) the age of the man, or (c) the vasectomy reversal patency rate. Ultimately the decision to pursue a vasectomy reversal is a personal one for each couple.
potential. At this visit, the patient can decide whether he is a good candidate for vasectomy reversal and assess if it is right for him. Issues to be discussed at this visit include:
Immediately before the procedure, the following information is important for patients:
After the procedure, patients should perform the following tasks:
Vasectomy
Vasectomy is a surgical procedure for male sterilization and/or permanent birth control. During the procedure, the vasa deferentia of a man are severed, and then tied/sealed in a manner such to prevent sperm from entering into the seminal stream...
. Two procedures are possible at the time of vasectomy reversal: vasovasostomy
Vasovasostomy
Vasovasostomy is a surgery by which vasectomies are partially reversed. Another surgery for vasectomy reversal is vasoepididymostomy.-Limitations:...
(vas deferens to vas deferens connection) and vasoepididymostomy
Vasoepididymostomy
Vasoepididymostomy or epididymovasostomy is a surgery by which vasectomies are reversed. It involves connection of the severed vas deferens to the epididymis and is more technically demanding than the vasovasostomy....
(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 expensive, and usually do not restore the pre-vasectomy condition.
History
Technical advances in vasectomy reversal mirror those in microsurgeryMicrosurgery
Microsurgery is a general term for surgery requiring an operating microscope. The most obvious developments have been procedures developed to allow anastomosis of successively smaller blood vessels and nerves which have allowed transfer of tissue from one part of the body to another and...
over the past 100 years. As a discipline, microsurgery was first performed by Carl Nylen in Sweden for middle ear surgery in 1910, but grew most rapidly as a discipline in the 20th century stimulated by its success in microvascular reconstruction of war-injured soldiers. The first microsurgical vasectomy reversal was performed by Earl Owen in 1971.
Prevalence
Vasectomy is a common method of contraceptionContraception
Contraception is the prevention of the fusion of gametes during or after sexual activity. The term contraception is a contraction of contra, which means against, and the word conception, meaning fertilization...
worldwide, with an estimated 40-60 million individuals having the procedure and 5-10% of couples choosing it as a birth control
Birth control
Birth control is an umbrella term for several techniques and methods used to prevent fertilization or to interrupt pregnancy at various stages. Birth control techniques and methods include contraception , contragestion and abortion...
method. In the U.S., about 5% of men who have had a vasectomy will change their minds and have a vasectomy reversal afterwards. The most common reason for a reversal is remarriage and a desire for more children. Other men in long-standing relationships have changed their minds and would like more children. There are occasional unfortunate individuals who have lost children and want to have more children. Vasectomy reversals are also performed in attempts to relieve post-vasectomy pain syndrome
Post-vasectomy pain syndrome
Post-vasectomy pain syndrome is a chronic and sometimes debilitating genital pain condition that may develop immediately or several years after vasectomy. Because this condition is a syndrome, there is no single treatment method, therefore efforts focus on mitigating/relieving the individual...
.
Biological considerations
SpermSperm
The term sperm is derived from the Greek word sperma and refers to the male reproductive cells. In the types of sexual reproduction known as anisogamy and oogamy, there is a marked difference in the size of the gametes with the smaller one being termed the "male" or sperm cell...
are produced in the male sex gland or testicle
Testicle
The testicle is the male gonad in animals. Like the ovaries to which they are homologous, testes are components of both the reproductive system and the endocrine system...
. From there they travel through tubes (efferent tubules), exit the testes and enter a “storage site” or epididymis
Epididymis
The epididymis is part of the male reproductive system and is present in all male amniotes. It is a narrow, tightly-coiled tube connecting the efferent ducts from the rear of each testicle to its vas deferens. A similar, but probably non-homologous, structure is found in cartilaginous...
. The epididymis is a single, 18 feet (5.5 m), tightly coiled, small tube, within which sperm mature to the point where they can move, swim and fertilize eggs. Testicular sperm are not able to fertilize eggs naturally (but can if they are injected directly into the egg in the laboratory), as the ability to fertilize eggs is developed slowly over several months of storage in the epididymis. From the epididymis, a 14-inch, 3 mm-thick muscular tube called the vas deferens
Vas deferens
The vas deferens , also called ductus deferens, , is part of the male anatomy of many vertebrates; they transport sperm from the epididymis in anticipation of ejaculation....
carries the sperm to the urethra
Urethra
In anatomy, the urethra is a tube that connects the urinary bladder to the genitals for the removal of fluids out of the body. In males, the urethra travels through the penis, and carries semen as well as urine...
near the base of the penis. The urethra then carries the sperm through the penis
Penis
The penis is a biological feature of male animals including both vertebrates and invertebrates...
during ejaculation
Ejaculation
Ejaculation is the ejecting of semen from the male reproductory tract, and is usually accompanied by orgasm. It is usually the final stage and natural objective of male sexual stimulation, and an essential component of natural conception. In rare cases ejaculation occurs because of prostatic disease...
. A vasectomy interrupts sperm flow within the vas deferens. After a vasectomy, the testes still make sperm, but because the exit is blocked, the sperm die and eventually are reabsorbed by the body.
A problem in the delicate tubes of epididymis can develop over time after vasectomy. The longer the time since the vasectomy, the greater the “back-pressure” behind the vasectomy. This “back-pressure” may cause a “blowout” in the delicate epididymal tubule, the weakest point in the system. The blowout may or may not cause symptoms, but will probably scar the epididymal tubule, thus blocking sperm flow at second point. To summarize, with time, a man with a vasectomy can develop a second obstruction deeper in the reproductive tract that can make the vasectomy more difficult to reverse. Having the skill to detect and fix this problem during vasectomy reversal is the essence of a skilled surgeon. If the surgeon simply reconnects the two freshened ends of the vas deferens without examining for a second, deeper obstruction, then the procedure can fail, as sperm-containing fluids are still unable to flow to the place of the connection. In this case, the vas deferens must be connected to the epididymis in front of the second blockage, to bypass both blockages and allow the sperm to reenter the urethra in the ejaculate. Since the epididymal tubule is much smaller (0.3 mm diameter) than the vas deferens (3 mm diameter, 10-fold larger), epididymal surgery is far more complicated and precise than the simple vas deferens-to-vas deferens connection.
Preparation
A general or regional anesthetic is most commonly used, as this offers the least interruption by patient movement for microsurgery. Local anesthesiaAnesthesia
Anesthesia, or anaesthesia , traditionally meant the condition of having sensation blocked or temporarily taken away...
, with or without sedation
Sedation
Sedation is the reduction of irritability or agitation by administration of sedative drugs, generally to facilitate a medical procedure or diagnostic procedure...
, 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 scrotumScrotum
In some male mammals the scrotum is a dual-chambered protuberance of skin and muscle containing the testicles and divided by a septum. It is an extension of the perineum, and is located between the penis and anus. In humans and some other mammals, the base of the scrotum becomes covered with curly...
with soap and water, the vas deferens
Vas deferens
The vas deferens , also called ductus deferens, , is part of the male anatomy of many vertebrates; they transport sperm from the epididymis in anticipation of ejaculation....
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
Vasectomy
Vasectomy is a surgical procedure for male sterilization and/or permanent birth control. During the procedure, the vasa deferentia of a man are severed, and then tied/sealed in a manner such to prevent sperm from entering into the seminal stream...
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
Prostate
The prostate is a compound tubuloalveolar exocrine gland of the male reproductive system in most mammals....
(a “saline vasogram”). If a blockage is suspect above the vasectomy site, then this must be dealt with as well, if sperm is to return to the ejaculate after surgery. The testicle end of the vas deferens is then compressed and inspected for fluid. This fluid is examined with a microscope for color, consistency and for sperm. This information is used to decide whether or not a secondary epididymal obstruction is present (see Table below).
| 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 testis 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
Vasovasostomy
Vasovasostomy is a surgery by which vasectomies are partially reversed. Another surgery for vasectomy reversal is vasoepididymostomy.-Limitations:...
) is planned. If sperm are not found, then an epididymis to vas deferens connection (vasoepididymostomy) is needed 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.
Vasovasostomy
For a vasovasostomyVasovasostomy
Vasovasostomy is a surgery by which vasectomies are partially reversed. Another surgery for vasectomy reversal is vasoepididymostomy.-Limitations:...
, 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 vasoepididymostomyVasoepididymostomy
Vasoepididymostomy or epididymovasostomy is a surgery by which vasectomies are reversed. It involves connection of the severed vas deferens to the epididymis and is more technically demanding than the vasovasostomy....
involves a connection of the vas deferens
Vas deferens
The vas deferens , also called ductus deferens, , is part of the male anatomy of many vertebrates; they transport sperm from the epididymis in anticipation of ejaculation....
to the epididymis
Epididymis
The epididymis is part of the male reproductive system and is present in all male amniotes. It is a narrow, tightly-coiled tube connecting the efferent ducts from the rear of each testicle to its vas deferens. A similar, but probably non-homologous, structure is found in cartilaginous...
. This is necessary when there is no sperm present in the vas deferens.
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 pregnancyPregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
rates. In a recently published report 95% of men with a vasovasostomy had motile sperm in the ejaculate within 1 year after vasectomy reversal. Interestingly, 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.
What has also been published is that:
- 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 outcome of pregnancy ratePregnancy rate
Pregnancy rate in infertility treatment is the success rate for pregnancy. It is the percentage of all attempts that leads to pregnancy, with attempts generally referring to menstrual cycles where insemination or any artificial equivalent is used, which may be simple artificial insemination or AI...
after vasectomy reversal depends not only on the patency rate, but also on known or unknown female factor issues. Pregnancy rates range widely in published series, anywhere from 30-76%, and depend on many factors. Some of these include female age, female reproductive potential, female uterine and ovulatory issues. There are also male specific reasons for variations in pregnancy rates, including antisperm antibodies and epididymal dysfunction and other reasons listed below. However, in general, pregnancy rates with vasovasostomy are higher than those with vasoepididymostomy.
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 estradiolEstradiolEstradiol is a sex hormone. Estradiol is abbreviated E2 as it has 2 hydroxyl groups in its molecular structure. Estrone has 1 and estriol has 3 . Estradiol is about 10 times as potent as estrone and about 80 times as potent as estriol in its estrogenic effect...
levels, an assessment of menstrual cycleMenstrual cycleThe menstrual cycle is the scientific term for the physiological changes that can occur in fertile women for the purpose of sexual reproduction. This article focuses on the human 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 tissueScar tissueScar tissue can refer to:*Granulation tissue, a product of healing in major wounds*The tissue of a scar*"Scar Tissue", a Red Hot Chili Peppers song*Scar Tissue , the autobiography of Anthony Kiedis, lead singer of the Red Hot Chili Peppers...
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-inflammatoryAnti-inflammatoryAnti-inflammatory refers to the property of a substance or treatment that reduces inflammation. Anti-inflammatory drugs make up about half of analgesics, remedying pain by reducing inflammation as opposed to opioids, which affect the central nervous system....
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 hematomaHematoma
A hematoma, or haematoma, is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This distinguishes it from an ecchymosis, which is the spread of blood under the skin in a thin layer, commonly called a bruise...
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
Seroma
A seroma is a pocket of clear serous fluid that sometimes develops in the body after surgery. When small blood vessels are ruptured, blood plasma can seep out; inflammation caused by dying injured cells also contributes to the fluid....
) 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
Compartment syndrome
Compartment syndrome is a limb threatening and life threatening condition, defined as the compression of nerves, blood vessels, and muscle inside a closed space within the body . This leads to tissue death from lack of oxygenation due to the blood vessels being compressed by the raised pressure...
or deep venous thrombosis
Venous thrombosis
A venous thrombosis is a blood clot that forms within a vein. A venous thrombosis is a blood clot that forms within a vein. A venous thrombosis is a blood clot that forms within a vein. (Thrombosis is a medical term for blood clotting (Haemostasis) occurring in the wrong place, i.e...
from prolonged positioning, testis atrophy due to damaged blood supply, and reactions to anesthesia
Anesthesia
Anesthesia, or anaesthesia , traditionally meant the condition of having sensation blocked or temporarily taken away...
.
Choosing a surgeon
Beware of surgeons and websites that claim they are the best at vasectomy reversal, without offering real evidence that this is true. Also, beware of vasectomy reversal procedures that seem too inexpensive. A more important way to shop is to look for “value” in a procedure, as value incorporates “quality” with cost and is expressed as quality/cost. In fact, the issue of the quality of the vasectomy reversal is just as important as cost. However, it is also true that determining the quality of a vasectomy reversal surgeon is not easy to do. Some questions to consider asking the vasectomy reversal surgeon you are considering:- Is an operating microscope used for the reversal procedure?
- Has the surgeon been formally trained in urologic microsurgery and vasectomy reversal?
- Does the surgeon quote personal success rates or that of others for the vasectomy reversals?
- Has the surgeon published their vasectomy reversal success rates?
- How does the surgeon define patency rate (“moving” sperm or “any” sperm) after vasectomy reversal?
- How many vasectomy reversal procedures does the surgeon perform annually?
- Is the surgeon comfortable with vasoepididymostomyVasoepididymostomyVasoepididymostomy or epididymovasostomy is a surgery by which vasectomies are reversed. It involves connection of the severed vas deferens to the epididymis and is more technically demanding than the vasovasostomy....
or must they refer the patient to a more experienced surgeon for another if vasovasostomyVasovasostomyVasovasostomy is a surgery by which vasectomies are partially reversed. Another surgery for vasectomy reversal is vasoepididymostomy.-Limitations:...
is not applicable? - Will they plan to bank sperm at the time of the vasectomy reversal procedure (which can save the patient from having another procedure to retrieve sperm if the reversal fails)?
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 injectionIntracytoplasmic sperm injection
Intracytoplasmic sperm injection is an in vitro fertilization procedure in which a single sperm is injected directly into an egg.-Indications:...
(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.
Published research attempts to identify the issues that matter most as couples decide between IVF-ICSI and vasectomy reversal, two very different approaches to family building. This research has generally taken the form of cost-effectiveness or cost-benefit analyses and decision analyses and Markov modeling. Since it is difficult to perform randomized, blinded prospective trials on couples in this situation, analytic modeling can help uncover what variables affect outcomes the most. From this body of work, it has been observed that vasectomy reversal can be the most cost effective way to build a family if: (a) the female partner is reproductively healthy, and (b) the surgeon can achieve good vasectomy reversal outcomes. If the surgeon can achieve high “patency” rates (moving sperm in the ejaculate) after vasectomy reversal, then vasectomy reversal is competitive with IVF-ICSI. In the special instance of couples with advanced maternal age
Advanced maternal age
Advanced maternal age is defined as an increase in the age at which women give birth to their first child, is now a widespread, and indeed near universal, phenomenon across the OECD countries....
(defined as a female partner > 38 years old), case series’ have reported that pregnancy rates with vasectomy reversal are competitive with IVF-ICSI. When Markov modeling was applied to probe the issue of pregnancy rates after reversal surgery in more depth, the results revealed that female reproductive health is far more important than: (a) the age of the vasectomy, (b) the age of the man, or (c) the vasectomy reversal patency rate. Ultimately the decision to pursue a vasectomy reversal is a personal one for each couple.
Alternatives: how to choose
Sometimes it is not clear to couples who want children whether they should do a vasectomy reversal or pursue assisted reproduction. There are several questions for couples to ask themselves.- How long ago was the vasectomy performed? An older vasectomy, especially those more than 20–25 years, may make vasectomy reversal less likely to work.
- How many children do we want? Sperm retrieval and IVF-ICSI may be a better fit for the couple who wants only one child, as it generally results in both fresh embryos and frozen embryos that can make conceiving one child very reasonable.
- Are we comfortable with dealing with birth control issues again? Birth control may be required again after vasectomy reversal.
- How long are we willing to wait for a child? The average time to pregnancy after vasectomy reversal ranges from 9–14 months.
- What will each approach cost us? Most insurance companies do not cover the cost of vasectomy reversal. However, sometimes insurance companies cover the cost (partially or fully) for IVF-ICSI.
- Are we comfortable with assisted reproductive technology? Or, how do we feel about children conceived with the help of technology?
Patient expectations
Every patient who is considering vasectomy reversal should undergo a screening visit before the procedure to learn as much as possible about his current fertilityFertility
Fertility is the natural capability of producing offsprings. As a measure, "fertility rate" is the number of children born per couple, person or population. Fertility differs from fecundity, which is defined as the potential for reproduction...
potential. At this visit, the patient can decide whether he is a good candidate for vasectomy reversal and assess if it is right for him. Issues to be discussed at this visit include:
- Female partner’s history of past pregnancies
- Male’s medical and surgical history
- Complications during or after the vasectomy
- Female partner’s age, menstrual cycle and fertility
- Brief physical examination to assess male reproductive tract anatomy
- A review of the vasectomy reversal procedure, its nature, benefits and risks, and complications
- Alternatives to vasectomy reversal
- Freezing of sperm at the time of vasectomy reversal
- Questions about the surgery, the success rates, and recovery
- Analysis of hormones such as testosteroneTestosteroneTestosterone is a steroid hormone from the androgen group and is found in mammals, reptiles, birds, and other vertebrates. In mammals, testosterone is primarily secreted in the testes of males and the ovaries of females, although small amounts are also secreted by the adrenal glands...
or FSHFSHFSH may refer to:* Follicle-stimulating hormone* Fox Sports Houston, a regional Fox Sports Net affiliate station for the Houston, Texas area* Facioscapulohumeral muscular dystrophy* International Civil Aviation Organisation code for Flash Airlines...
in selected cases to better determine whether sperm production is normal
Immediately before the procedure, the following information is important for patients:
- They should eat normally the night before the vasectomy reversal, but follow the directions that anesthesia recommends for the morning of the reversal. If no specific directions are given, all food and drink should be withheld after midnight and on the morning of the surgery.
- Stop taking aspirin, or any medications containing ibuprofen (Advil, Motrin, Aleve), at least 10 days prior to vasectomy reversal, as these medications have a side effect that can reduce platelet function and therefore lower blood clotting ability.
- Be prepared to be driven home or to a hotel after the vasectomy reversal
After the procedure, patients should perform the following tasks:
- Remove dressings from inside the athletic supporter in 48 hours; continue with the scrotal support for 1 week. Shower once the dressings are removed.
- Apply frequent ice packs (or frozen peas, any brand) to the scrotum the evening after the vasectomy reversal and the day after that for 24 hours to reduce swelling.
- Take prescribed pain medication as directed.
- Resume a normal, well-balanced diet upon returning home or to the hotel. Drinks lots of fluids.
- Normal, non-vigorous activity can be restarted after 48 hours or when feeling better. Activities that cause discomfort should be stopped for the time being. Heavy activities such as jogging and weight lifting can be resumed in 2 to 4 weeks depending on the particular procedure.
- Refrain from sexual intercourse for 2 weeks to 4 weeks depending on the procedure and the surgeon’s recommendations.
- The semen is checked for sperm at 4-6 weeks and monthly semen analyses are then obtained for about 4-6 months or until the semen quality stabilizes.
- You may experience discomfort after the vasectomy reversal. Symptoms that may not require a doctor's attention are: (a) light bruising and discoloration of the scrotal skin and base of penis. This will take one week to go away. b) limited scrotal swelling (a grapefruit is too large); (c) small amounts of thin, clear, pinkish fluid may drain from the incision for a few days after reversal surgery. Keep the area clean and dry and it will stop.
- If you received general anesthesia, a sore throat, nausea, constipation, and general "body ache" may occur. These problems should resolve within 48 hours.
- Consider calling a provider for the following issues: (a) wound infection as suggested by a fever, a warm, swollen, red and painful incision area, with pus draining from the site. Antibiotics are necessary to treat this. (b) scrotal hematoma as suggested by extreme discoloration (black and blue) of the skin and continuing scrotal enlargement from bleeding underneath. This can cause throbbing pain and a bulging of the wound. If the scrotum continues to hurt more and continues to enlarge after 72 hours, then it may need to be drained.