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VASECTOMY
REVERSAL
Approximately 500,000 men request vasectomies each
year and it is recognized that 5% of them will change their minds,
usually due to remarriage, death of a child or improved circumstances
allowing for more children. Over the past 20 years, the surgical
technique of vasovasostomy provided excellent results, permitting a man
to re-establish his fertility. The surgery is performed as an
outpatient, with well over 95% success for those men who have sperm at
the time of surgery.
Within the aspect of medicine or life, good judgement
is based on experience and experience is based on poor judgement.
Therefore, you, as the patient, look to find the physician with the
greatest experience and most skill in performing these operations (over
50 per year).
For those couples experiencing infertility due to a
man's vasectomy, there are the alternatives of T.D.I. (therapeutic donor
insemination) or IVF/ICSI (in-vitro fertilization with intracytoplasmic
sperm injection), but restoration of a man's fertility by reconnecting
the tubes at the site of the previous vasectomy appears to provide
couples with the most optimal and least expensive option for a family.
HOW IS VASECTOMY REVERSAL
PERFORMED?
A small incision is made in the scrotal skin over the
old vasectomy site. The two ends of the vas deferens are found and freed
from the surrounding scar tissue. A drop of fluid from the
testicular end of the vas is placed on a glass slide and examined using
a light microscope (picture below). This is a crucial part of the
operation because the information obtained is used to decide what type
of microsurgical reconstruction needs to be performed. Since the
testicle continues to produce sperm after a vasectomy, the fluid in the
vas should contain sperm. There are 3 possible scenarios which may be
encountered when examining the vasal fluid. The first and best scenario
is that the vasal fluid contains whole sperm. The second possible
finding is that the fluid is thin and copious and contains only sperm
parts or no sperm. The third is that the fluid is thick, pasty and
contains no sperm. This means that a "blow out" or rupture has
occurred in the epididymis. This causes a secondary blockage which needs
to be bypassed to allow the sperm to get out into the vas. If this
second blockage is present and is not recognized then the operation is
doomed to failure.
If the vasal fluid contains sperm then the two ends of
the vas deferens can be sewn together. This procedure is known as
a vasovasostomy (pictures below).
The lumen or channel inside the vas deferens through which the sperm
swim is only 0.2 to0.3 millimeters in diameter ( roughly the size of a
pen dot). An operating microscope is employed to magnify the
operating field 16 times. The vas can then be better visualized and the
sutures can be precisely placed. The technique we prefer is a two
layered closure using 10-0 and 9-0 suture (half the thickness of a human
hair). We place 6-8 interrupted sutures in the mucosa or inner layer of
the vas to insure that the repair is water tight. This is very important
because one reason that vasectomy reversals fail is that sperm leak out
from the vas at the surgical site and cause inflammation and a new
blockage. The muscular layer of the vas is then reapproximated adding
strength to the repair. The surrounding connective tissue is also
brought together to take any tension off of the repair site. The skin
incision is then closed.
If an epididymal blowout has occurred then the
blockage must be bypassed. The epididymis is closely examined and a
tubule is opened and the fluid checked for the presence of sperm. If
motile sperm are found then the vas can be sewn to the open epididymal
tubule (picture below). This is called a vasoepididymostomy.
A vasoepididymostomy is a technically more difficult procedure to
perform than a vasovasostomy because the epididymal tubules are very
thin and delicate. The results of vasoepididymostomy are not as good as
with vasovaostomy. It is for this reason that if the vasal fluid looks
good or has sperm parts, then a vasovasostomy is performed. Motile sperm
can also be collected from the epididymis and frozen for later use if
the vasoepididymostomy fails.
RESULTS
The results of vasectomy reversal are reported as two
percentages. The first is patency rate which means the percentage of men
who have the return of sperm in the ejaculate after reversal. This means
that the operation was technically successful. The second statistic
which is the most important is the pregnancy rate. The pregnancy rate is
always lower than the patency rate because many more factors play a role
in getting pregnant other that the presence of sperm.
The results of microsurgical vasovasostomy
from the Vasovasostomy Study Group data are >90% patency if sperm
were present in the vasal fluid at the time of surgery and
pregnancy rates up to 76%. The results of Dr. Werthman's personal series
to date is 100% patency rate if sperm were present at surgery. For microsurgical
vasoepididymostomy the patency rate is about 60% and the
pregnancy rate is 40%. It is for this reason that we recommend sperm
harvesting and freezing at the time of vasoepididymostomy. This way no
further procedures need be done to get sperm should the
vasoepididymostomy fail. We perform this service at no extra charge.
Data collected by the Vasovasostomy Study Group (the
largest multicenter study of vasectomy reversals, published in 1991)
showed a distinct increase in success rates when the surgery was
performed using an operating microscope by a skilled microsurgeon. The
American Urological Association offers several fellowships (1-2 years of
specialized intensive training) in male infertility and microsurgery.
While many doctors will attempt this surgery, most have no formal
training as microsurgeons. It is incumbent upon the prospective patient
to make sure that the surgeon he chooses is a fellowship trained
microsurgeon and infertility expert who practices microsurgery on a
consistent basis. Even though a failed vasectomy reversal can be
successfully repaired, the first attempt is the best chance.
RELATED
WEBSITES ON VASECTOMY REVERSALS:
Patient's
Guide to Vasectomy Reversal
Vasectomy
Reversal - The Reed Centre
Vasectomy
Reversal Movie Clip
Microscopic
Vasectomy Reversal
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