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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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