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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
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