Vasectomy Reversal

A common question or comment when I converse with people about my area of expertise is, "Oh, I didn't know you could reverse those!"

For the couple facing infertility after a vasectomy, there are essentially two options through which they can achieve their own genetic child. The male partner can opt for a vasectomy reversal and conception is done through natural sexual intercourse after a short period of healing.

Alternatively, couples may opt to pursue assisted reproductive techniques such as in vitro fertilization (IVF) which necessitates sperm retrieval from the male partner.

Other options such as adoption and use of donor sperm are also reasonable, but for the purposes of this discussion, the focus will be on vasectomy reversal.

What is involved in a vasectomy reversal?

During a vasectomy a small portion of the vas deferens, which is the sperm transport tube arising from the testicle, is removed and each free end is usually cauterized and tied to block the flow of sperm and prevent re-canalization (re-connection of the scarred ends over time). During a vasectomy reversal, the scarred down ends of the vasectomy site are dissected free, freshened up, and re-connected. Based on certain intra-operative findings, the connection may be a simple re-connection of the ends of the vas (Vasovasostomy) or a more sophisticated re-connection between the vas and the epididymis (Vasoepididymostomy). This type of surgery requires the use of an operating microscope and he expertise of someone who is specially trained to do this type of exacting surgical work.

The goal is to restore the free flow of sperm into the ejaculate.

How long do the surgery and recovery take?

Compared to the original vasectomy, it is a significantly more complicated technical undertaking for the surgeon to perform a vasectomy reversal. Normally, three to four hours of surgery are required, depending on the complexity of the re-connection. From the patient's standpoint, it passes pretty quickly as he is under general anesthesia.

The procedure itself usually can be accomplished through incisions not much bigger than the original incisions for the vasectomy. There is usually some scrotal bruising and swelling, which usually takes 7-10 days to resolve.

Perhaps the most important aspect of the recovery is the avoidance of ejaculation for three weeks to allow the re-connection to heal properly. 1-2 days may be required for recovery prior to going back to work.

What are the success rates?

The success rates of the surgery can be measured in two ways – The likelihood of returning sperm to the semen The likelihood of achieving a pregnancy

The largest and most comprehensive outcome study regarding vasectomy reversal was the Vasovasostomy Study Group, an expert panel of surgeons who pioneered this technique in the 1980s and early 90s. What they found and what has been confirmed multiple times since then is that the success of the vasectomy reversal by either measure is correlated to how long the vasectomy has been in place.

At less than five years, the odds of returning sperm to the ejaculate are well above 90% and the odds of a pregnancy (assuming a healthy female partner) are about 60%. There is a slow decline in both rates but even at fifteen years, there is still a 50-60% chance of return of sperm and pregnancy rates are still in the 30% range, very comparable with IVF/ICSI.

Additionally, several studies have shown that vasectomy reversal is more cost-effective as a strategy when compared with IVF.

So what are the downsides or risks involved?

As with any aspect of medical decision making, there are some downsides and risks associated with vasectomy reversal.

The usual time to pregnancy after a reversal is 9-12 months. This is due in part to the fact that conception occurs naturally, and so may take several cycles to happen to begin with. Sperm can be seen in the ejaculate as early as three weeks, and quality tends to improve over the first two years after a procedure as the healing completes itself and the inflammation subsides. subsides The attendant risks of the procedure are exposure to general anesthesia as well as bleeding and infection. These are not very commonly encountered.

Occasionally, anti-sperm antibodies are seen which may also inhibit motility of sperm after the procedure. Again, this is not a commonly seen after effect.

Post-operative care instructions

After a vasectomy reversal, some bruising, swelling, and oozing of the wound should be expected. It is very common to have bruising extend onto the shaft of the penis. 2-3 days off work should be all that is required in the initial stages of recovery.

Swelling is a normal part of the healing process as well. As a general guideline, if the wrinkles of the scrotum can be seen and appreciated, then the swelling is within a reasonable level.

Activity level should be light, avoiding any heavy exercise or straining. Walking is encouraged to promote the flow of blood through the legs and to help re-expand the lungs after anesthesia.

As a general rule, stay ahead of your pain and discomfort. This is best accomplished by taking a steady dose (two tablets) of an over-the-counter pain reliever such as ibuprofen or Tylenol every six hours for the first 2-3 days after surgery. Use the stronger pain medicine if needed.

Dressings should be left in place and kept dry for two days following surgery. After that, leave the wound open to the air. There is no need to keep it covered or use antibiotic ointment as all the stitches are buried and absorbable within 4-6 weeks.

Warning signs that should merit a call to the office are fever >101, pus or an opening of the operative site, excessive bleeding that cannot be stopped by gentle pressure, shortness of breath, or asymmetric swelling in the legs.

Ejaculation should be avoided for a total of three weeks. Please feel free to bring a sample for inspection at about a month after surgery.

To schedule an office visit with Dr. Shin, please contact him at 202-223-1024 and request a consult for vasectomy reversal. Please specifically ask for a consult (45 minutes) and feel free to bring along your partner, a notepad, and all of your questions.

A picture through the microscope of a vasovasostomy (connecting the ends of a vasectomy). As a frame of reference, the opening within the vas is roughly the size of a period on a printed page. 6-8 microsutures are placed within the inner layer.

Picture of an epididymis, the first part of the sperm transport system. When performing a vasectomy reversal, occasionally a connection must be made between the vas and the epididymis. This is a very sophisticated and complex reconstruction that requires special training to perform.

An artisitc rendition of the type of connection performed with a vaso-epididymostomy (vas to epididymis connection).

Photographs (c) Dr. Anthony Thomas

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