Metro Urology

Background

Approximately 500,000 vasectomies Rugby tickets are performed annually in the United States. While a vasectomy is an effective means of birth control, it is intended to be permanent. The reality is that as many as 6% of men who undergo vasectomies will seek a consultation at some point in the future for a vasectomy reversal. Despite the fact that vasectomies usually entail the destruction of the two ends of the vas deferens and removal of a piece of the vas deferens, most of these men and their partners will be candidates for either vasectomy reversal or sperm acquisition with in-vitro fertilization.

Anatomy and Physiology

Sperm are made in the testicles within tiny spaces called seminiferous tubules. After leaving the testicles the sperm travel through the epididymis, a tightly coiled tubule, which occupies a small space alongside the testicle but if unwound would be 10 feet long. After traveling through the epididymis, the sperm enter the vas deferens, a thick-walled tube which conducts the sperm from the scrotum into the pelvis. Within the pelvis, the fluid containing the sperm is joined by fluid from the seminal vesicles behind the prostate in the ejaculatory duct. The fluid is expelled from the ejaculatory duct during ejaculation.

A vasectomy is performed by interrupting the vas deferens within the scrotum. The testicles continue to produce sperm and these sperm are ultimately reabsorbed. Most urologist believe that the blockage produced by a vasectomy and the higher pressures within the vas deferens and epididymis can result in secondary blockages within the epididymis. If this occurs, simply reversing the vasectomy by hooking up the two ends of the vas deferens would fail to return sperm to the ejaculate and a more complex operation is required (see below).

Fertility Options After a Vasectomy

There are two options for couples who wish to have their own biologically related children after a vasectomy: they can pursue a vasectomy reversal or in-vitro fertilization. Other options include intrauterine insemination with donor sperm and adoption. Of course, with these two options, the children will not be genetically related to the father.

Vasectomy Reversal

Vasectomy reversals are nearly as old as vasectomies themselves but major technical improvements over the past 20 years have dramatically improved success rates as measured both by the return of sperm to the ejaculate and by pregnancies. Innovations such as the use of the operating microscope and the development of extremely fine needles, sutures and instruments now allow for highly precise suture placement for aligning the two ends of the vas deferens or the vas deferens to the epididymis.

Vasectomy Reversal – The Procedure

A vasectomy reversal may be performed using general anesthesia or with sedation and local anesthesia. This surgery is performed on an outpatient basis meaning that men generally return home within a few hours of the completion of the procedure.

The procedure begins with an examination of the two ends of the cut vas deferens through a tiny incision in the scrotum (about ½ inch). The vas deferens on the testicular side is opened and the fluid is examined for the presence or absence of sperm. If sperm are identified or if there is a large amount of watery fluid, the two ends of the vas deferens are then sewn together – a procedure known as a vasovasostomy. If there are no sperm in the fluid and the fluid is pasty, a secondary epididymal blockage is suspected. If confirmed, the vas deferens is sewn to the epididymis – a procedure known as an epididymovasostomy or vasoepididymostomy.

Once the decision is made to perform either a vasovasostomy or epididymovasostomy, the operating microscope is positioned over the scrotum. These microscopes allow for tremendous magnification of the operative field and, in properly trained hands, significantly more precise suture placement and better results. The inside diameter of the vas deferens is only ½ of a millimeter (0.02 inches). For comparison, a human hair is 1/10 of a millimeter. Most male infertility specialists join the two ends of the vas deferens in multiple layers (“multilayered anastomosis”) or with a modified one layer technique. Male infertility specialists use very fine suture material which is 1/3rd to 1/5th the diameter of a human hair and almost impossible to see without a microscope. To perform an epididymovasostomy, an epidiymal tubule containing sperm is identified and attached to the vas deferens, thereby reestablishing continuity of the genital tract. This is an exceedingly delicate operation – the epididymis has a very thin and fragile wall and a tiny channel containing sperm.

Vasectomy Reversal – Results

There are two measures of success following a vasectomy reversal: the return of sperm to the ejaculate (“patency”) and the establishment of a pregnancy.

The landmark published study of vasectomy reversals is the vasovasostomy study group report, published in 19911. This study reported vasectomy reversal results for more than 1400 men. Overall, 86% of men undergoing first time vasectomy reversals had sperm return to the ejaculate. Interestingly, the patency rate was related to the length of time since the vasectomy: patency rates were 97% if the time since the vasectomy was less than 3 years but 71% if more than 14 years. Pregnancy rates were also dependent upon the length of time since the vasectomy. The overall pregnancy rate was 52% but if the interval since vasectomy was less than 3 years the pregnancy rate was 76% and if the interval was greater than 14 years the pregnancy rate was 30%.

Much has changed over the last 15 years since the report of the vasovasostomy study group. Microsurgery has undergone numerous refinements. The technique of vasoepididymostomy has undergone dramatic changes with corresponding improvements in results. With these changes have come improved patency and pregnancy rates. Most contemporary series of vasovasostomies report patency rates between 90% and 99.5% and pregnancy rates of 40-55%2. Over the past few years several studies have shown that even with long periods of time since vasectomy, the patency and pregnancy results are excellent after microsurgical vasectomy reversal 3,4.

Approximately 3% of men who have a technically successful reversal (motile sperm seen in the ejaculate after the reversal) will scar down the area where the two ends of the vas deferens were put together and eventually the ejaculate will contain no sperm5.

Many factors influence the pregnancy rate, the most important of which is the age of the female partner. When the female partner is less than 30 years old, two thirds of couples achieve a pregnancy even with more than 15 years between vasectomy and vasectomy reversal6. If men have the same female partner before and after vasectomy (i.e. not remarriage), 86% of couples achieve pregnancies7. For couples in which the female partner is 35-39 years old, recent data suggests pregnancy and live birth rates around 45%8. These data show how important female fertility issues are in predicting the ultimate result.