Reversal Surgery (Vasovasostomy and Vasoepididymostomy):

Although men should consider vasectomy a permanent decision, reversal procedures may restore fertility in some men who change their minds. The main reasons for requesting a vasectomy reversal are remarriage or the death of a child. Reversal may also be performed to relieve post-vasectomy pain, which occurs in a small percentage of men. However, fewer than 10% of patients who request reversals do so because of physical or psychological problems following vasectomy.

Vasovasostomy Reversal Surgery Procedures

There are two types of vasectomy reversal surgical procedures:

• Vasovasostomy. The severed ends of the vas deferens are sewn back together.
• Vasoepididymostomy. The vas deferens is surgically reattached directly to the epididymis. This procedure is more difficult to perform and is used when vasovasostomy cannot be performed or does not work.

These procedures help restore sperm flow so that sperm can be ejaculated out of the urethra. Both types of procedures are performed on an outpatient basis and the patient can return home the same day.

It is not possible to know in advance which procedure will be performed. The surgeon will make the decision whether to use vasovasostomy or vasoepididymostomy based on a fluid sample taken at the start of the operation. The fluid is removed from the vas end closest to the testicle and examined for its appearance and the presence of sperm.

If sperm are present or the fluid is clear, it indicates that there is no blockage in the epididymis, and a vasovasostomy can be performed. No sperm, or a creamy, thick appearance of fluid, is a sign of blockage, and the vasoepididymostomy surgical approach to bypass the blockage should be used. Other factors may also determine the surgeonâ ' s choice of reversal surgical procedure. In some cases, a combination of the two surgeries may be used, with vasovasostomy performed on one side and vasoepididymostomy on the other side.

Vasovasostomy. Vasovasostomy uses several different surgical approaches. Usually a microsurgical technique is used, in which a microscope helps magnify the surgical area. Vasovasostomy takes 2 - 3 hours to perform. The patient is given local anesthesia and a mild sedative.

Vasoepididymostomy. Vasoepididymostomy is a more complex microsurgical technique. To appreciate the difficulty of this operation, one should realize that the epididymis is 1/300th of an inch wide with a wall thickness of 1/1000th of an inch. Microscopic techniques are critical for the success of this procedure and require a surgeon who specializes in them. Vasoepididymostomy takes up to 4 hours to perform. The patient is given either general anesthesia or an epidural block.

Recovery and Follow-Up

Pain after reversal surgery is usually not severe and can be controlled with mild analgesics such as acetaminophen (Tylenol). A cold pack placed on the scrotum area can help relieve swelling. Your doctor may recommend that you wear a jockstrap for a few weeks to help provide compression and to keep the surgical incisions in place. Most patients can return to work and resume normal non-strenuous activities within a week, but patients may need to refrain from heavy lifting and other rigorous physical activities for up to 4 weeks following surgery. Patients should wait 2 - 4 weeks before having sex.

The doctor will perform a semen analysis every 2 - 3 months after reversal surgery to check your sperm count. It generally takes around 2 months for sperm to reappear following vasovasostomy, and around 3 - 15 months following vasoepididymostomy. Either a stabilized sperm count, or pregnancy, indicates successful reversal surgery.

If reversal surgery is not successful, a repeat surgery can be performed. However, the success rates for repeat reversals are lower than for an initial reversal.

Pregnancy Results after Reversal Surgery

On average, around 50% of couples achieve a pregnancy within 1 - 2 years after reversal surgery. Several factors determine the likelihood of a successful outcome. The experience of the surgeon is one critical factor. The time interval between the original vasectomy and the reversal procedure is another important factor. The closer the time between vasectomy and reversal, the better. In one large study, the pregnancy rates were 76% for those who had vasectomy less than 3 years before reversal surgery, but decreased to 30% for those men who had a vasectomy more than 15 years earlier.

Sperm removed during vasovasostomy can be frozen and used for assisted reproductive technologies in case of unsuccessful reversal surgery. If reversal surgery is not successful, a doctor may also be able to retrieve sperm from the testes or epididymis using various sperm retrieval techniques such as testicular fine needle aspiration, microsurgical epididymal sperm aspiration, percutaneous epididymal sperm aspiration, or testicular sperm extraction. [For more information, see In-Depth Report #67: Infertility in men.]

Intracytoplasmic Sperm Injection (ICSI)

The best assisted reproductive technology procedure for men who have had vasectomies or failed reversal surgery is intracytoplasmic sperm injection (ICSI). The procedure involves injecting a single sperm into an egg. The fertilized egg is then implanted in the woman using in vitro infertilization (IVF). [For more information, see In-Depth Reports #67 Infertility in men and #22 Infertility in women.]

Some men may consider pursuing ICSI in place of vasectomy reversal surgery. Even though the introduction of ICSI has helped improve pregnancy rates after vasectomy, reversal surgery is usually still a better choice for most men who want children. Reversal surgery costs less than ICSI and men have the potential to achieve long-lasting fertility. ICSI is performed a limited number of times, and the success rates are best if the women is younger than age 37. ICSI/IVF also increases the chance for multiple births, which can pose risks to the mother and babies. However, ICSI may be more effective than reversal surgeries in men whose vasectomies were conducted at least 15 years earlier.