VASECTOMY REVERSAL

Vasectomy is the most effective and safest form of sterilization. There are a variety of contraceptive methods available including barrier methods, oral contraceptives, and surgical sterilization. Although considered permanent, surgical sterilization is the most common form of contraception practiced by couples in their thirties and older. The majority of couples chose tubal ligation despite the fact that vasectomy is less expensive, safer, and more effective. Approximately 300,000 vasectomies are performed each year in the United States. The typical man undergoing vasectomy is in his late twenties or early thirties, has two or more children, and is married. Vasectomy creates sterility by blocking the egress of sperm from the testes. Sperm are normally produced within the testes and exit the testis into the epididymis, which is a ten-foot long tubule located just behind the testis. It takes sperm approximately one week to travel through the epididymis. Upon ejaculation, sperm leave the tail of the epididymis and travel through the vas deferens to reach the prostate.

Male Reproductive System

Sperm are then mixed with seminal fluid produced by both the seminal vesicles and prostate before they are expelled from the urethra. The vast majority of seminal fluid (90%) is derived from the prostate and seminal vesicles. Less than 5% of seminal volume is derived from the testis and epididymis. Thus ejaculate volume does not change significantly following vasectomy. Studies of the men following vasectomy demonstrate that both hormone and sperm production remain normal. The sperm produced by the testis accumulate in the epididymis and proximal vas deferens where they are digested and resorbed by the body. The pressure can build up within this system because of the continuous output of sperm into an obstructed system. This pressure is often relieved by the formation of a sperm granuloma (leakage of sperm) at the vasectomy site. However, blowouts can form anywhere in this system and, unfortunately, often occur more proximally within the epididymis.
 

Approximately 10% of vasectomized men desire reversal of their vasectomy due to the high divorce rate in this country and other life circumstances. The typical man requesting vasectomy reversal is in his late 30's, divorced, and about to marry a woman in her late 20's who does not have any children of her own. Less commonly, stable married couples may change their minds about contraception because of a death of child, recovery from an illness in either spouse, or changes in income. There are several options for couples who desire fertility after vasectomy. The first option is surgical exploration and reconstruction of the male reproductive system to restore the flow of sperm to the prostate. The second option is to harvest sperm from the husband and then use those sperm to fertilize the wife's eggs in the laboratory, in vitro fertilization (IVF). The last options are donor insemination or adoption.

Vasectomy reversal is one of two different operations performed upon two independent testicular units depending upon the findings during the course of the operation. The first step in a vasectomy reversal is to identify the cut ends of the vas deferens.

Patency of the distal end (the side closest to the prostate) of the vas deferens is confirmed by squirting water towards the prostate and making certain that it flows freely. The patency of the proximal vas deferens (the side closest to the testis) and the epididymal tubule is confirmed by examining the fluid from within the proximal vas deferens under the microscope for sperm. The presence of sperm within the intravasal fluid confirms the patency of the tubes going from the testis to the site of the vasectomy. In these patients the two free ends of the vas deferens are reconnected to reverse the vasectomy. The absence of sperm within the intravasal fluid suggests that there is another blockage somewhere between the vasectomy site and the testis, most commonly within the epididymis. In these patients it may be necessary to go back to the epididymis in order to bypass this second site of obstruction in an effort to reverse the vasectomy. This type of reconstruction is called an epididymovasostomy. However, the absence of sperm within the intravasal fluid does not always mean that there is another site of obstruction. In fact, approximately one half of men who do not have sperm within the intravasal fluid will have sperm present in their ejaculate following vasovasostomy suggesting that there never was a blockage between the testis and the vasectomy site.

The decision of whether to perform a vasovasostomy or an epididymovasostomy when there are no sperm at the vasectomy site is very complex. Some of the factors taken into consideration include, the consistency or quality of the intravasal fluid, the duration of obstruction, the findings on the opposite side, and whether or not there have been prior attempts at reversing the vasectomy. This is a very important decision since if there is a blockage within the epididymis, a vasovasostomy will not work. However, the argument against performing an epididymovasostomy every time there are no sperm found within the vas deferens is that the pregnancy rate following epididymovasostomy is so much lower than vasovasostomy.

A vasovasostomy is performed by reattaching the two free ends of the vas deferens.

Microsurgical techniques achieve the best results. There are a variety of microsurgical techniques for reanastomosing the two ends of the vas deferens, with no one type of procedure being significantly better. The choice of the exact method is up to the individual surgeon, but microsurgical techniques have much better results than those performed without the microscope. The results of a vasectomy reversal are surgical patency, which means sperm in the semen, and pregnancy. The average patency rates achieved with vasovasostomy performed by microsurgery are approximately 90% using modern microsurgical techniques. Pregnancy rates are dependent upon many factors independent of the surgery and average approximately 60%. It has been estimated that the maximal pregnancy rate that can be achieved with vasovasostomy is 67%.

Epididymovasostomy is a much more complicated procedure requiring a great deal more expertise at microsurgery.

The site of epididymal anastomosis is chosen by examining the fluid within the epididymal tubule for sperm. Unlike vasovasostomy, epididymovasostomy is never successful if sperm are not present within the tubule at the site of anastomosis. Microsurgery is mandatory for an epididymovasostomy because of the small size of the epididymal tubule. Surgical patency rates for epididymovasostomy range from 50% to as high as 80%. Pregnancy rates are significantly lower, 30 to 50%. The success rates are higher the further away from the testicle the connection between the epididymis and vas deferens is performed. The overall outcome of a vasectomy reversal is largely determined by whether or not sperm are present within the testicular end of the cut vas deferens at the time of surgery. The presence or absence of sperm within the vas deferens at the time of surgery determines whether or not an epididymovasostomy will be necessary and the success rates for epididymovasostomy are significantly lower than a vasovasostomy. Unfortunately, there is no accurate way to predict whether or not that will be the case beforehand.

The main predictor used in discussion of vasectomy reversal is the time between the vasectomy and vasectomy reversal. It has been shown that the likelihood of finding sperm within the vas deferens decreases as the duration of obstruction increases. Although the number ten years has been popularized as a cutpoint, there actually is a linear relationship over time without any true cutpoint. The chance of finding sperm within the vas within five years of vasectomy is 86% and after more than 20 years is still 60%.

Therefore, there is no time after which it is impossible to reverse a vasectomy, although the chance of requiring an epididymovasostomy increases with time. The other factor that is predictive of the presence of sperm within the vas deferens at the time of reversal is the length of the proximal vas segment. It appears that the longer the vas segment on the testicular side is, the more likely it is that sperm will be present within the vas deferens at the time of reversal.

In other words, the frequency of epididymal blowout is reduced with more distal obstruction. However, as with duration of obstruction, the length of the proximal vas segment is not absolutely predictive of the presence of sperm within the vas deferens or the eventual outcome of a vasectomy reversal.


Until quite recently, there was no alternative to vasectomy reversal for those couples who desired children where the husband with a vasectomy was the genetic father. The alternative to vasectomy reversal is sperm harvesting and IVF.

As mentioned above, a vasectomy does not significantly alter a person's ability to produce sperm. Therefore, almost all men who fathered children in the past will have sperm present within the testis and epididymis following a vasectomy. Therefore, sperm can be harvested directly from either the testis or epididymis by either percutaneous puncture and aspiration of either organ or open surgical exploration with harvesting of sperm. The numbers and quality of sperm acquired by these techniques are not sufficient to initiate a conception by artificial insemination (placement of sperm in the wife's uterus) but are more than adequate for IVF using intracytoplasmic sperm injection (ICSI). The combination of these two techniques, sperm harvesting and IVF using ICSI, are highly successful. Pregnancy rates per attempt average around 35% or higher. Unfortunately, cumulative pregnancy rates, as is routinely reported for vasectomy reversal, have not been reported for sperm harvesting with IVF. There are many factors that play a role in deciding which approach is the best for each couple. One of the main issues is the wife's fertility status. It makes most sense to proceed directly to sperm acquisition and IVF if the wife will require IVF for female factors regardless of the husband's sperm count. However, most couples requesting vasectomy reversal include young fertile wives. Therefore, the main factor in the decision regarding which approach to employ is costs. There have been two studies comparing the costs of IVF to vasectomy reversal. The first study analyzing this issue used published success rates and costs for each approach. The results of this analysis revealed a significant cost advantage of vasectomy reversal by either vasovasostomy or epididymovasostomy over sperm harvesting and IVF.

One of the main reasons for this is that as the success of IVF increases, the risk of multiple gestation also increases. Multiple gestation (twins and triplets) leads to low birth weight and neonatal intensive care unit admissions which significantly increases the cost of this approach. One of the criticisms of this type of analysis is that it uses published data from differing centers with significantly different costs and that the success rates are calculated differently since many couples who fail one cycle of IVF will often make another attempt. A second study compared the costs and success rates of a repeat vasectomy reversal for patients who had failed a previous attempt to the costs and success of IVF.

	Repeat Reversal	IVF
Number	18	9
Patency rate	78%
Pregnancy number	12	6
Delivery rate	56%	56%
Average charges	$8,273	$17,092
Cost per delivery	$14,892	$35,570

There are two significant advantages to this study. The first is that the study group is comprised of the most difficult patients with potentially the worst prognosis for vasectomy reversal. The second important feature of this study is that both approaches were performed at the same institution consecutively over time, thus being a fair cost and success rate comparison. They observed a similar pregnancy rate with both techniques but a significant cost advantage per delivery of repeat vasectomy reversal as compared to IVF. Thus, based upon a pure cost-benefit analysis, it makes most sense for the average couple to undergo vasectomy reversal rather than go through IVF. Additional factors to be considered are the risks of IVF being displaced upon the wife for a male problem and the ability to have multiple children following a single procedure for vasectomy reversal. In conclusion, vasectomy reversal is a relatively common procedure. Advances in both microsurgical techniques and assisted reproductive technology allow most couples a realistic chance of pregnancy following vasectomy. The primary predictors of a successful outcome include duration since vasectomy and the wife's age but neither are absolute.