Microsurgical Vasectomy Reversal

Microscopic Vasovasostomy and Epididymovasostomy

A vasectomy reversal is a microscopic operation that reestablishes a connection of the vas deferens, the tube that carries sperm into the ejaculate that was previously cut during a vasectomy.  At the time of vasectomy reversal, two procedures are possible. A vasovasostomy may be performed, which is when the two ends of the vas deferens are reconnected.  Sometimes an epididymovasostomy is performed, which is when the vas deferens is reconnected to the epididymis because of a secondary obstruction in the epididymis (see below).  We perform both procedures entirely under the microscope.

Sperm production occurs in the testis.  After passage through the efferent ducts, sperm are stored and undergo maturation in the epididymis.  The epididymis is a continuous, tightly coiled tube approximately 15-18 feet in length, which leads into the vas deferens.  Sperm that have not passed through the epididymis are generally not able to fertilize eggs under normal conditions.  The vas deferens is responsible for directed and propelling sperm into the urethra.

The decision of whether to perform a vasovasostomy or an epididymovasostomy depends upon the quality of the fluid from the testicular side of the vas deferens. The fluid is expressed and examined under a microscope at the time of surgery. If sperm are present in this fluid, then a reconnection between the two vas ends can be performed – vasovasostomy. When sperm are present in this fluid, we expect 90% or more patients to demonstrate a return of sperm to their ejaculate postoperatively, with an associated 60-70% pregnancy rate. If no sperm are present, but the vasectomy fluid looks abundant and appropriate for ultimate sperm production (clear, watery), then a vasovasostomy is performed with a successful outcome of 60%. If poor-quality fluid is present (e.g., thick, pasty) and sperm are absent, or no fluid at all is found, then an epididymovasostomy (connection of the vas to the epididymis) is performed with a successful outcome of approximately 40%–50%.

Increasing numbers of men are coming to the urologist for vasectomy reversals, most commonly because of remarriage and the desire to initiate a pregnancy.  Vasectomy reversals are also requested by couples who have merely “changed their minds,” as well as by couples who have lost a child and are attempting to initiate another pregnancy. 

Microsurgical advances result in significant pregnancy rates, and it is essential that the surgeon be skillful with microsurgical technique, as precise suture placement is critical to the success of the procedure.  The surgeon must also have the ability to perform the more difficult epididymovasostomy procedure.

The success of a vasectomy reversal depends on:
1.  The skill of the surgeon
2.  The findings at the time of surgery

VASOVASOSTOMY

While there are many methods for performing a vasovasostomy, we prefer a strict, two-layer, watertight procedure utilizing microscopic sutures and the latest microsurgical equipment. Selection of a single-layer, full thickness closure versus a strict two-layer (mucosal and seromuscular) closure is best dictated by the experience of the surgeon, which, indeed, is the most important factor in achieving the desired outcome.

EPIDIDYMOVASOSTOMY

The procedure is performed on an outpatient basis at The Greenspring Station Surgicenter or The Johns Hopkins Hospital Outpatient Center Operating Room.  These facilities boast state of the art microsurgical equipment and the nation’s best anesthesiologists and staff to assist in these procedures.  This arrangement allows you to return home or to a nearby hotel without actually being admitting directly to the hospital, thus saving considerable expense and making the overall experience much more pleasant. 

Operating time for a vasovasostomy or epdidymovasostomy is approximately 3-4 hours.  A general anesthetic is usually used.  We prefer that out-of-town patients stay in the Baltimore area for at least 1 day after surgery.  Postoperative follow-up includes an evaluation of the healing wound at 2 weeks and a semen analysis at 6-8 weeks.  Monthly semen analyses are then obtained for approximately 4-6 months, or until the sperm count stabilizes.  It can take up to 6 months for sperm to return to the ejaculate following a vasovasostomy and up to 1 year following an epididymovasostomy.  If semen quality is less than expected, anti-inflammatory medications are often introduced to decrease scarring.

Cryopreservation of sperm (sperm banking) can be performed at the time of vasectomy reversal if whole, motile sperm are present.  Cryopreservation is performed as a safety “backup” in case inadequate sperm counts are present after surgery.  Because vasectomy reversals may infrequently scar despite good initial results, cryopreservation may also be performed on ejaculated specimens early in the course of recovery when semen quality is exceptionally good.