Microsurgical Vasectomy Reversal
Detailed description
For men with vasectomy who seek to restore their fertility the two treatment options are IVF with sperm extraction or vasectomy reversal. For most couples vasectomy reversal has advantages over IVF as it usually gives a higher cumulative chance of pregnancy. Importantly, IVF can reduce the prospect of a future successful vasectomy reversal due to the need for sperm extraction that generally damages either the epididymis, which is a continuation of the vas deferens or the intra-testicular collecting system (the rete testis). On the other hand vasectomy reversal can simplify and optimise the prospect of future IVF (as most patients undergoing vasectomy reversal have sperm restored their semen and so can use ejaculated sperm for later IVF if pregnancy is not achieved naturally).
About 5% of Australian men who have had vasectomy later seek reversal. The Australian Institute of Heath and Welfare data indicate that 500 to 600 vasectomy reversal operations performed annually. Nationally, both vasectomy and vasectomy reversal are now substantially more common than fallopian tube occlusion for female sterilisation and microsurgical fallopian tube reanastomosis for sterilisation reversal.
Microsurgical methods
Microsurgical methods lead to higher patency rates by comparison to macro-surgical (ie without a microscope) techniques.
There is a correlation between the number of cases of microsurgical vasectomy reversal previously performed by the surgeon and patency rates. Dr Dezarnaulds has performed hunderds of vasectomy reversals. She has three vasectomy reversal operating lists per month.
Indications
By far the most common reason for vasectomy reversal is a desire to achieve pregnancy. Approximately 1% of men develop post-vasectomy pain of sufficient severity to interfere with quality of life. Although the cause of post-vasectomy pain syndrome is unknown vasectomy reversal provides effective relief in many. No change or an exacerbation of pain after vasectomy reversal is possible.
Surgical method
Placement of incision
Vasectomy reversal usually is performed through incisions on either side of the scrotum.
Mobilisation and reconnection (anastomosis) of vas deferens
The vasectomy sites are identified. The vas deferens is followed “up and down” to normal tissue (beyond any damage from the vasectomy) and mobilised to avoid tension on the site of the anastomosis (join). The healthy vas deferens (‘pipes’) are divided and the open ends are prepared and brought together. These ends are joined with tiny sutures placed under the vision of a microscope (microsurgery).
Assessment of presence of sperm
Some recommend assessment of the presence, concentration and motility of sperm at the testicular end of the vas deferens to assess whether vasoepididymostomy (‘big pipe, little pipe’) rather than vasovasostomy should be performed. Evidence against checking for sperm is that motile sperm are present on examination of the testicular end of the vas in only about 35% of men undergoing vasectomy reversal despite this postoperative patency rates are about 90%. Hence intraoperative assessment of sperm presence is likely to unnecessarily result in the more complicated, less successful vasoepididymostomy procedure and is not recommended by Dr Dezarnaulds.
Intraoperative sperm retrieval
Intraoperative sperm harvesting for the purpose of possible future attempts to conceive using IVF with intra cytoplasmic sperm injection (ICSI) is controversial.
The quality of sperm collected from the cut testicular end of the vas deferens is generally poor.
Numerous authors have concluded that sperm harvesting during vasectomy reversal is neither useful nor cost effective.
Dr Dezarnaulds does not recommend sperm retrieval at the time of surgery (if you wish for it please discuss with Dr Dezarnaulds preoperatively, sperm retrieval at the time of reversal is possible but not recommended).
Postoperative care
Postoperatively patients are advised to rest for one week and to avoid sexual intercourse and strenuous physical activity for 4 weeks after surgery. Postoperative pain relief tablets will be provided.
Postoperative monitoring
A semen analyses is advised 3 months post-operatively. Should the initial semen analysis show no sperm or the sperm count be very low repeat analysis should be undertaken 3 months later. Some men choose to croystore (freeze) sperm in case they develop a late obstruction with closing over or scaring at the reversal sites (uncommon but it can occur). If sperm do not return to the ejaculate by 6 months after vasovasostomy or by 18 months after vasoepididymostomy, the procedure should be considered to have failed. Most pregnancies that are achieved without further intervention occur within 24 months after surgery.
Management of operative failures
Risks and complications
Complications following microsurgical vasectomy reversal are uncommon. Haematoma (post operative bleed into the scrotum) is the most frequent complication. About 2% of men will develop a significant haematoma. Most of these are managed conservatively (wait until they reabsorb). Infection of the wound or underlying haematoma occurs in less than 1% of men. Less common complications include wound problems and long lasting post-operative pain.
Key Points
Vasectomy reversal is a way to restore fertility in men who have had a vasectomy. Experienced surgeons using microsurgical techniques achieve the highest success rates.
The nature of the surgical technique and in particular, the choice between vasovasostomy and vasoepididymostomy should be made at the time of surgery, after determining the extent and level of obstruction from the vasectomy.
Prior sperm extraction for IVF reduces the prospect of future successful vasectomy reversal.
For the average man undergoing vasectomy reversal patency rates (return of sperm) are about 90% and pregnancy rates range from 50% to 70%. Female partner age is the single most important predictor of pregnancy following vasectomy reversal.
