A Vasovasostomy (VV) or Vasectomy Reversal Procedure is a surgical procedure that is designed to bypass obstruction in the male genital tract. Vasectomy is the leading cause of obstruction of the vas deferens, but men may be born with or acquire obstruction later in life from trauma or infection.
During a vasectomy, the vasa deferentia, that tubes which carry sperm from the testicles to the seminal vesicles, are cut, tied, cauterized (burned or seared), or otherwise interrupted. A vasovasostomy creates an opening between the separated ends of each vas deferens so that the sperm may enter the semen before ejaculation.
The purpose of a vv or vasectomy reversal procedure is to restore a man’s fertility and ultimate success is an unassisted pregnancy.
Factors that influence the success rate are:
- Age and fertility of the female partner
- Surgeon’s experience and the technique of vasectomy reversal
- Length of time since the vasectomy was performed the, so called obstructive interval.
In a large study of 1469 patients from multiple institutions, the success rate was inversely proportional to the obstructive interval. The shorter the interval, the higher the success rate. In men with obstructed intervals less than 3 years, the likelihood of sperm present in the semen after reversal (patency rate) was 96% and the pregnancy rate was 75%. On the other hand, when the obstructed interval was greater than 15 years, the patency rate was 70% with the pregnancy rate was 30%. Most men presenting to reversal have obstructed intervals between 3-14 years, the patency rate was 78%-87% and the pregnancy rate was 44-53%. In interpreting this data, one should keep in mind that the age of the female partner plays a very important role in the pregnancy and delivery rate.
It is important to point out with longer obstructed interval, the higher the likelihood that a more complex reconstruction may be required. The operation is called the epididymovasostomym(EV). At the time of the surgery, it will be determined whether EV will be necessary. The success for epididymovasostomy is lower than for the standard vasectomy reversal.
What is an epididymovasostomy (EV)?
Occlusion of the male reproductive duct is noted in 10-20% of all infertile men. It is very important for the diagnosis to be made since it is potentially correctable. The cause of ductal obstruction includes congenital absence or narrowing of the duct, scarring due to infection and vasectomy.
The epididymis is the structure behind the testicle, it is made of coils of tiny tubule through which sperm migrate and mature. The procedure to correct epididymal obstruction is epididymovasostomy during which the vas deferens is attached to an epididymal tubule in order to bypass the obstruction in between.
The patency rate for epididymovasostomy is about 50-60% with a pregnancy rate of 30-40%. Some men may not have sperm present for up to 12 months after surgery. Pregnancy may take one to two years to achieve. Up to 10% of initially successful EV may develop recurrent obstruction after sperm were initially present. I recommend sperm banking as a safeguard against this problem.
How are these procedures done?
Vasectomy reversal are done as outpatient procedures by specialty trained urologists at Georgia Urology. Anesthesia will be either general or spinal.
What can I expect after a vasectomy reversal procedure?
Oral pain medication for 24-48 hours. Tylenol or Motrin may also be used. No heavy lifting, sports, or sexual activity should be engaged for 4 to 6 weeks. You may return to work in 7 days unless your job is physically demanding, then a 10-14 day wait is recommended. Semen analysis will be obtained at 3 months post op. Sperm may not return for 6 months or more following VV and for up to 12 months following EV.
Bleeding and infection are uncommon. Scarring and persistent pain at the operative site occur rarely.
What is the average length of time to achieve pregnancy after a vasectomy reversal procedure?
The average length of time to achieve pregnancy is about one year. 3-5 % of initially successful VV may develop recurrent obstruction after sperm were initially present. It is recommended that you consider sperm banking once the sperm count has peaked to safeguard against this problem.
You may also consider the option of sperm harvest at the time of EV. In men whose procedures failed, the need for sperm remains. We can either collect sperm from the epididymal fluid or remove a small piece of the testis for sperm extraction. This sperm can then be used for IVF or be substituted later with ejaculated sperm. The advantage of ejaculated sperm is that the much cheaper insemination may be feasible if the ejaculates contain sperm of sufficient quantity and quality.
Frequently asked questions:
Q: Who are the candidates for vasectomy reversals?
A: With few exceptions, nearly all vasectomised men are candidates for microscopic reversal procedures, either a vas-vas (vasovasostomy, VV) or a vas-epididymis (epididymovasostomy, EV) connection may be performed. Couples with significant female fertility issues such as fallopian tube blockage or inadequate egg reserve should consider in vitro fertilization (IVF) since the restoration of normal sperm count may not overcome the co-existing female factor.
Q: What are the factors which determine pregnancy rate following vasectomy reversal?
A: Four major factors are considered in advising individuals regarding the pregnancy rate following vasectomy reversal:
- Obstructive interval or number of years since vasectomy: as reported by the most authoritative study based on the results of 1469 men (VasoVasostomy Study Group, 1991), the pregnancy rates are 76% for reversal performed within 3 years of vasectomy, 53% for 3 to 8 years, 44% for 9 to 14 years and 30% for 15 years or more.
- Age of the female partner: for those couple with the female partners 30 years or younger, this is not likely to be a issue. In a study of 115 couples (Fuch, 2001), the pregnancy rates were 49% with the female age at 31-35, 45% at age 36-40 and 20% at age 41-45. Delivery rates were proportionally lower in the older group as one would expect. Since the success rate is inverse proportional to the passage of time on both partners’ part, the consensus is to proceed with vasectomy reversal sooner rather than later if the decision has been made.
- The use of an operating microscope: the disuse of an operating microscope in the performance of vasectomy reversal simply cannot be supported by the literature. The magnification required to achieve precise suture placement and accurate alignment cannot be provided by visual aids other than an operating microscope with sufficient magnifying power.
- The surgeon: carefully choosing your urologist simply makes sense; whereas some physicians prefer to emphasize the volume of their practice, our recommendation is to consider fellowship trained male infertility specialists who are well versed in all aspects of micro-surgery and fertility related issues.
Q: How involved is the surgery and what’s the recovery like?
A: For routine reversal or VV, two one-inch incisions are made high in the scrotum. The amount of dissection is limited and you can almost equate the reversal to a “super-sized” vasectomy. The operative time is 2 to 3 hours. For more complicated reversal or EV, the incisions are longer in order to deliver the testes onto the operative field. A fair amount of tissue swelling is expected post-op. The operative time is 3 to 5 hours since epididymal exploration may be time consuming.
Recovery varies according to the procedure, routine VV is well tolerated with minimal narcotic requirement and one may return to a desk job in 3-5 days. EV is a bit more taxing, one should be prepared to rest for 7 days or more.
What is sperm aspiration?
A: Sperm aspiration in conjunction with in vitro fertilization and sperm injection, IVF/ICSI, is an invaluable tool in the management of the infertile couples. Sperm aspiration is done under local anesthesia with a butterfly needle to obtain viable sperm and is inexpensive; however, IVF/ICSI is not. Aspirated sperm are few in number and immature in function, fertilization requires these sperm be individually injected into each egg in the laboratory. Pregnancy is then established following successful fertilization and embryo transfer to the uterus. Direct insemination is not possible with these sperm and has no role in the management of the vasectomised men prior to reversal.
Q: What is sperm retrieval with reversal?
A: The rationale behind retrieving sperm at the time of reversal is to eliminate the need for future sperm aspiration for IVF if the reversal fails to produce sperm in the ejaculate. The sperm retrieved can only be used for IVF since only a small number of sperm are obtained.
Most men do not require sperm retrieval for the following reasons:
- Routine vaso-vasostomy has a very high patency rate, 80-90% or higher, especially with a short obstructive interval.
- Sperm aspiration is easy and inexpensive; even if the reversal fails, it is no more costly to aspirate sperm later than to retrieve sperm initially. Granted, one does obviate having yet another, albeit minor, procedure done.
On the other hand, the case for retrieval can be made for those undergoing epididymo-vasostomy following extended obstructive interval since the patency will be significantly lower at 50-60%. In these men, we ask them to consider retrieval as an option; some insist on retrieval to avoid any future procedure while others have no problem with a “wait and see” approach.
Sperm may be retrieved by collecting the sperm containing vasal or epididymal fluid or by removing a small piece of testis tissue. The amount of testis removed is about 250 mg, about the size of 2-3 rice grains. It adds very little time to the procedure. Recovery is not much different than reversal without.
Arrangement for sperm processing and storage must be made with the andrology lab prior to procedure.
Call Georgia Urology today to schedule an appointment with one of our highly trained urologists to learn more about vasectomy reversal procedures.