VASECTOMY REVERSAL
Most surgeons prefer to have the patient given either a continuous anesthetic block or general anesthesia because of the length of time required for the operation. A vasovasostomy generally takes two to three hours to perform, depending on the complexity of the surgery and the experience of the operating physician. More complex surgeries may take as long as five hours. The advantage of general anesthesia is that the patient remains unconscious for the duration of the surgery, which ensures that he remains comfortable. Regional anesthesia, such as a spinal block, allows the patient to remain awake during the procedure while blocking pain in the area of the surgery.
After an adequate level of anesthesia has been reached, the surgeon will make an incision from the top of one side of the scrotum, sometimes moving upward as far as several inches (centimeters) into the abdominal area. A similar incision will then be made on the other side of the scrotum. The vasa deferentia will be identified and isolated from surrounding tissue. Fluid will be removed from the testicular end of each vas deferens and analyzed for presence of sperm. If sperm are found, then a simpler procedure to connect the cut ends of the vasa deferentia will be performed. If no sperm are found, a more complex procedure called a vasoepididymostomy or epididymovasostomy (in which the vas deferens is attached to the epididymis, a structure in which the sperm mature and are stored) may be more successful in restoring sperm flow.
There are two techniques that may be used to reconnect the cut ends of the vasa deferentia. A single-layer closure involves stitching the outer layer of each cut end of the tube together with a very fine suture thread. This procedure takes less time but is often less successful in restoring sperm flow. A double-layer closure, however, involves stitching the inner layer of each cut end of the tube first, and then stitching the outer layer. After reconnection is established, the vasa deferentia are returned to their anatomical place and the scrotal incisions are closed. Without using a surgical microscope, this operation would be very difficult if not impossible to perform well or with close to the same precision.
Diagnosis/Preparation
Before a vasovasostomy is performed, the patient will undergo a preoperative assessment, including a physical examination of the scrotum. This evaluation will allow the surgeon to determine what sort of vasectomy reversal should be performed and how extensive the surgery might be. A medical history will be taken. The physician will review the patient’s medical records in order to determine how the patient’s vasectomy was performed; if large portions of the vasa deferentia were removed during surgery, the vasectomy reversal will be more complicated and may have a lower chance of success. The patient’s partner should also undergo a fertility assessment, including a gynecologic exam, to assess her reproductive health. Some surgeons prefer to give the patient a broad-spectrum antibiotic about half an hour before surgery as well as a mild sedative.
Demographics
An estimated 5% of men who have had a vasectomy later decide that they would like to have children. Some reasons for wanting a vasectomy reversal include death of a child, death of a spouse, divorce, or experiencing a change in circumstances so that having more children is possible. One study found that divorce was the most commonly reported reason for a vasovasostomy and that the average age of men requesting a vasovasostomy is approximately 40 years.
About 7.4% of infertile men have primary genital tract obstructions caused by trauma, gonorrhea or other venereal infections, or congenital malformations of the vasa deferentia. Many of these men are good candidates for surgical treatment of their infertility.
Normal results
If a successful vasectomy reversal has been performed, the average time to achieving pregnancy after the procedure is one year, with most pregnancies occurring within the first two years. A good sperm count usually returns within three to six months.
FREQUENTLY ASKED QUESTIONS
Success can be measured in two different ways:
- The presence of sperm in the ejaculate
- A successful pregnancy
Some of the best success rates reported in the literature for vasovasotomy are a patency rate of 99% with a pregnancy rate of 64%, not including couples where the woman was infertile. This means that in the hands of the surgeon who quoted these rates, he was able to restore sperm flow in the vas tube 99% of the time, and this allowed a pregnancy rate of 64%.
Not every time that sperm flow returns to the vas is pregnancy guaranteed. The expected results for vasoepididymostomyin the hands of the same surgeon are lower, reportedly at 65% patency rate and a 41% pregnancy rate.
Success rates vary and decrease from the time of original vasectomy:
- Under 3 years 97% 76%
- 3-8 years 88% 53%
- 9-14 years 79% 44%
- Greater than 15 years 71% 30%
There is some bruising and swelling, but usually oral pain medications and scrotal support are more than enough to keep the patient comfortable.
Usually the patient will be restricted to very light activity the first two days after surgery… sitting on the couch and walking from room to room, stair walking is ok. From that point on, no heavy lifting greater than 20 lbs over the next 4 weeks.
4 weeks after the procedure the patient may resume sexual intercourse.
