What is a vasectomy reversal?
The vasectomy reversal is a microsurgical procedure with the goal of restoring fertility after a vasectomy. In a vasectomy reversal, the surgeon reconstructs the two small tubes, called vas deferens, that deliver sperm fluid into the ejaculate. This generally takes two to three hours in the operating room and requires a special operative microscope to allow clear visualization while the tubes are carefully sewed back together. The inner lumen of the vas deferens is very small, only about 300 microns in diameter. The sutures required for vasectomy reversal are even smaller, and are actually finer than a human hair. It's a very delicate surgery, so we need to use the surgical microscope under high magnification to accurately see what we are doing.
Are there different variations of the surgery?
There are two main types of vasectomy reversal procedures, vasovasostomy and vasoepididymostomy. The challenge is that we don't know which of the two needs to be done until we start the procedure. The more common procedure is vasovasostomy, which is where essentially we realign the vas deferens and sew it back together. We know we can perform this procedure when I inspect the inside of the vas intraoperatively and see evidence of sperm.
However, other times, I inspect the vas and unfortunately see no evidence of sperm, and often the fluid is thick and cloudy. This tells us that a secondary obstruction has developed upstream. In these cases, we need to perform the more complicated vasoepididymostomy. The reason this one is more technically challenging is because we need to bypass part of the vas deferens and, instead, sew directly to the epididymis, which is the gland located behind the testicle. The issue is that the epididymal tubules are much, much smaller than the vas deferens. The size mismatch is what makes this procedure so technically demanding; it’s a little like sewing a garden hose to a coffee straw.
What factors should you consider when deciding on a vasectomy reversal?
The most important factor when meeting with a man to talk about vasectomy reversal is time from the prior vasectomy. Within 10 years of the prior vasectomy, success rates of a reversal will be higher. Vasovasostomy success rates, meaning return of sperm to the ejaculate, are well north of 90% in experienced hands. There are additional male factors to consider as well. For instance, during the physical exam, if I'm able to palpate a small amount of scar tissue at the prior vasectomy, that is called a granuloma. And in fact, the presence of a granuloma is actually a positive predictive factor that there will be better quality sperm fluid and that the man will have higher success rates.
When the goal is conceiving a natural pregnancy, it’s very important to look at the female factors as well, such as age and fertility status. For example, if the female partner is in her very late 30s or early 40s, then she likely has diminished ovarian reserve, or decreased chances of achieving a spontaneous pregnancy. In these cases, it’s important to acknowledge that while I could do a technically perfect vasectomy reversal with return of plenty of sperm to the ejaculate, the couple still may not be able to conceive naturally. This is why in some cases, it is critical that the female partner undergo evaluation by a reproductive endocrinologist to better understand her fertility potential and alternative options.
Can you expand upon those fertility options, like in vitro fertilization and sperm extraction?
The main other option for a biologic pregnancy would be a sperm retrieval procedure to obtain sperm that can be used for in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI). In cases of advanced maternal age or diminished ovarian reserve, IVF often has higher success rates as compared to vasectomy reversal. The sperm retrieval procedure can be performed via a variety of methods and involves procuring sperm directly from the testicle or epididymis. Examples of these procedures that I am also able to offer include: Testicular Sperm Extraction (TESE), Microsurgical Epididymal Sperm Aspiration (MESA), and Percutaneous Epididymal Sperm Aspiration (PESA).
A second important factor in deciding between vasectomy reversal vs. sperm retrieval and IVF is the timeline. With a vasectomy reversal, we usually have to wait a few months following the procedure for sperm to return to the ejaculate before the couple can try to conceive a child. If a couple is eager to achieve a pregnancy as fast as possible, it may make more sense to proceed with sperm retrieval and IVF.
Finally, it is worth noting that here at CU Urology, for couples that are interested, we are able to perform a sperm retrieval procedure at the same time as a vasectomy reversal, which gives the couple additional flexibility in achieving their reproductive goals.
What is the recovery period like for a vasectomy reversal?
This is an outpatient procedure, meaning you go home the same day. I recommend patients take it easy for two weeks while they recover. At four weeks out we start checking for return of sperm to the ejaculate, and they may start trying to conceive a child.
Is there anything else a patient should consider?
The wonder of vasectomy reversal is its ability to restore the potential for a natural, spontaneous pregnancy. However, it’s important to highlight this is a specialized, delicate procedure. For this reason, it’s critical to seek out an experienced male reproductive urologist not only to give yourself the best chances of success, but also to make sure you get a fair and balanced breakdown of the different options as they relate to your specific situation.
