Microsurgical Vasectomy Reversal
For men with vasectomy who seek to restore their fertility the two rational treatment options are either IVF with sperm extraction or vasectomy reversal. For most couples vasectomy reversal has advantages over IVF as it provides the widest range of future therapeutic options a higher cumulative chance of pregnancy. Significantly, IVF reduces 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). Vasectomy reversal on the other hand, simplifies and optimizes the prospect of future IVF as most patients undergoing the procedure have sperm restored their semen and so have ready supply if required for later IVF if pregnancy is not achieved.
Between 4% and 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.
Provided here is an extract of an article on vasectomy reversal that I wrote for the 'Australian Doctor' which is supplied to general practitioners in Australia. As it was originally written for doctors it contains very detailed descriptions to enable you to thoroughly research vasectomy reversal and to have access to exactly the same information that I provide to doctors who refer their patients to me for the procedure.
Microsurgical methods and surgical expertise
Microsurgical methods lead to higher patency rates by comparison to macro-surgical techniques. Although the subject of considerable debate, several large studies have found that a modified microsurgical one-layer anastomosis and the classical multi-layer microsurgical technique yield comparable results when performed by experienced microsurgeons. Technically patent anastomoses are achieved in approximately 95% of procedures performed by experienced reproductive microsurgeons. Patency rates following macro-surgical vasovasostomy are significantly lower at approximately 70%. For microsurgical vasoepididymostomy performed by experienced microsurgeons patency rates of approximately 65% are achieved. It should be noted however that vasoepididymostomy is usually only carried out in the most surgically challenging of cases.
There is a direct correlation between the number of cases of microsurgical vasectomy reversal previously performed by the surgeon and patency rates. Thus in order to provide optimal patency and pregnancy rates surgeons performing vasectomy reversal should undertake formal microsurgical training.
By far the most common indication is a desire to achieve pregnancy with a new partner due to change of relationship; less than 1 in 30 men who undergo vasectomy reversal are in the same relationship that produced their children. Approximately 1% of men develop post-vasectomy pain of sufficient severity to interfere with quality of life. Although the pathogenesis of post-vasectomy pain syndrome is unknown, vasectomy reversal provides effective relief in up to two-thirds of cases with some benefit in about half of the remaining men. Rarely a man may seek reversal for psychological, psycho-sexual or religious reasons.
Patient history should inquire of the patient’s age, prior pregnancies and children in the same and different relationships. The duration of time since the vasectomy and whether there were any post-operative complications from the vasectomy should be ascertained. A general medical history should be taken with specific questioning about hereditary or acquired bleeding diathesis or anticoagulant therapy is wise (as each may increase the risk of post-operative haematoma).
Female age is the single most important factor influencing the prospect of pregnancy after vasectomy reversal. Before vasectomy reversal is performed for restoration of fertility, evaluation of the female partner’s reproductive potential is prudent and should be considered as being no less important than evaluating the male partner of a woman seeking elective sterilisation reversal. A reproductive history and where indicated assessment of ovarian function and pelvic anatomy may be necessary.
Physical examination is generally uninformative and not usually predictive of outcome. It may reveal that large segments of the vas deferens were removed and help to identify those in whom the standard incision may need to be modified. Examination also may reveal testicular abnormalities or epididymal induration. Epididymal fullness suggests obstruction at that level but does not predict accurately which patients will require vasoepididymostomy. Obesity may increase technical difficulty and increase the risk of haematoma.
Preoperative testing of men contemplating vasectomy reversal is unnecessary except for routine preoperative tests that may be required or preferred due the patient’s general medical state.
Between 50% and 70% of men develop circulating anti-sperm antibodies following vasectomy. The precise cause of the development of sperm antibodies is uncertain. The so-called ‘testis-blood barrier’ usually minimizes exposure of sperm. Leakage of sperm at the time of vasectomy is likely to contribute to the development of sperm antibodies. Some investigators have suggested that such antibodies may decrease the chance for successful pregnancy after vasectomy reversal. Studies into pregnancy rates following vasectomy reversal demonstrate mean postoperative conception rate of between 60% and 85% for patients of less than 15 years from their vasectomy undergoing microsurgical vasovasostomy. The presence of circulating anti-sperm antibodies correlates poorly with postoperative fertility and the results of testing are not sufficiently sensitive or specific to predict the outcome of vasectomy reversal. As a result sperm antibody testing has largely been abandoned by reproductive microsurgeons as a preoperative test.
Testicular changes after vasectomy
Pathologic changes in testicular histology commonly occur following vasectomy. Electron microscopy revealed that interstitial fibrosis was present in the testis of 23% of men following vasectomy and that some evidence of adverse impact on spermatogenic cells within the seminiferous tubules is almost universal. These testicular changes are not associated with antisperm antibody status. The fertility in men who undergo successful vasectomy reversal (as defined by both sperm in the ejaculate and conception) is strongly inversely correlated with pathological changes in the testes post-vasectomy. With this said, intention to undertake vasectomy reversal is not an indication for investigative testicular biopsy as the results of doing so is very unlikely to influence the rationale of proceeding to microsurgical reversal.
Placement of incision
Vasectomy reversal usually is performed through oblique incisions on either side of the anterior aspect of the scrotum. When the vasectomy was performed high in the scrotum or removed a large segment of the vas deferens, it may be necessary to extend the scrotal incisions upward into the lower inguinal region to provide ready access to the vasectomy site.
Mobilisation of vas deferens
The vas should be mobilised sufficiently to avoid any tension on the site of the anastomosis. After division of the vas deferens on either side of the vasectomy site the prepared ends are approximated; specialised clamp designed to facilitate approximation and anastomosis are extremely useful. The entire scarred portions of the vas above and below the vasectomy site should be excluded to ensure anastomosis of healthy tissue. In most instances the vasectomy does not require excision site and may be left in situ. If it is removed then care must be taken to ensure the completed anastomosis does not come in contact to an area that has been subject to diathermy used to eliminate bleeding in the process of excision. Diathermy should not be used on the opposing transected ends of the vas. To prevent damage to the vas and only precise microscopically directed diathermy is used to cauterize vessels located in the surrounding adventitia.
Assessment of presence of sperm
Some authors recommend assessment of the presence, concentration and motility of sperm at the testicular end of the vas deferens to assess whether vasoepididymostomy rather than vasovasostomy should be performed. Current evidence however indicates that motile sperm are present in only 35% of men undergoing vasovasostomy despite this postoperative patency rates in such men generally exceed 90% hence it is now uncommonly necessary.
Most surgeons perform anastomoses using fine mono-filament nylon sutures. The actual anastomosis is generally performed with a multi-layered anastomosis placing five to seven interrupted 8-0 or 9-0 nylon sutures through the full-thickness of each end of the vas, with additional interrupted sutures in the outer muscular and adventitial layers, placed between the full-thickness sutures. Some surgeons prefer to perform vasovasostomy using a two or three-layered microsurgical anastomosis by first placing five to eight interrupted 10-0 nylon sutures in the inner mucosal edges of the ends of the vas, incorporating a small portion of the inner muscular layer, and then 7 to 10 additional interrupted 9-0 nylon sutures in the outer muscular and adventitial layers.
The decision to undertake microsurgical vasoepididymostomy or not is based on the surgical anatomy, the extent of collateral damage from the prior vasectomy and positioning of the vasectomy site. Vasography is not required. Some authors have recommended that the presence, motility and morphology absence of sperm at the testicular end of the transected vas should be used to decide intra-operatively to proceed to vasoepididymostomy. Patency rates from microsurgical vasovasostomy in the absence of any visible sperm are higher than those for vasoepididymostomy and so the latter is most commonly performed for re-do vasectomy reversal after an initial failed procedure.
When vasoepididymostomy is required, the scrotal contents must be extruded to incise the tunica vaginalis. The procedure is performed using an end-to-side anastomosis with a single epididymal tubule pulled up into the lumen of the vas deferens. Four to six interrupted 10-0 nylon sutures are used to oppose the mucosa of each and the outer muscular layer of the vas is approximated to the incised edges of the epididymis tunic a series of interrupted 9-0 nylon sutures.
Intraoperative sperm retrieval
Intraoperative sperm harvesting for the intended purpose of possible future attempts to conceive using of IVF with intra cytoplasmic sperm injection (ICSI) is both controversial and problematic. Any sperm so obtained requires the local laboratory capacity for cryopreservation in a manner suitable for use in ICSI. Prior to the introduction of ICSI sperm obtained during the operation could not be used for either intrauterine insemination or conventional IVF because their numbers and motility were too low to be useful.
The nature and quality of sperm collected from the cut testicular end of the vas deferens is universally sub-optimal; being both cytoplasmically degraded and has high levels of DNA fragmentation. This due to a combination of obstruction of flow along the epididymis and vas deferens due to vasectomy, the physical distance from testis to vasectomy site, the release of autosomal enzymes upon lysis of sperm in situ and the prolonged time from production of sperm in the testis to availability for retrieval. Sperm obtained from the epididymis is of higher functional capacity. In all cases, the technical aspects of vasovasostomy or vasoepididymostomy should have priority over attempts to harvest sperm for cryopreservation.
Numerous authors have concluded that sperm harvesting during vasectomy reversal is neither useful nor cost effective. Where it is considered both the patient and his partner should be provided detailed information on the nature, practicality risks and cost of both of IVF and long term sperm storage.
Postoperatively, the use of scrotal drains and peri-operative antibiotics is the option of each surgeon. Short-term (4 hours) use of scrotal drains does decrease both haematoma and post-operative infection rates, so there should be a low threshold for their use. Patients should be advised to use a scrotal supporter and to avoid sexual intercourse and strenuous physical activity for 4 weeks after surgery. Postoperative pain generally can be controlled adequately with oral analgesics.
A semen analyses should be obtained approximately 3 months post-operatively. Should the initial semen analysis not reveal sperm or the have virtual azoospermia (sperm only visible following centrifugation of the sample) then repeat analysis should be undertaken 3 months later. In men who do not achieve a pregnancy further monitoring of semen quality may identify the small number that develop late obstruction due to scar formation at the anastomotic site. The incidence of postoperative re-obstruction ranges between 1% to 3% after microsurgical vasovasostomy and as high as 35% following vasoepididymostomy. If sperm do not return to the semen 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
Repeat operation may be offered to men should their primary vasectomy reversal fail. While many men consider the prospect of successful repeat operation to be sufficient to contemplate most decline to undergo further surgery. Repeat procedures may be more difficult technically because the remaining viable segments of the vas will be shorter. In the largest published study sperm returned to the semen after surgery in 75% of men, and 43% of their partners subsequently conceived. Repeat attempt at vasectomy reversal should be considered particularly where the prior operation had been performed macro-surgically or by a surgeon performing small numbers of microsurgical procedures. After a failed vasoepididymostomy, a repeat procedure may or may not be possible, depending on the amount of scar that forms around the epididymis after the first operation.
Risks and complications
Complications following microsurgical vasectomy reversal are uncommon. Haematoma is by far the most frequent varying between 0.5% and 3% with drainage of the operation site markedly reducing the risk. Infection either of the wound or underlying haematoma occurs in less than 1% of operations. Rarer still are wound problems and long lasting post-operative pain. Occasional patients may develop short-term urinary retention following surgery. Fournier’s gangrene has not been reported following vasectomy reversal. Provided that patients are well informed about the nature of the procedure, the potential post operative complications along with its success and failure rate, medico-legal action is rare.
Vasectomy reversal is a technically feasible and safe means to restore fertility in men who previously have had a vasectomy. Experienced surgeons using microsurgical techniques achieve the highest technical 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.
Prior sperm extraction for IVF reduces the prospect of future successful vasectomy reversal, where are vasectomy reversal increases the chance of future successful IVF. Although harvesting sperm for cryopreservation at the time of vasectomy reversal is possible, it also may not be useful or cost effective.
For the average man undergoing vasectomy reversal patency rates exceed 90% and pregnancy rates range between 50% and 70%. While both rates decrease as the interval between vasectomy and its reversal increases, female age is the single most important predictor of pregnancy following vasectomy reversal.