Microsurgical Vasectomy Reversal
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 provides the widest range of future therapeutic options 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). Vasectomy reversal on the other hand, simplifies and optimises 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.
Microsurgical methods lead to higher patency rates by comparison to macro-surgical (ie without a microscope) 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.
There is a 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. 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. An exacerbation of pain after vasectomy reversal is possible.
Placement of incision
Vasectomy reversal usually is performed through incisions on either side of the scrotum.
Mobilisation of vas deferens
The vas is then 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 using specialised clamps. 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 site need not be excised but may be left in situ.
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.
I reanastomose (rejoin) the Vas Deferens using fine mono-filament nylon sutures placed under microscope guidance.
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.
The nature and quality of sperm collected from the cut testicular end of the vas deferens is generally sub-optimal having high levels of DNA damage.
Numerous authors have concluded that sperm harvesting during vasectomy reversal is neither useful nor cost effective.
Postoperatively 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.
Risks and complications
Complications following microsurgical vasectomy reversal are uncommon. Haematoma is by far the most frequent varying between 0.5% and 3%. 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.
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 as vasectomy reversal increases the chance of future successful IVF.
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.