Microscopic Vasovasostomy and Epidiymovasostomy
What is a vasectomy reversal?
A vasectomy reversal is an operation that reestablishes a connection between the two ends of vas deferens that were separated at the time of a prior vasectomy. Discussed below are the success rates based on whether sperm and fluid are still presents in the vas deferens at the time of surgery. Sometimes the vas deferens is reconnected to the epididymis (epididymovasostomy) because of a secondary obstruction in the epididymis. We perform the entire procedure under the microscope.
Sperm production takes place in the testis (See Fig. 1). After passage through the efferent ducts, sperm are stored and undergo maturation within the epididymis. Those sperm that have not passed through the epididymis are generally not able to fertilize eggs under normal conditions. The epididymis is a continuous, tightly coiled tube approximately 15-18 feet in length, which leads into the vas deferens. The vas deferens is responsible for directing and propelling the sperm into the urethra.
Increasing numbers of men are coming to the urologist for vasectomy reversals, most commonly because of remarriage and the desire to initiate a pregnancy. Vasectomy reversals are also requested by couples who have merely “changed their minds,” as well as by couples who have lost a child and are attempting to initiate another pregnancy. Fortunately, microsurgical advances are now resulting in significant pregnancy rates (see Table 1).
TABLE 1. Success Rates
|Sperm Present||Fluid Quality||Procedure||Patency Rate||Pregnancy Rate|
The success of a vasectomy reversal depends on:
- The skill of the surgeon
- The findings at the time of surgery
The surgeon should be skillful with microsurgical technique, as precise suture placement is critical to the success of the procedure. The surgeon must also have the ability to perform the more difficult epididymovasostomy procedure.
As mentioned previously, other important factors in determining a successful outcome are the surgical findings. When the vas is opened, fluid will flow from the testicular side of the vasectomy site. If sperm are present, then we expect 90% or more of patients to demonstrate a return of sperm with an associated 60 – 70% pregnancy rate. In no sperm are present, yet the vasectomy fluid looks abundant and appropriate for ultimate sperm production (e.g., clear, watery), then a direct vasovasostomy is performed with a successful outcome of approximately 50%. If poor-quality fluid is present (connection of the vas to the epididymis) is performed with a successful outcome of approximately 40% – 50%.
We use a two-layer anastomosis utilizing microscopic sutures and the latest microsurgical equipment. The procedure is performed at Christian Hospital on an outpatient basis.
Operating time for a vasovasostomy or epididymovasostomy is approximately 3 hours. A general anesthetic usually is used. Postoperative follow-up includes an evaluation of wound healing at 10-14 days and semen analysis at 6-8 weeks. Monthly semen analysis are then obtained for approximately 4-6 months, or until the semen analysis stabilizes. If semen quality is less than expected, anti-inflammatory medications are often introduced to decrease scarring.
Cryopreservation of sperm (sperm baking) is routinely performed at the time of vasectomy reversal if whole, motile sperm are seen. Cryopreservation is performed as a safety “backup” in case inadequate sperm counts are present after surgery. Because vasectomy reversals may infrequently scar, despite good initial results, cryopreservation may also be performed on ejaculated specimens early in the course of recovery when semen quality is exceptionally good. Sperm are stored at the Reproductive Associates of Delaware Sperm Bank.
If any questions remain, please feel free to contact either my nurse or my secretary at (302) 652-8990.
David J. Cozzolino, M.D.