Vas Reversal
Vasectomy Reversal Patient Information
Vasectomies are a safe and very effective form of contraception, but they don’t have to be permanent. Changes in life happen, men can change their mind and conceive after a vasectomy. With advanced microsurgical techniques, vasectomy reversals are increasingly successful. The first step is meeting with a fellowship-trained microsurgeon.
Dr. Brugh has been performing microsurgical vasectomy reversals for over 25 years, making him one of the most experienced fellowship trained microsurgeons in the mid Atlantic. After finishing his urologic surgery residency at University of Virginia, Dr Brugh completed the prestigious Male Reproductive Medicine and Microsurgery fellowship-training program of Dr. Larry Lipshultz at Baylor College of Medicine in Houston, Texas.
One of the most important aspects of Dr Brugh’s practice is your experience. He wants you to be comfortable with your choice to have a vasectomy reversal. He does that by teaching you about the procedure, how the surgery is done and what to expect after the surgery. Vasectomy reversal consists of two different procedures, microscopic vasovasostomy and microscopic epididymostomy. Keys to a successful reversal are intraoperative decision making of which procedure will lead to the best chances of success and microsurgical skills to perform that procedure.
How does a reversal work?
Sperm production takes place in the testis. Sperm then pass into the epididymis, a long (15-18 foot), thin walled and tightly coiled tube where sperm are stored and mature. Sperm then leave the epididymis and travel through the vas deferens. They are held within the vas deferens until the ejaculation when they are expelled through the urethra. During a typical vasectomy a small segment of the vas deferens is removed and the open ends are sealed closed. The closed ends of the vas deferens prevent sperm to be present in semen after a vasectomy. Even with this obstruction to the sperm transport, sperm continue to be produced in the testis as they were prior to the vasectomy. Due to this continued production of sperm, vasectomy reversal is possible to re-establish transport of sperm from the testis to the urethra. There are two operations (vasovasostomy and epididymovasostomy) that are used to reverse a vasectomy, and which of the two is performed is dependent on the presence of sperm in the vasal fluid at the time of the procedure. Both of these surgeries are performed using an operating microscope.
Increasing numbers of men are coming to the urologist for vasectomy reversals, most commonly because of remarriage and the desire to initiate pregnancy. Vasectomy reversals are also requested by couples who have “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.The surgeon should be skillful with microsurgical technique, as precise suture placement is critical to the success of the procedure.
Information about Vasectomy Reversal Success Rates
There are two key components to success during vasectomy reversal:
- The skill of the surgeon
- The findings at the time of surgery
The surgeon must also have the ability to perform the more difficult epididymovasostomy procedure as the decision to perform this procedure must be made during the reversal. The second point, findings at the time of surgery, will dictate which of the two types of vasectomy reversal performed. During the procedure, the testicular end of the vas deferens is opened and fluid will flow out. This fluid is collected and examined under a microscope to determine if sperm are present in this fluid. If sperm are present, then the two ends of the vas deferens can be reconnected, a vasovasostomy. If no sperm are present, yet the vasal fluid looks abundant and appropriate for ultimate sperm production, then a vasovasostomy can be performed.
Years between Vasectomy and Vasectomy Reversal
Return of Sperm to the Ejaculate
Pregnancy Rate
If sperm are not present and the fluid is thick and pasty, or no fluid at all is found, then the sperm are not successfully being transported into the vas deferens. This is due to a rupture in the epididymis causing obstruction in the epididymis. In this case an epididymovasostomy is performed to “bypass” this obstruction. Success rates for epididymovasostomies vary; 50%-60% of men will have sperm in their ejaculate and 30%-40% of their wives will attain a pregnancy.
We use a two-layer anastomosis utilizing microscopic sutures.
Vasectomy reversals are performed on an outpatient basis. This allows you to return home or to a nearby hotel without actually being admitted directly to the hospital, thus saving considerable expense and making the overall experience much more pleasant.
Operating time for a vasovasostomy or epididymovasostomy is approximately 3-4 hours. A general anesthetic is usually used. Postoperative follow-up includes an evaluation of wound healing at 10 days to 2 weeks and a semen analysis at 6-8 weeks. If semen quality is less than expected, anti-inflammatory medications are often introduced to decrease scarring.
Cryopreservation of sperm (sperm banking) can be performed at the time of vasectomy reversal if whole, motile sperm are present. Cryopreservation of sperm 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.
Vasovasostomy
While there are many methods for performing a vasovasostomy, we prefer a strict, two-layer, watertight procedure (Figure 1). Magnification with an operating microscope allows for more precise re-anastomosis. Selection of a single-layer, full-thickness closure versus a strict two-layer (mucosal and seromuscular) closure is best dictated by the experience of the surgeon, which indeed, is the most important factor in achieving the desired outcome.
Epididymovasostomy
When thick, pasty vasal fluid with no sperm is found during a vasectomy reversal, an epididymovasostomy is performed. During an epididymovasostomy a single epididymal tubule is incised just before the epididymal blockage. Fluid is sampled from the epididymis and examined microscopically for the presence of sperm. If no sperm are found, an incision is made closer to the testis (further from the blockage) to identify sperm. Once sperm are found the anastomosis is then performed with two layers of extremely fine suture (Figure 2).