Microsurgical Vasectomy Reversal
Microsurgical vasectomy reversal using a state of the art, high-powered surgical microscope and the highest quality microsurgical instruments is proven through numerous studies to be superior than any other method. Microsurgical techniques enable optimal visualisation of the vas deferens allowing accurate and precise placement of each suture. Using a multi-layered technique of extremely fine sutures provides far better results than older less precise methods and also allows an uneventful recovery.
Results of vasectomy reversal
Technical success for the average man undergoing microsurgical vasovasostomy is high with patency rates (return of sperm) of 90-95%. Sperm usually returns gradually and in a progressive manner such that for the average man undergoing vasectomy reversal by 6 weeks after surgery approximately 50% of men will have sperm present; by 10 weeks this rises to 80%; by 12 weeks to 90% and by 6 months to 95%.
The outcome is better for those with a shorter time from vasectomy to reversal with declining patency rates with an increasing duration of interval from vasectomy to reversal: at less than 10 years patency rates of 95% are achieved; at 15 years they are approximately 90%; at 20 years about 80% and 25 years 70%. The decline in patency rates with time is less likely to be directly related to anastomotic patency than to either vasal or epididymal obstruction by thickened cellular debris accumulating one the testicular side of the vasectomy site which ultimately may form concretions with in vas or epididymis thus leading to additional sites of occlusion. Early publications that hypothesize epididymal blowout as a primary mechanism of surgical failure remain controversial and await validation.
Vasectomy reversal pregnancy rates
For the average man undergoing microsurgical vasectomy reversal the postoperative pregnancy rate is between 50% to 80% and following microsurgical vasoepididymostomy 30% to 50%. By comparison following macro-surgical vasovasostomy 20% to 40% of partners conceive. The key influence on pregnancy rate is the age of your female partner. The older the female partner the lower the chance of achieving a successful pregnancy.
Impact of prior IVF
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.
Specifically, where prior epididymal sperm aspiration (PESA) and testicular needle aspiration (TESE) have been performed to obtain sperm for IVF prior to vasectomy reversal, patency rates are significantly reduced. When bilateral PESA has previously been attempted patency rates are less than 30% and when unilateral are approximately 70-80%. This is because is a highly convoluted tubular structure which is a continuation of the luminal epithelium of the vas deferens (minus the latter’s muscular coat). As epididymal tubule’s diameter is considerably less than that of a 25-27 gauge needle used for PESA, damage to and subsequent obstruction of the epididymis is a near obligatory consequence. For TESE the negative effect is somewhat less with patency rates between 80% and 90%. The mechanism is outflow obstruction as consequence of inadvertent collateral damage to the intra-testicular collecting system (rete testis), post procedure fibrosis consequent upon both multiple passes of the aspirating need through the testis or resolution of intra-testicular haematoma. A small incisional biopsy of the testis is unlikely to have a similar effect.
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 non-microsurgical 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.
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.
The vas is mobilized 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; specialized clamp designed to facilitate approximation and anastomosis are extremely useful. The entire scarred portions of the vas above and below the vasectomy site is excluded to ensure anastomosis of healthy tissue. In most instances the vasectomy does not require excision site and it may be left in situ. Care is taken to ensure the completed anastomosis does not come in contact with an area that has been subject to diathermy used to eliminate bleeding in the process of excision. To prevent damage to the vas deferens only precise microscopically directed diathermy is used to cauterize vessels located in the surrounding tissue.
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.
The actual anastomosis is generally performed with a multi-layered anastomosis placing interrupted 8-0 or 9-0 fine mono-filament 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 surrounding layers but there are no high quality comparative studies to suggest that either method is better than the other.
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 tissue immediately surrounding the testis and epididymis). 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. Numerous authors have concluded that sperm harvesting during vasectomy reversal is neither useful nor cost effective. 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.
Preparing for surgery
As someone considering vasectomy reversal, the most important thing is to be well informed. You should make sure that you are well aware of the nature of what you are doing - the nature of the surgery, its success rate, the risks and complications, considerations prior to surgery, recovery and post-operative care and cost.
Vasectomy reversal is a day surgery procedure. You will be admitted to hospital an hour or two prior to operation to enable the nursing and administrative staff to ensure all details are correct and that it is safe to proceed. The procedure is carried out under a light general anaesthesia which takes about one to one and a half hours. From your persepctive this will seem like an instant (as is the case with all anaesthetics). You will be discharged from hosital 3 to 4 hours after your operation is completed and are able to walk immediately. The next day it is wise to lie down and rest as much as possible. Common sense is crucial when recovering, as your surgery is performed with very delicate stitches that are less than the diameter of a human hair. Wound care is straight forward. You may shower the day after surgery but you should otherwise keep the operation area clean and dry. If you have any significant discomfort the very best thing to do is to rest. Most men recover quickly and can resume non-strenuous activity within a week however if you take longer than average then you should live within the limits of what your body is telling you.
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.
When the duration of time between vasectomy and reversal is less than 10 years 95% microsurgical vasectomy reversal is successful in restoring fertility.
EXPERIENCE AND EXPERTISE MATTER