Minimally Invasive Procedures for Kidney Cancer & Prostate Cancer

Vasectomy Reversal
Vasectomy Reversals
Vasectomy Reversals

Vasectomy Reversals

If you’ve had your vasectomy operation within the past 10 years, it is likely that your reversal can be performed as an in-office procedure and costs can be reduced significantly. If your vasectomy operation was performed more than 10 years ago, it is more likely that an outpatient surgery will be required and day surgery will have to be scheduled.

How much pain can I expect after surgery?

Discomfort after vasectomy reversal varies from patient to patient. In general, pain may be similar or somewhat more severe than the pain felt after the original vasectomy. Pain medication such as codeine is prescribed and is usually only needed for one to two days after the surgery, after which acetominephin (such as Tylenol ®) or ibuprofen (such as Motrin ® or Advil ®) is all that is needed. To decrease the pain and swelling after surgery, ice packs are recommended, which are placed on the scrotum for about ten minutes every half hour for the first post-operative day. A scrotal support is worn for four weeks after the surgery to decrease discomfort and lessen swelling. Normal strenuous activity can be resumed four weeks after the surgery with you physician’s permission.

How soon can I have sex after surgery?

It is generally best to wait three weeks after surgery before resuming any type of sexual activity.

How long after the surgery will it take for sperm to re-appear?

The first semen analysis is done one or two months after the surgery and again at two to three month intervals, either until sperm counts and mobility are normal, or pregnancy occurs.Three months after a vasovasostomy, the semen analysis often reveals a good sperm count with poor mobility. After 6 months the count is usually stable or slightly improved and the mobility is significantly improved. After a vasoepididymostomy, sperm usually takes longer to appear in the ejaculate and in most cases takes at least 4 to 6 months to appear.

Is there any chance that my sperm count will decline after an initially successful vasectomy reversal?

Studies have shown that after initially successful reversal surgery, resulting in good sperm counts and mobility, a significant number of men later experience significant deterioration in sperm counts. About 10% of men after successful vasovasostomy and about 20% of men after successful vasoepididymostomy will experience deterioration in sperm counts when followed for at least two years after surgery. Lower sperm counts following successful surgery can be caused by the formation of scar tissue, which can occur from sperm leakage at the reversal site or from a disruption of the blood supply at the site of the surgery. Considering that 10 to 20% of patients deteriorate after successful surgery, patients may want to try sperm banking especially after a vasoepididymostomy.

How soon can I expect a pregnancy to occur after my vasectomy reversal?

The average time from reversal surgery to conception is 12 months. Studies indicate that pregnancies after reversal surgery can occur from one month to 82 months after reversal surgery. Most pregnancies occur within 24 months of reversal surgery.

What options do I have if the surgery is unsuccessful?

About 14% of men with vasovasostomies and 40% with vasoepididymostomies have no sperm in their semen after surgery. After vasovasostomy, sperm is usually present in the semen after two months and should definitely show up within six months. After vasoepididymostomy, sperm usually appear in the semen during the first six months, but they may not appear for as long as 12 to 15 months. If sperm are not present in the semen by six months after vasovasostomy or by 12 to 18 months after vasoepididymostomy, then the reversal surgery is considered unsuccessful. If surgery is unsuccessful, you can consider repeat reversal surgery (see question #14) or assisted reproductive techniques such as in-vitro fertilization (IVF) with Intracytoplasmic sperm injection (ICSI) (see question #15). For a man who has no sperm in the ejaculate after reversal surgery, sperm for IVF/ICSI can be obtained through a minor surgical procedure which takes sperm directly from the testicles and/or epididymis. Microsurgical epididymal sperm aspiration (MESA) takes sperm directly from the epididymis to use in ICSI.

How long will the surgery take?

Microsurgical vasovasostomy usually takes about 2 to 3 hours while vasoepididymostomy may take as long as 5 hours. The patient is then observed in the recovery room for an additional 1 to 3 hours. The length of surgery depends on the type of procedure, the amount of scarring present from prior surgery, the presence of and degree of inflammation, and the ease with which sperm can be examined in the vas deferens or epididymal tubule.

What type of anesthesia is used?

Vasectomy reversal may be performed with local, regional, or general anesthesia, depending on what the surgeon and patient want. General anesthesia is commonly used because it provides maximum patient comfort considering the length and nature of the surgery.

Where are the incisions made?

A vasectomy reversal is usually performed through incisions in the front of each side of the scrotum. The incision is vertical (up and down) so that it can be lengthened if needed. If there is difficulty in finding the site of the vasectomy, if the vasectomy was performed high in the scrotum, or if a long segment of the vas deferens was removed, it may be necessary to extend the scrotal incisions up to the lower inguinal (abdominal) region.

If a prior hernia procedure was performed, blockage of the vas deferens may have occurred. If this is the case, an incision into the site of the previous hernia repair may be necessary.

What are the complications that can occur?

Normal signs and symptoms after surgery include slight swelling, bruising, or discoloration of the scrotal area. These usually do not require a doctor’s attention. A sore throat, headache, nausea, constipation, and body ache due to the anesthesia and surgery may also occur. These symptoms usually go away within a few days. Severe complications that require additional surgery are rare. Postoperative complications that require prompt attention include, but are not limited to, wound infections and severe scrotal hematoma (black and blue bruised scrotum). A wound infection is present if you develop a fever or if your incision becomes warm, swollen, red, or painful. A hematoma is present if excessive bleeding under the skin occurs along with a throbbing pain and a bulging of the incision site.

Will I be able to go home the day of surgery?

The surgery may be done either in the office with local anesthesia or an ambulatory surgery center or hospital, generally as a day surgery. Usually, the man arrives in the morning and leaves the hospital the same day.

No special preoperative tests are needed before a vasectomy reversal other than the standard lab tests required by some hospitals, ambulatory facilities, or anesthesiologists. For men over 40 years old, an EKG is usually required.

Do tests for anti-sperm antibodies or follicle stimulating hormone levels help predict the success of my surgery?

Measurement of serum anti-sperm antibodies appears to be of little diagnostic value with regard to male fertility potential.Anti-sperm antibodies are proteins that can hinder the movement and function of sperm. Some research shows that anti-sperm antibodies may decrease the chances for pregnancy after reversal surgery; however, studies have found almost no relation between preoperative testing for anti-sperm antibodies and pregnancy. The difficulty in testing for anti-sperm antibodies before reversal surgery is that only serum (blood) antibodies can be tested, which do not accurately predict the antibodies that may be found in the semen after surgery. Because of these difficulties, most surgeons do not find anti-sperm antibody testing to be useful. Follicle-stimulating hormone (FSH) is not normally examined in men requesting vasectomy reversal.

FSH is a hormone produced in the pituitary gland that stimulates the testes to make sperm. A high FSH level suggests reduced sperm production and testicular failure, and can indicate that there is less possibility of obtaining a good sperm count after surgery. Men who have a history of fertility prior to vasectomy rarely have an elevated FSH level. On the other hand, if serum FSH is low or normal, it does not always mean sperm production is normal. It is not unreasonable to measure serum FSH before surgery in men who have never fathered a child, in men who have abnormally small testicles, or in men whose vasectomies were performed many years before the reversal surgery.

Should my wife undergo any tests before I have my vasectomy reversal?

Your wife should undergo a gynecological exam to ensure adequate fertility potential. For older couples or those whose family history indicates, genetic counseling may also be helpful.

How do I choose a surgeon?

The skill and experience of the surgeon who performs your reversal surgery is one of the main determinants of the success of your surgery. It is a good idea to ask your potential surgeon whether he or she can perform a vasoepididymostomy using an operating microscope. During surgery, the surgeon needs to be experienced in assessing the vas fluid quality, evaluating signs of epididymal blockage, and determining the best location for a vasoepididymostomy, if needed. A vasoepididymostomy is necessary in about one-third of cases, and the need for it can only be definitively determined during surgery.

When would a surgeon perform a vasoepididymostomy rather than a vasovasostomy?

While a vasovasostomy is the first choice of treatment for vasectomy reversal, vasoepididymostomy, the more difficult procedure, is required in about one third of cases. At the beginning of the reversal surgery, the surgeon isolates and removes the scarred ends of the vas deferens. As soon as this is done, the cut ends of the vas deferens closest to the testicles are examined for sperm content and vas fluid quality. Fluid is taken from the vas deferens by syringe (see Figure 8) and inspected using a laboratory microscope.

Figure 8

In general, if sperm is present in the vas fluid, a vasovasostomy is performed. If sperm is not present in the vas fluid, a vasoepididymostomy is performed. Lack of sperm in the vas fluid usually points to breakage and blockage of the epididymal tubules caused by the back pressure which forms after vasectomy. A vasoepididymostomy merely connects the vas deferens to the epididymis at a site which will allow sperm to flow from the epididymis directly into the vas deferens thereby avoiding the site of the blockage. Vas fluid quality, especially clarity, is also important. Usually, when sperm are absent, the vas fluid looks cheesy, thick, and cloudy. When this occurs, a vasoepididymostomy is needed. In some rare instances, however, the vas fluid has a watery consistency and is clear in color. When this occurs, even if sperm is absent from the vas fluid, a vasovasostomy is performed. On average, two thirds of these surgeries result in sperm in the ejaculate and one third of couples will become pregnant.

Even if you plan on waiting to try to conceive, for most couples it is best not to delay the reversal procedure. The average time interval from a vasectomy reversal until pregnancy is 12 months, and it takes 24 months after surgery until the highest percentage of pregnancies is achieved. It is important to keep this in mind. Also, the longer the interval between vasectomy and reversal is, the less the chance that pregnancy after reversal would occur. Although many successful reversals are done several years after vasectomy, when you have the option, sooner is better.

Recent medical and surgical advances have created many options for infertile couples. Choice of infertility treatments usually depends on weighing the likelihood of pregnancy with a specific treatment versus other more complex and costly treatments. IVF is a technique that can help couples conceive who might not otherwise be able to through natural methods. IVF involves incubation of human eggs and sperm in a culture dish. For fertilization to occur, the egg must have optimal maturity and the sperm must function normally. Once a fertilized egg develops into an embryo it is put back into the female. Assisted fertilization techniques like IVF are a good option for men with severe sperm function defects or for men in whom no cause of infertility can be found. Pregnancy rates, however, are very low with routine IVF and are usually coupled with gamete micromanipulation which requires special preparation of the egg and sperm. Intracytoplasmic sperm injection (ICSI) is the most useful micromanipulation technique developed so far to improve IVF fertilization rates in patients with severe male factor infertility. This procedure involves the direct injection of a single sperm into an egg. For men who have had a vasectomy, sperm is obviously absent from the ejaculate. Therefore, since the IVF/ICSI procedure requires sperm, sperm must be taken from the testicle or epididymis through a minor surgical procedure. The procedure for obtaining sperm is less complicated than reversal surgery but involves local anesthesia and insertion of a needle into the testicle or epididymis to retrieve sperm.

One cycle of IVF can cost anywhere from $8,000 to $15,000 depending on the variety of infertility factors involved and whether sperm retrieval procedures for the man is necessary. Currently, the national birth rate for IVF reported by The Society for Assisted Reproductive Technology and the American Society for Reproductive Medicine is only 18.3% per cycle. Because of the expense, lower pregnancy rates, and potential side effects from hormonal therapy for the female partner, reversal surgery and repeat reversal surgery are usually the preferred options for vasectomized men. IVF is an alternative to consider if vasectomy reversal is unsuccessful, rather than as an alternative to the surgery completely.

A common cause of reversal surgery failure is that a vasovasostomy was performed when a vasoepididymostomy was needed. Some other reasons for vasovasostomy failure are an inaccurate evaluation of the vas due to poor surgical technique and blockage from scarring as a result of disruption of the blood supply. Success rates after repeat reversal surgery are slightly lower than success rates after first reversals, mainly because the duration of vas obstruction is longer for repeat reversal surgery.

The large case study described above compared the results of first and repeat vasectomy reversals. This study reported that, following repeat reversals, sperm were present in the semen of three-fourths (150 out of 199) of men after surgery and that pregnancy was reported in 43% of couples (52 out of 120) who were evaluated for pregnancy. These results are very similar to those of first reversals, and many men feel that these success rates are high to try a repeat operation.Chances of a successful repeat reversal surgery may be predicted by the sperm content of the vas fluid sampled during surgery of the first reversal. If sperm was present in the vas fluid during the first vasovasostomy and the individual fails to produce sperm in the ejaculate, blockage at the site of vas reevaluation may exist, and the patient may need to repeat the vasovasostomy. If, on the other hand, sperm were absent in the vas fluid, the patient likely needed a vasoepididymostomy during the first procedure and will probably need a vasoepididymostomy if the reversal surgery is repeated.

Your doctor will examine you before surgery by physically feeling your scrotum to determine the firmness and size of the testicles. If you have one or more shrunken testicles, this may indicate irreversible testicular failure; therefore, surgery may not be able to restore fertility. If your doctor comes across a swollen and perhaps firm epididymis, this means that an epididymal blockage may be present. While not definitive, these findings may suggest that a vasoepididymostomy will need to be performed. On the other hand, if the epididymis is not swollen, a vasovasostomy is still not guaranteed.

Dr. Thomas will also try to determine the length of the vas deferens that was left after vasectomy (vas remnant) during the same scrotal examination. The longer the vas remnant is (see Figure 10), the better the chance for vasovasostomy and future success. The shorter the vas remnant is (see Figure 11), the greater the chance that the epididymis will have developed a blockage making a vasoepididymostomy necessary. In the rare event that a very long segment of the vas deferens is missing, it is more likely that extensive surgery will be necessary. On occasion, prior surgery such as hernia repair can cause damage to the vas deferens, resulting in a missing segment. Lastly, disorders of the testicles such as varicoceles (a swelling of the veins surrounding the testicles which cause damage) can be detected by examining your scrotal contents. These disorders may need to be corrected at a later date if vasectomy reversal surgery alone does not lead to pregnancy.

The site of the vasectomy is a factor in the outcome of reversal surgery.

Figure 10

Figure 11

A vasectomy can be performed close to the testicle and epididymis or farther away (see Figure 10). A disruption of the vas deferens farther away from the testicle will leave a long segment of vas deferens (vas remnant) and increase the chance of a successful reversal. The shorter the vas remnant is (see Figure 11), the greater the chance of scarring and blockage in the epididymis which makes a vasoepididymostomy necessary.

While the length of time from vasectomy to reversal surgery can affect the chances for success, no amount of time is considered too long to perform reversal surgery. Data from the largest research study on vasectomy reversal reveals progressively less favorable results as the time from vasectomy to reversal increases. These are the rates for 1,247 men studied who had a vasovasostomy:

This data indicates that despite long periods of time from vasectomy to reversal surgery (even greater than 15 years), vasectomy reversal can result in successful pregnancies. One reason for lower success rates, with longer intervals between vasectomy and reversal surgery, is the higher rate of epididymal blockage as the time interval lengthens. Breakage and blockage of the epididymal tubule is caused by increased pressure in the vas deferens and epididymis below the level of the vasectomy site. If the epididymis is blocked, vasoepididymostomy needs to be performed to make the reversal successful.

Map to El Paso Urology

El Paso Urology
4687 N Mesa, Suite 100
El Paso, TX 79912
Ph. (915) 532 3119
Fax. (915) 351 6048

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