Vasectomy Reversal

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Mary K. Samplaski, M.D.
Director, Section of Male Infertility, Andrology  and Microsurgery
USC Urology

Background:

The process of vasectomy reversal (VR) involves restoring continuity to the male reproductive channels. In layman’s terms, this may be thought of as “re-connect the tubing”. Up to 5% of men undergoing vasectomy will eventually pursue reversal.

While the majority of VRs are post vasectomy, these same surgical techniques may be applied to men with other vasal obstructions. Obstructions of the epididymis and scrotal portion of the vas deferens that can be corrected with VR include male reproductive tract scarring, such as blockages from birth, or blockages seen after infections, trauma, prior genital surgery.

Anatomy and Physiology:

Sperm are produced within the seminiferous tubules. They then pass into the epididymal tubules, where they undergo maturation. Sperm then enter the vas deferens, where they are propelled forward with ejaculation.

Surgical connections may be made to either the vas or epididymis, depending on where the blockage is. In men with a history of elective vasectomy, there is generally a single area of vasal obstruction. After vasectomy, high pressures may result in epididymal rupture, resulting in secondary epididymal obstruction. This is seen more commonly in men who had their vasectomy more than 10 years prior, or in men who have failed a prior vasectomy reversal.

Pre-Operative Assessment:

All men should undergo a complete history and physical examination. At the surgeon’s discretion, hormonal or genetic testing may be ordered. If there is any question regarding normal sperm production on exam, a testis biopsy or aspiration may be performed in advance of reconstruction. Female partners should be interviewed for female factors, and if there is any concern, should be sent for a formal reproductive gynecologic evaluation. Intraoperative cryopreservation of sperm may be offered, and the necessary arrangements made. Men should be counselled regarding the two possible types of connections that may be made (vasovasostomy (VV) or vasoepididymostomy (VE)); that this determination will be made intraoperatively; and the implications for each of the connections.

Alternatives to VR include in vitro fertilization with surgical sperm retrieval, donor sperm insemination, adoption, or no treatment.

Initial Operative Procedure:

Microsurgical vasal reconstructions are generally performed at an outpatient surgical center. General anesthesia is recommended to minimize patient movement. A microsurgical approach has been shown to improve outcomes.

The vas is identified and dissected free of its surrounding scar on both the abdominal and testicular ends. The healthy vasal stumps are prepared and approximated to ensure a tension-free anastomosis.

Determining the Type of Reconstruction: Vasovasostomy (VV) versus Vasoepididymostomy (VE):

The fluid expressed from the testicular vasal stump will determine the type of surgical connection performed. This decision is made intraoperatively. This fluid is inspected both grossly and under a bench microscope for the presence of sperm or sperm parts (heads or tails). Copious, thin, clear fluid, with sperm or sperm components seen indicates vasal patency and directs the surgeon to perform a VV. If the fluid obtained is absent, thick and pasty, or no sperm or sperm components are seen, this indicates an epididymal obstruction and the need for a VE. If copious, clear, thin fluid, even without sperm present, is seen, then VV should be performed.

Vasovasostomy (VV):

VV may be performed by single or multi-layer anastomosis.

For the single-layer anastomosis (or connection), six equally-spaced, full-thickness, 9-0 nylon sutures are placed on the internal layer of the vas. Supporting sutures are placed between the previously to support the internal layer of stitches. In the multi-layer anastomosis, three sequential layers of sutures are placed. The decision for which type of anastomosis to make is made by the individual surgeon.

VV success depends on several factors. A microsurgical approach has been shown to yield higher patency and pregnancy rates as compared with a non-microsurgical approach (1). The presence of sperm or sperm parts at the time of reconstruction portends a patency rate of >90% (2). The vasal obstructive interval is also important, and when >9 years have passed since the male underwent his initial vasectomy, the success rates decline to <60% of the success achieved when the reconstruction was performed within three years of vasectomy (3). Female partner age also affects success rates, and one study found that when the female partner was <30 years pregnancy rates were 64%, but this dropped to 28% in women 40 years or older (4).

Anastomotic scarring occurs in 2-12% of men undergoing VR and can occur at any time post-operatively. No clear risk factors have been identified for this (5).

While microsurgical VV remains the gold standard, other techniques are being investigated, including biofilm wraps, the operative robot (6) and fibrin glue (7). These techniques have had varying success.

Vasoepididymostomy (VE):

VE is considered the most technically challenging operation in male microsurgery. The epididymal tubule has a diameter of 150-250 µm (substantially smaller than the vas) and extreme precision is necessary for these delicate anastomoses. The use of an operative microscope is a requirement.

Once the determination has been made that a VE is necessary, the surgeon inspects the epididymal tubules, including inspection for a change in the caliber of epididymal tubules, indicating the point of obstruction. Once this area has been identified, a single epididymal tubule is identified and isolated.

A variety of VE techniques have been described, and the technique chosen is dependent on the surgeon’s choice. The intussusception vasoepididymostomy is commonly used. In this technique, 10-nylon sutures are placed to draw the walls of an opened epididymis tubule into the lumen of the vas (the intussusception technique). Supporting 9-0 nylon sutures are then placed, in order to create a tension-free anastomosis.

VE success rates depend on many of the same factors as VV. Microsurgical training and experience is even more important for this delicate operation. In addition, for VE,  it may take up to 12 months for sperm to return to the ejaculate, versus 3-6 months for VV (8). In the hands of experienced microsurgeons, patency rates can be achieved in >80% of patients, however pregnancy rates may be lower (9).

 

References:

 

  1. Fox M. Vasectomy reversal--microsurgery for best results. Br J Urol 1994;73:449-53.
  2. Belker AM, Thomas AJ, Jr., Fuchs EF, Konnak JW, Sharlip ID. Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J Urol 1991;145:505-11.
  3. Hernandez J, Sabanegh ES. Repeat vasectomy reversal after initial failure: overall results and predictors for success. J Urol 1999;161:1153-6.
  4. Fuchs EF, Burt RA. Vasectomy reversal performed 15 years or more after vasectomy: correlation of pregnancy outcome with partner age and with pregnancy results of in vitro fertilization with intracytoplasmic sperm injection. Fertil Steril 2002;77:516-9.
  5. Kolettis PN, Fretz P, Burns JR, D'Amico A M, Box LC, Sandlow JI. Secondary azoospermia after vasovasostomy. Urology 2005;65:968-71.
  6. Schiff J, Li PS, Goldstein M. Robotic microsurgical vasovasostomy and vasoepididymostomy: a prospective randomized study in a rat model. J Urol 2004;171:1720-5.
  7. Ho KL, Witte MN, Bird ET, Hakim S. Fibrin glue assisted 3-suture vasovasostomy. J Urol 2005;174:1360-3; discussion 3.
  8. Jarow JP, Sigman M, Buch JP, Oates RD. Delayed appearance of sperm after end-to-side vasoepididymostomy. J Urol 1995;153:1156-8.
  9. Chan PT, Brandell RA, Goldstein M. Prospective analysis of outcomes after microsurgical intussusception vasoepididymostomy. BJU Int 2005;96:598-601.
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