In Depth Vasectomy Reversal Information
By Philip Werthman, M.D., M.M.H., F.A.C.S.
The information below is technical and in depth for those who have an interest in the procedure and would like a deeper understanding of the most effective methods currently in use. For those couples experiencing infertility due to a man’s vasectomy, there are the alternatives of T.D.I. (therapeutic donor insemination) or IVF/ICSI (in-vitro fertilization with intracytoplasmic sperm injection), but restoration of a man’s fertility by reconnecting the tubes at the site of the previous vasectomy appears to provide couples with the most optimal and least expensive option for building a family.
How is Vasectomy Reversal Performed?
With the patient comfortably under anesthesia, a 1-2 inch incision is made in the scrotal skin over the old vasectomy site. The two ends of the vas deferens are found and freed from the surrounding tissue. The vasectomy scar is usually removed. A drop of fluid from the testicular end of the vas is placed on a glass slide and examined using a light microscope. This is a crucial part of the operation because the information obtained is used to decide what type of microsurgical reconstruction needs to be performed.
Since the testicle continues to produce sperm after a vasectomy, the fluid in the vas should contain sperm. There are three possible scenarios that may be encountered when examining the vasal fluid.
The first and best scenario is that the vasal fluid contains whole sperm.
The second possible finding is that the fluid is thin and copious and contains only sperm parts or no sperm.
The third is that the fluid is thick, pasty and contains no sperm. This last scenario usually means that a “blow out” or rupture has occurred in the epididymis, the organ where the sperm are stored.
The epididymis is a single-cell layered tubule that if uncoiled is approximately 14 feet long and is coiled into four inches worth of space. Sperm leak out if the pressure in the tubule becomes greater than the resistance in the wall of the tubule, similar to the way a pipe breaks in the basement when the water pressure gets too high. The body tries to heal this tubule and a scar forms. This causes a second blockage in the epididymis, which needs to be bypassed to allow the sperm to get out into the vas. If this second blockage is present and is not recognized then the operation is doomed to failure.
Micro Surgical Vasovasostomy
If the vasal fluid contains sperm then the two ends of the vas deferens can be reconnected at the vasectomy site. This procedure is known as a vasovasostomy.
The lumen or channel inside the vas deferens through which the sperm swim is only 0.2 to 0.3 millimeters in diameter (about the size of a pen dot). For comparison, the coronary artery of the heart that is typically bypassed in open heart surgery is 10 times larger in diameter than the vas.
An operating microscope is used to magnify the operating field up to 16 times. The vas can then be better visualized and the sutures can be precisely placed. You can now easily understand that without the use of the microscope this operation would be very difficult, if not impossible to perform successfully.
All studies have demonstrated that microsurgical vasectomy reversal is more successful than those procedures performed without the microscope or with loupes (magnifying glasses worn by the surgeon). The technique we prefer is a two or three-layered closure using 10-0 and 9-0 suture (half the thickness of a human hair). We place 6-8 interrupted sutures in the mucosa or inner layer of the vas to ensure that the repair is water-tight . This is very important because one reason that vasectomy reversals fail is that sperm leak out from the vas at the surgical site and cause inflammation and a new blockage. The muscular layer of the vas is then re-approximated adding strength to the repair . The surrounding connective tissue is also brought together as a third layer to take any tension off of the repair site. The skin incision is then closed.
If an epididymal blowout has occurred, then the secondary blockage that occurs must be bypassed. To do this, most surgeons make a large opening in the scrotum and remove the testicle and epididymis from the scrotum to gain access to the epididymis and vas. The epididymis is closely examined, a tubule is opened and the fluid is checked for the presence of sperm. If sperm are found in the epididymal tubule then we know we are at a spot upstream from the second blockage and then the vas can be brought in and sewn to the open epididymal tubule (pictures above).
This is called a vasoepididymostomy. A vasoepididymostomy is a technically more difficult procedure to perform than a vasovasostomy because the epididymal tubules are very thin and delicate. The results of vasoepididymostomy are not as good as with vasovaostomy. It is for this reason that if the vasal fluid looks good or has sperm parts, then a vasovasostomy is performed. Motile sperm can also be collected from the epididymis right at the time of surgery and frozen for later use if the vasoepididymostomy fails.
Dr. Werthman has developed the Mini-incision Microsurgical Vasoepididymostomy which is performed through a very tiny skin incision. He has developed a way to access both the vas and epididymis without having to open up the entire scrotum. This means that the patient is more comfortable, has less pain after the procedure, and experiences a quicker recovery and much smaller scar. This has been recognized as one of the top 10 advances in fertility-related microsurgery by the American Urologic Association.
Not all vasectomy reversal surgeons are able to perform this more difficult procedure nor can it be performed precisely under local anesthesia with the patient moving around. It is important to make sure that the surgeon you choose can perform this successfully, if needed.
Re-do Vasectomy Reversals
Vasectomy reversals typically fail either because of scarring at the surgery site, imprecise suture placement or because a blockage in the epididymis was present and not recognized (a vasovasostomy was performed when a vasoepididymostomy was indicated).
Because a vasectomy reversal has failed does not mean all hope is lost. Re-doing the surgery using meticulous and proper technique can produce success in more than 80% of cases.
At the Center for Male Reproductive Medicine, we specialize in re-do vasectomy reversals. Ten percent of the reversals we perform are re-operations on patients who had failed surgery elsewhere. Dr. Werthman currently performs 2 to 4 vasectomy reversals per week.
Over half of our patients travel from outside the Los Angeles area and we are set up to treat out-of-town patients. Our staff is able to help you with all the information you require and can help with accommodations as well. Typically patients stay in LA for 2-3 days; the initial evaluation can be performed a day prior to the procedure and the patient may return home one day after the procedure.
THE BOTTOM LINE is that we offer patients all the possible options and combinations of treatments so you can choose what is best for you, not what we might want you to do because of our limitations.