The Procedure

Vasectomy involves cutting and removing a section of the vas deferens on each side. Thus, the passage of sperm is interrupted and cannot reach the outside world. However, men produce sperm continuously from the time of puberty and continue to do so after vasectomy. In most cases the operation does not interfere with the function of the testes.

After Vasectomy
The sperm produced by the testes has nowhere to go after a vasectomy and collects in the epididymis. This may result in "blow out", sperm leakage and scar formation. In addition anti-sperm antibodies develop in 60% of vasectomized men. These "after effects" are only important if vasectomy reversal is contemplated.

Vasectomy Reversal
Regret about vasectomy may be more common than suggested by the number of men requesting reversal as many couples request donor insemination rather than reconstructive surgery. Vasectomy is, therefore, a decision which should not be made without careful thought.

Prior to vasectomy reversal the surgeon may suggest screening for antibodies. Achieving a pregnancy may be difficult if high levels are detected.

The operation may be performed using macroscopic, microsurgical or laser assisted techniques. Most operations require a general anaesthetic, although uncomplicated procedures are sometimes performed under local anaesthetic or epidural. The operation can take up to three hours, but can usually be performed as a day case procedure. However 7-10 days convalescence is required post-operatively to assist the healing process.

An incision across the scrotum is required to expose the cut ends of the vas deferens. At this time it is important to ensure that sperm are present in the fluid that leaks out of the end of the vas. If this is not the case, there maybe a co-existing blockage in the epididymis and the operative procedure is then more complicated. The surgeon performing the operation may choose to reverse one side at a time. This allows the opportunity for repeat surgery on the other side if the first reversal is unsuccessful. Repeat reversal attempts on the same side have a very low chance of success.

Methods of Vasectomy Reversal

i. Vasovasostomy
Here the cut ends of the vas deferens are opposed and sutured together. Patency of the vas deferens can be achieved in 80% - 90% of cases. However, only 30 - 40% of patients achieve a pregnancy following vasectomy reversal.

ii. Vaso-epididymostomy
Here the cut end of the vas deferens is joined to a tubule within the epididymis. Results achieved by this method are less good than with vasovasostomy.

Reasons for poor results:

• More than 10 years between vasectomy and reversal carries a poor prognosis
• Too much vas deferens may have been removed at the time of the original operation
• The presence of high levels of anti-sperm antibodies
• Very rarely, the testes may atrophy due to damage to the blood supply at the time of operation
• Difference between patency and pregnancy rates.

Not every couple will achieve a pregnancy even if sperm appear in the ejaculate following reversal. Gradual scar tissue formation may cause stricture and finally re-blockage of the vas. In addition, the semen quality after vasectomy reversal may be poor and IVF/ICSI may still be necessary to achieve a pregnancy. Anti-sperm antibodies may appear in the ejaculate after vasectomy reversal. These attach to the sperm and decrease their fertilising capabilities. The age of the female partner may also be a factor if she is over 35.

Treatment of anti-sperm antibodies.

• "Washing" the sperm sample has not proved to be very successful as antibodies are tightly bound to the sperm.
• Steroid tablets may help - but have major side-effects if used in high doses.
• In vitro fertilisation (IVF) may be suitable for some cases. If spontaneous conception fails to occur this may be a good option in order to test the fertilising capabilities of the sperm. If the sperm are unable to fertilise the egg in the normal way, intracytoplasmic sperm injection (ICSI) is indicated.

Follow-up after Reversal

Sperm may appear in the ejaculate up to a year after vasectomy reversal. If this does not occur, further investigation is indicated. The female partner should already have been fully investigated. For the male partner, testicular biopsy should be considered prior to further surgery to ensure that the testes are still functioning normally.

Percutaneous Epididymal Sperm Aspiration (PESA)

If reversal has failed, sperm may be retrieved surgically from the epididymis and used for IVF/ICSI. The retrieved sperm is fragile with low motility and usually has to be injected into the egg in order to achieve fertilisation. Occasionally reconstructive surgery can be performed at the same time. PESA is indicated for patients with congenital absence of the vas or irreparable and bilateral damage to the vas or epididymis.

Continue to:Surgery - Costs >>>>