Vasectomy Reversal

Background

Approximately 500,000 vasectomies are performed annually in the United States. While a vasectomy is an effective means of birth control, it is intended to be permanent. The reality is that as many as 6% of men who undergo vasectomies will seek a consultation at some point in the future for a vasectomy reversal. Despite the fact that vasectomies usually entail the destruction of the two ends of the vas deferens and removal of a piece of the vas deferens, most of these men and their partners will be candidates for either vasectomy reversal or sperm acquisition with in-vitro fertilization.

Anatomy and Physiology

Sperm are made in the testicles within tiny spaces called seminiferous tubules. After leaving the testicles the sperm travel through the epididymis, a tightly coiled tubule, which occupies a small space alongside the testicle but if unwound would be 10 feet long. After traveling through the epididymis, the sperm enter the vas deferens, a thick-walled tube which conducts the sperm from the scrotum into the pelvis. Within the pelvis, the fluid containing the sperm is joined by fluid from the seminal vesicles behind the prostate in the ejaculatory duct. The fluid is expelled from the ejaculatory duct during ejaculation.

A vasectomy is performed by interrupting the vas deferens within the scrotum. The testicles continue to produce sperm and these sperm are ultimately reabsorbed. Most urologist believe that the blockage produced by a vasectomy and the higher pressures within the vas deferens and epididymis can result in secondary blockages within the epididymis. If this occurs, simply reversing the vasectomy by hooking up the two ends of the vas deferens would fail to return sperm to the ejaculate and a more complex operation is required (see below).

Fertility Options After a Vasectomy

There are two options for couples who wish to have their own biologically related children after a vasectomy: they can pursue a vasectomy reversal or in-vitro fertilization. Other options include intrauterine insemination with donor sperm and adoption. Of course, with these two options, the children will not be genetically related to the father.

Vasectomy Reversal

Vasectomy reversals are nearly as old as vasectomies themselves but major technical improvements over the past 20 years have dramatically improved success rates as measured both by the return of sperm to the ejaculate and by pregnancies. Innovations such as the use of the operating microscope and the development of extremely fine needles, sutures and instruments now allow for highly precise suture placement for aligning the two ends of the vas deferens or the vas deferens to the epididymis.

Vasectomy Reversal - The Procedure

A vasectomy reversal may be performed using general anesthesia or with sedation and local anesthesia. This surgery is performed on an outpatient basis meaning that men generally return home within a few hours of the completion of the procedure.

The procedure begins with an examination of the two ends of the cut vas deferens through a tiny incision in the scrotum (about ½ inch). The vas deferens on the testicular side is opened and the fluid is examined for the presence or absence of sperm. If sperm are identified or if there is a large amount of watery fluid, the two ends of the vas deferens are then sewn together - a procedure known as a vasovasostomy. If there are no sperm in the fluid and the fluid is pasty, a secondary epididymal blockage is suspected. If confirmed, the vas deferens is sewn to the epididymis - a procedure known as an epididymovasostomy or vasoepididymostomy.

Once the decision is made to perform either a vasovasostomy or epididymovasostomy, the operating microscope is positioned over the scrotum. These microscopes allow for tremendous magnification of the operative field and, in properly trained hands, significantly more precise suture placement and better results. The inside diameter of the vas deferens is only ½ of a millimeter (0.02 inches). For comparison, a human hair is 1/10 of a millimeter. Most male infertility specialists join the two ends of the vas deferens in multiple layers ("multilayered anastomosis") or with a modified one layer technique. Male infertility specialists use very fine suture material which is 1/3^rd to 1/5^th the diameter of a human hair and almost impossible to see without a microscope. To perform an epididymovasostomy, an epidiymal tubule containing sperm is identified and attached to the vas deferens, thereby reestablishing continuity of the genital tract. This is an exceedingly delicate operation - the epididymis has a very thin and fragile wall and a tiny channel containing sperm.

Vasectomy Reversal - Results

There are two measures of success following a vasectomy reversal: the return of sperm to the ejaculate ("patency") and the establishment of a pregnancy.

The landmark published study of vasectomy reversals is the vasovasostomy study group report, published in 19911. This study reported vasectomy reversal results for more than 1400 men. Overall, 86% of men undergoing first time vasectomy reversals had sperm return to the ejaculate. Interestingly, the patency rate was related to the length of time since the vasectomy: patency rates were 97% if the time since the vasectomy was less than 3 years but 71% if more than 14 years. Pregnancy rates were also dependent upon the length of time since the vasectomy. The overall pregnancy rate was 52% but if the interval since vasectomy was less than 3 years the pregnancy rate was 76% and if the interval was greater than 14 years the pregnancy rate was 30%.

Much has changed over the last 15 years since the report of the vasovasostomy study group. Microsurgery has undergone numerous refinements. The technique of vasoepididymostomy has undergone dramatic changes with corresponding improvements in results. With these changes have come improved patency and pregnancy rates. Most contemporary series of vasovasostomies report patency rates between 90% and 99.5% and pregnancy rates of 40-55%2. Over the past few years several studies have shown that even with long periods of time since vasectomy, the patency and pregnancy results are excellent after microsurgical vasectomy reversal 3^,4.

Approximately 3% of men who have a technically successful reversal (motile sperm seen in the ejaculate after the reversal) will scar down the area where the two ends of the vas deferens were put together and eventually the ejaculate will contain no sperm5.

Many factors influence the pregnancy rate, the most important of which is the age of the female partner. When the female partner is less than 30 years old, two thirds of couples achieve a pregnancy even with more than 15 years between vasectomy and vasectomy reversal6. If men have the same female partner before and after vasectomy (i.e. not remarriage), 86% of couples achieve pregnancies7. For couples in which the female partner is 35-39 years old, recent data suggests pregnancy and live birth rates around 45%8. These data show how important female fertility issues are in predicting the ultimate success of a vasectomy reversal (pregnancy).

Vasectomy Reversal versus In-Vitro Fertilization (IVF): How should we choose?

Vasectomy reversal and IVF are both reasonable options for most couples. The nationwide average pregnancy rate for IVF is 34.3% and the average live birth rate is 28.4%9. These statistics are collected by the CDC and are available online (see http://www.cdc.gov/reproductivehealth/ART/index.htm). Similar data for vasectomy reversals are not collected by the CDC but are available from published series. The average pregnancy rate for vasectomy reversal varies from series to series but is generally 40-55%. Pregnancy and live birth rates are strongly influenced by the age of the female partner as previously mentioned.

The advantages of vasectomy reversal are:

Children are conceived in a "natural" way - through intercourse.
Female partner does not need to take hormones to artificially increase the number of eggs produced by the ovaries.
Female partner does not need to undergo a procedure to harvest eggs from the ovaries.
The risk for multiple births (twins, triplets etc) is no different than for any couple having children by natural intercourse. Pregnancies with twins and triplets are more risky to the mother and the baby. Nationwide, 64.6 % of all live births using assisted reproductive techniques are singleton, 31.6% are twins and 3.8% are triplets or more (http://www.cdc.gov/reproductivehealth/ART02/section2a.htm#f8).
A vasectomy reversal leaves open the possibility of having more children in the future.
There is no need to decide what to do about embryos which are created but not used.

The advantages of IVF are:

If a pregnancy occurs in the first cycle, the average time to having a baby will be shorter using IVF.
If the female partner has fertility problems, the chances of establishing a pregnancy may be greater than following a reversal.
The male partner does not need a reversal (but would need a procedure to obtain sperm for IVF).
Can be successful even if the man is making relatively few sperm. This is rare in men who have had vasectomies since most have already had children.

The best example of a couple who might favor IVF would be one in which the wife is 39 years old and has a female infertility factor. The best example of a couple who might favor vasectomy reversal is one in which the wife is young and would like to have several children but not all at once. Every couple is unique and it is the fertility specialist's responsibility to present all options thereby helping the couple to choose the one that is best for them.

Pre-operative evaluation

All patients who are interested in having children after a vasectomy undergo a thorough office evaluation. During this evaluation, Dr Milbank will discuss your medical history, concentrating on your fertility history and the vasectomy. A physical exam will provide information which may suggest the need for a vasoepididymostomy, although the final decision is determined by findings at the time of surgery. Finally, and most importantly, Dr Milbank will review the options available to you for having children after you have had a vasectomy (see Fertility Options After A Vasectomy.). He will answer any and all questions you may have.

Pre-operative preparation

On the night before the operation, you should have nothing to eat or drink after midnight. An exception may be made for medications - ask at the time of your appointment with Dr. Milbank. You should not take any aspirin products or non-steroidal anti-inflammatory pain medications for 1 week prior to surgery. Acetaminophen (Tylenol) may be used. You should not shave the operative area.

Operative day

On the morning of your surgery, you should report to the surgical center at the time previously arranged by the surgical center. Again, since you will be having anesthesia, do not eat or drink anything before the surgery. No other special preparation is required.

Dr. Milbank performs most of his vasectomy reversals at the High Pointe Surgery Center (HPSC). HPSC is a leader in providing outpatient surgical care to individuals in Minnesota and Western Wisconsin. For more information about HPSC click here,(http://hpsurgery.com/index.php).

At the surgical center, Dr. Milbank will meet you before the surgery. If you have thought of any questions that you did not ask at your pre-operative visit, he will answer those questions prior to starting the surgery.

The surgery generally requires between 2 and 4 hours depending upon whether or not a vasoepididymostomy is required. The surgery can be performed with either general anesthesia or local anesthesia with sedation (some people refer to this as "Twilight"). There should be no significant discomfort during the procedure either way. In fact, many men report less discomfort during and after a reversal than during and after the original vasectomy.

After the surgery, you will be brought to a recovery room for a few hours until you are fully awake following anesthesia or sedation. Once you are fully recovered you will be discharged from the facility. Dr Milbank will talk to you and discuss the operative findings with you before you leave. You should have a family member or friend with you to drive you home.

Post op care

Download the post op instruction sheet.

Follow-up after the reversal

Dr. Milbank likes to see all patients about six weeks after the operation to check the incisions and see how you are doing. A semen analysis may be done at that first visit. It may take up to one year to see sperm return to the ejaculate but most of the time sperm will return to the ejaculate long before one year.

After the six week visit, a semen analysis should be performed every 3 months or until a pregnancy occurs. This is because approximately 3-5% of patients will have sperm return only to scar down and an additional 3-4% of patients may develop significant antibodies to their own sperm which interfere with fertility10. It is best to detect these conditions as early as possible. Office visits are not required for these analyses but if you ever have any questions and would like a follow-up appointment this can be arranged at any time.

Finances

Vasectomy Reversal Fees

Metro Urology Surgical Fee: $3200
High Pointe Facility Fee (Includes Anesthesia): $3889
Total Cost: $7089

Metro Urology requires payment 7-10 days prior to the procedure. High Pointe requires payment prior to or on the day of surgery.

If for some reason your surgery cannot be performed at HPSC, a different Facility Fee will apply. This would occur if you have significant health problems. In this case, you will be informed at your pre-operative office visit or when you schedule surgery.

Metro Urology can only guarantee their fees and financial policies. We have made arrangements with High Pointe Surgery Center for their fees for the patient's convenience. However, since Metro Urology is not formally affiliated with High Pointe Surgery Center, we cannot be held responsible for the relationship between the patient and High Pointe Surgery Center.

"Risk-Sharing" Program

In rare circumstances, a man may undergo a microsurgical vasectomy reversal and not have sperm return to his semen. Since he and his partner likely still want to have children, Metro Urology will refund the surgical fee in hopes that this will assist the couple in their ongoing desire to have children either through a redo surgery, IVF or adoption. This guarantee ONLY applies to Metro Urology surgical fees; not those of any outside entity, including the surgery center or other 3rd parties.

The reimbursement schedule is based upon the specifics of the case and is as follows:

Less than 3 Years	$3200
3-8 Years	$3000
9-14 Years	$1500
>14 Years	$750

This schedule applies only to reversals performed by Dr. Milbank following scrotal vasectomies (the kind more than 99% of people have).

References

1 Belker AM, Thomas AJ Jr et al. J Urol. 1991 Mar;145(3):505-11.
2 Campbell's Urology 8th Edition.
3 Fuchs EF and Burt RA. Fertil Steril 2002 Mar; 77(3):516-9.
4 Boorjian S, Lipkin M and Goldstein M. J Urol. 2004 Jan;171(1):304-6.
5 Kolettis PN, Fretz P et al. Urology. 2005 May;65(5):968-71.
6 Fuchs EF and Burt RA. Fertil Steril 2002 Mar; 77(3):516-9.
7 Chan PT and Goldstein M. Fertil Steril 2004 May; 81(5):1371-4.
8 Kolettis PN, Sabanegh ES et al. J Urol. 2003 Jun;169(6):2250-2.
9 http://www.cdc.gov/reproductivehealth/ART02/sect2_fig3-13.htm#Figure%207
10 Kolettis PN, Fretz P et al. Urology. 2005 May;65(5):968-71.