Vasectomy and Vasovasostomy (Reversal Surgery)

Description

Alternative Names

Reversal Surgery

Although men should consider vasectomy a permanent decision, vasovasostomy is a reversal procedure that may restore fertility in many men who change their mind. Vasovasostomies are also effective in relieving chronic pain from vasectomies in the rare case that this occurs.

One Australian study suggested that although the rate of vasectomies has not changed over the past few decades, the desire for reversal surgery increased by over 70% in the late 1990s compared to the early 1980s. Men who had vasectomies in their 20s are more likely to seek reversal later on than older men. The main reasons for requesting a reversal are remarriage, the death of a child, or an improvement in finances. Reversal may also be performed to relieve postvasectomy pain, which occurs in a small percentage of men. Fewer than 10% of patients who request reversals do so because of physical or psychological problems following vasectomy.

Vasovasostomy (Reversal Surgery) Procedures

Standard Procedure. Vasovasostomy reconnects the severed ends of the vas deferens to reestablish the flow of sperm. The procedure is difficult:

• It involves sewing together the two tiny ends of both tubes, each with pinhead-sized openings.
• If the vas deferens is blocked, the surgeon may try to connect the epididymis to an area in the vas deferens that bypasses the blockage.

Vasovasostomy can usually be done on an outpatient basis and patients can usually return to work within one to two weeks. It is far more difficult and expensive than vasectomy itself, however, and is even costlier if the procedure involves connecting the vas to the epididymis, which takes about three hours. It should be noted that reversal surgery is usually not reimbursed by insurance companies, and that the results may not be known for some time.

Microscopic versus Magnification Techniques. The surgeon may view the surgical site using either magnification instruments (called macroscopic vasovasostomy) or microscopic techniques. Advanced microscopic techniques are proving to increase the chances of a reversal's success. Although macroscopic vasovasostomy has a slightly lower success rate, pregnancy rates can still be over 50%, and it is less expensive and has a shorter operating time than microscopic procedures.Still, a 2003 study suggested the microscopic approach is preferable for repeat vasovasostomies when the initial procedure failed.

Laser Techniques. Laser surgery is being investigated and may prove to require less surgical expertise, reduce operating time, and result in fewer complications. At this time, however, results vary widely.

Pregnancy Rates after Vasovasostomy

An Australian study reported that the pregnancy rates in the late 1990s after reversal surgery were nearly four times higher than they were in the early 1980s. Pregnancy rates of over 50% are now being reported after a vasovasostomy.One study indicated that when successful conception occurs, it does at an average of one year after the surgery.

A successful reversal is more likely if the following conditions are present:

• The section removed during vasectomy was not long.
• The original procedure was performed on straight sections of the vas deferens.
• The pieces joined during the vasovasostomy are of equal size.

The closer in time the vasovasostomy is to the original vasectomy the better. In one large study, the pregnancy rates were 76% for those who had vasectomy less than three years before reversal surgery, decreasing to 30% for those who had vasectomy more than 15 years prior. The lower rates as time goes by are probably due to increasing chance for obstruction of the epididymis and the development of anti-sperm antibodies. Success rates, according to a 2003 study, are slightly better if the male partner does not change female partners after the procedure. The procedure may offer some chance for successful pregnancies even in women over 35 (who are, in any case, at higher risk for failure).

Causes of Vasovasostomy Failure

Even though tubes are re-opened and sperm is restored in as many as 85% of men who undergo vasovasostomy, pregnancy is not guaranteed. A number of factors may play a role in the failure of reversal surgery.

Epididymis Obstruction. If the sperm count does not recover within a reasonable period after vasovasostomy, it is often due to blockage from scarring that has occurred in the epididymis. This sometimes can be corrected with a second procedure. One study reported that the physician may be able to detect obstruction before the vasovasostomy by pressing and manipulating (palpating) the epididymis. If any part seems swollen or larger than other parts, an obstruction is very likely to be present and the patient is likely to need a vasoepididymostomy, which creates a bypass around the obstruction.

Antisperm Antibodies. In many cases in which vasovasostomy fails, the reversal procedure reopens the tubes but fertility is impaired because of a process called autoimmunity. With this condition, important immune factors called antibodies attack the body's own cells, mistaking them for antigens (any foreign microinvader that the immune system perceives as a threat).

In the case of vasectomy, the autoantibodies attack the sperm, and so are called antisperm antibodies. Such antibodies develop when sperm continue to be produced after vasectomy, but, instead of being confined to the reproductive passages, they leak out into the body. Once out of their natural habitat, the immune system perceives them as foreign invaders and develops antibodies to attack them.

Antigens are large molecules (usually proteins) on the surface of cells, viruses, fungi, bacteria, and some non-living substances such as toxins, chemicals, drugs, and foreign particles. The immune system recognizes antigens and produces antibodies that destroy substances containing antigens.

The antisperm antibodies bind to specific parts of the sperm (e.g., the head or tail) and cause problems depending on the site of attachment. Sperm may stick together (agglutinate), fail to interact with the woman's cervix, or fail to penetrate the egg. Even after vasovasostomy, such antibodies often persist.

Oxidation. The immune factors that trigger the autoimmune process may have other harmful effects as well. In a process called oxidation, they can trigger the release of particles called free radicals, highly reactive oxygen molecules that, in excess, can do considerable damage to cells and genetic material. When high levels of free radicals persist after a vasectomy, they may, in theory at least, injure sperm DNA, contributing to infertility.

Reoperations After a Failed Vasovasostomy

Repeat Vasovasostomy. If pregnancy fails, in some cases a repeat vasovasostomy may be effective. Success rates depend on several factors:

• The doctor's skill.
• Complications from the original operation.
• Effects of anti-sperm antibodies.
• Time elapsed since vasectomy (the shorter the better).
• History of previous children. In one study, conception rates after reoperations were highest (80%) in couples who had had previous children. The pregnancy rate was only 17% when men had remarried.

A 2003 study indicated that the microscopic approach may be preferable for many repeat vasovasostomies.

Vasoepididymostomy. Vasoepididymostomy is a microsurgical technique that is useful when a vasovasostomy has failed because of damage to the epididymis. This procedure creates a bypass around the obstruction. It may be done on one or both sides of the testes.

To appreciate the difficulty of this operation, one should realize that the epididymis is 1/300th of an inch wide with a wall thickness of 1/1000th of an inch. Microscopic techniques are critical for the success of this procedure and require a surgeon who specializes in them. Refinements in vasoepididymostomy techniques are showing promising results, resulting in opened tubes in 77% to over 85% of cases.

Success rates are higher for repairing obstructions closer to the testicles because the epididymis is wider in this area. In general, pregnancy rates are around 25%, but higher rates have been reported. In one 2002 study of men who had vasectomy reversal more than 15 years after the original procedure, 62% required vasoepididymostomy, and the overall pregnancy rate was 43%. Pregnancy rates ranged from 49% in those who had had their vasectomy 15 to19 years earlier to 25% in those who had the surgery 25 or more years before, with the highest rates occurring, not surprisingly, in those with the youngest wives.

Damage in other ducts and small tubes are a major reason for vasoepididymostomy failure. Ultrasound before the operation may be valuable to determine if these abnormalities exist, which would make it unlikely that the procedure would be successful.

If an initial vasoepididymostomy fails but conditions are favorable, a repeat procedure may still succeed. In a small 1999 study, two-thirds of men who had repeat vasoepididymostomy had sperm in their semen, and natural conception occurred in 25% of patients (3 out of 12) within 18 months.

Freezing Sperm Before a Reversal Surgeries

If the patient did not contribute sperm for freezing and banking before vasectomy, some physicians suggest freezing sperm obtained during vasovasostomy as insurance against failure. Such sperm can be used in assisted reproductive methods later on if natural intercourse fails to achieve pregnancy.

There is some controversy, however, surrounding routine use of frozen sperm before a vasovasostomy. One study reported that so many sperm were non-motile at the time of the reversal surgery that freezing sperm obtained during the procedure provided little benefit. Nevertheless, new fertilization techniques are using even non-motile sperm with some success. And other studies have reported some successful pregnancies with frozen sperm. Some experts recommend routine sperm retrieval only for men undergoing bilateral vasovasostomy (those performed on both sides) and possibly for men who are having vasovasostomy with vasoepididymostomy. Men should discuss these options with their physician.