Vasectomy Reversal

Watch  Dr. Boyle talk about vasectomy reversal.

Microsurgical Vasectomy Reversal – Vasovasostomy, Epididymovasostomy
A vasectomy reversal is a microsurgical operation that reestablishes a connection of the vas deferens, the tube that carries sperm into the ejaculate that was previously cut during a vasectomy.  At the time of vasectomy reversal, two procedures are possible:
1. A vasovasostomy may be performed, which is when the two ends of the vas deferens are reconnected. 
2. Sometimes an epididymovasostomy is performed, which is when the vas deferens is reconnected to the epididymis because of a secondary obstruction in the epididymis (see below).  Dr. Boyle performs both procedures entirely under the operating microscope.





















Choosing your Surgeon Wisely
When choosing a surgeon to perform your vasectomy reversal, it is essential to choose wisely.  Its not about simply choosing Dr. Boyle, but choosing a fellowship trained microsurgeon who performs vasectomy reversal procedures weekly and is considered an expert in this area.  Many urologists will offer to perform, and do perform vasectomy reversal when patients inquire, but are not adequately trained to do so.  Dr. Boyle worries about their outcomes and is committed to inform and educate patients on the importance of surgeon selection.  Dr. Boyle advises patients to call and speak to their prospective surgeon before making a consultation to inquire about their training and expertise.  A fellowship is a 1-2 year training period following residency which allows a surgeon to specialize in a particular procedure or technique, allowing them to have a true area of expertise.  There are only a handful of fellowships in microsurgery and male infertility nationally, and only a select number of urologists nationally who have completed this training and are capable of performing both a vasovasostomy and epididymovasostomy.  Beware of individuals who claim fellowship training but have only spent a few weeks in training - they have not completed a fellowship, but have observed an expert like Dr. Boyle.  Ask your prospective surgeon the number of vasectomy reversal procedures they have performed and how regularly they perform them.  Choose a surgeon who has performed a large number and performs them every week, not just a handful a year.  Ask your prospective surgeon their own personal outcomes - any microsurgeon who performs this procedure will provide their own results openly.  You must feel comfortable and confidant with your surgeon and feel that he or she is accessible to you. 

Sperm production
Sperm production occurs in the testis.  After passage through the efferent ducts, sperm are stored and undergo maturation in the epididymis.  The epididymis is a continuous, tightly coiled tube approximately 15-18 feet in length, which leads into the vas deferens.  Sperm that have not passed through the epididymis are generally not able to fertilize eggs under normal conditions.  The vas deferens is responsible for directed and propelling sperm into the urethra.

The decision of whether to perform a vasovasostomy or an epididymovasostomy depends upon the quality of the fluid from the testicular side of the vas deferens. The fluid is expressed and examined under a microscope at the time of surgery. 

If sperm are present in this fluid, then a reconnection between the two vas ends can be performed – vasovasostomy.  When sperm are present in this fluid, we expect >95% or more patients to demonstrate a return of sperm to their ejaculate postoperatively, with an associated 75% pregnancy rate.  If no sperm are present, but the vasectomy fluid looks abundant and appropriate for ultimate sperm production (clear, watery), then a vasovasostomy is performed with a successful outcome of 73%.  If poor-quality fluid is present (e.g., thick, pasty) and sperm are absent, or no fluid at all is found, then an epididymovasostomy (connection of the vas to the epididymis) is performed with a successful outcome of approximately 50%.



















Dr. Boyle’s Vasectomy Reversal Success Rates (updated 6/2008)

Fluid Quality   Sperm Present    Procedure PerformedSperm Return to Ejaculate      Pregnancy
GoodYesVasovasostomy98%   75%
GoodNo Vasovasostomy73%   60%
Poor No Epididymovasostomy50%   45%
         

Increasing numbers of men are coming to the urologist for vasectomy reversals, most commonly because of remarriage and the desire to initiate a pregnancy.  Vasectomy reversals are also requested by couples who have merely “changed their minds,” as well as by couples who have lost a child and are attempting to initiate another pregnancy. 

Microsurgical advances result in significant pregnancy rates, and it is essential that the surgeon be skillful with microsurgical technique, as precise suture placement is critical to the success of the procedure.  The surgeon must also have the ability to perform the more difficult epididymovasostomy procedure.

The success of a vasectomy reversal depends on:
1.  The skill of the surgeon
2.  The findings at the time of surgery




VASOVASOSTOMY

While there are many methods for performing a vasovasostomy, we prefer a strict, two-layer, watertight procedure utilizing microscopic sutures and the latest microsurgical equipment.   Selection of a single-layer, full thickness closure versus a strict two-layer (mucosal and seromuscular) closure is best dictated by the experience of the surgeon, which, indeed, is the most important factor in achieving the desired outcome.















EPIDIDYMOVASOSTOMY
Epididymovasostomy is a much more complicated procedure requiring a great deal more expertise at microsurgery.  A single epididymal tubule is incised just before the obstruction and gently squeezed for fluid.  The fluid is checked for sperm and, if none are present, a more proximal transection is made.  Unlike vasovasostomy, epididymovasostomy is never successful if sperm are not present within the tubule at the site of the anastomosis.  The anastomosis is then performed with two layers of extremely fine suture under the operating microscope.  Again, microsurgery is mandatory for an epididymovasostomy because of the small size of the epididymal tubule.

















The procedure is performed on an outpatient basis our surgicenter.  This facility boasts state of the art microsurgical equipment and the nation’s best anesthesiologists and hospital staff to assist in these procedures.  This arrangement allows you to return home or to a nearby hotel without actually being admitting directly to the hospital, thus saving considerable expense and making the overall experience much more pleasant. 

Operating time for a vasovasostomy or epdidymovasostomy is approximately 3-4 hours.  A general anesthetic is usually used.  We prefer that out-of-town patients stay in the Baltimore area for at least 1 day after surgery.  Postoperative follow-up includes an evaluation of the healing wound at 2 weeks and a semen analysis at 6 weeks.  Monthly semen analyses are then obtained for approximately 4-6 months, or until the sperm count stabilizes.  It can take up to 6 months for sperm to return to the ejaculate following a vasovasostomy and up to 1 year following an epididymovasostomy.  If semen quality is less than expected, anti-inflammatory medications are often introduced to decrease scarring.

Cryopreservation of sperm (sperm banking) can be performed at the time of vasectomy reversal if whole, motile sperm are present.  Cryopreservation is performed as a safety “backup” in case inadequate sperm counts are present after surgery.  Because vasectomy reversals may infrequently scar despite good initial results, cryopreservation may also be performed on ejaculated specimens early in the course of recovery when semen quality is exceptionally good.

Vasectomy Reversal Post-Operative Instructions
(These are general guidelines and should not be considered direct instructions from Dr. Karen Boyle.)

Please review the instructions below to assist in your recovery from your vasectomy reversal.

•Wear the scrotal support for at least one week following the procedure.

•Place an ice pack (a bag of frozen peas works well) inside scrotal support on top of gauze dressing – change every few hours until bedtime the day of the procedure.

•Keep the gauze and fluff dressing in place for one day.

•Relax and rest for one to two days following your procedure.  Avoid excessive walking, sitting for prolonged periods of time, and unnecessary exertion.  You will recover quicker and easier if you take it easy for these days immediately post-op.

•Avoid exercise (no running, heavy lifting, straining, etc.) for one to two weeks.  Avoid straddle activities like cycling, horseback riding for at least one month.

•It is expected to have a small amount of blood stain the gauze dressing.  Sometimes the incision may separate slightly before healing.  There may be some swelling and firmness at the site of the incisions.

•Take the antibiotic as prescribed to help prevent infection.

•You may take the narcotic medication as prescribed for discomfort or you may take over-the-counter Motrin or Advil as directed.  Do not take any aspirin products for two weeks following the procedure.

•You may shower tomorrow– pat your scrotum dry, do not rub.  Do not take a bath or go swimming for two weeks.

•The incisions were closed with absorbable suture.  This suture dissolves on its own and does not need to be removed.

•Abstain from intercourse and ejaculation for two weeks.  Then, begin having frequent, regular ejaculation.  This will help keep the reversal sites open and sperm traveling through the vas deferens into the ejaculate.

•Follow-up in two weeks for a postoperative appointment.  Call to make this appointment.  We will obtain the first semen analysis evaluation at six weeks following your vasectomy reversal.













Karen Elizabeth Boyle, M.D.
Reproductive Medicine & Surgery, Sexuality and Aesthetics

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  Karen E. Boyle, M.D.

  Phone: 877-290-5055
  Fax:     410-825-5811

Chesapeake Urology Associates at Greater Baltimore Medical Center (GBMC)
Physicians Pavilion North
6535 North Charles Street, Suite 625
Baltimore, MD 21204

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