Family doctor

Between one and three percent of men who have had a vasectomy will seek a reversal. The reason is usually due to remarriage but quite a few couples decide for various reasons to have further children. In a large multi centre study in the USA, the average age of a man presenting for a reversal was 37, following a vasectomy performed on average, seven years before. The operation is usually done under general anaesthetic and overall, gives rise to a 50 percent chance of a baby.

The Operation

A vasectomy reversal is usually performed through incisions each side of the scrotum that are a little larger than those used for the vasectomy. The vas is a very small muscular tube with a 2mm outer diameter and an inner diameter through which sperm flow (the lumen), of less than 1/2mm. Since the structure is so small, the stitches must be placed very exactly so that there is minimal scaring. Too much scarring can cause the lumen of the vas to close and the procedure to fail. Best results are achieved by the use of an operating microscope with placement of tiny sutures that can barely be seen with the naked eye. The operation is usually done under a general anaesthetic and takes on average two hours. However, you usually only stay for the day, going into hospital in the morning and home in the evening. Most men find it no more uncomfortable than having a vasectomy and Panadol is usually adequate pain relief. You obviously cannot drive yourself home the same day as the operation. It is most important to take the next week off work and spend most of the time lying down. If you must get up and about, please use supportive underpants.

Practical points

1. Do not eat or drink after midnight if your operation is in the morning, and not after 7.00am if it is in the afternoon.
2. Please shave the hair at the front and sides of the scrotum from the base of the penis down. You do not need to shave the pubic hair.
3. Take supportive underpants (not your best) or a jockstrap into the hospital with you and to theatre to wear after the operation.
4. Arrange a week off work.
5. Avoid intercourse for two weeks after the operation and heavy lifting for four weeks.

Complications

Complications following a vasectomy reversal are rare. The commonest complication is bleeding from the edges of the scrotal incision but this is usually just an ooze and stops over the following 12 hours. Occasionally, a large bruise develops in the scrotum - this is usually apparent before you go home, and settles with time and rest. An infection of the scrotum rarely occurs but if it does, will present a few days after the surgery and is apparent because the pain becomes worse rather than better and the scrotum becomes red. If this or other problems occur, please contact your surgeon.

Chances of Success

All studies on results agree that there is a correlation between the chance of a pregnancy and the length of time since the vasectomy - the shorter the interval, the better the outcome. The biggest study on vasectomy reversal showed that if the interval was less than three years, 75 percent of couples achieved a pregnancy, if three to eight years, 50 percent, nine to 14 years, 40 percent and over 14 years post vasectomy, 30 percent of couples achieved a pregnancy. There were over 1,000 couples in the study and the overall pregnancy rate was 52 percent. Repeat vasectomy reversal reversals were less successful with only 40 percent of couples achieving a pregnancy. Other factors that influence success are the use of an operating microscope and whether or not sperm are present in the vas fluid expressed at the time of the operation.

Follow up

You will be asked to re-attend five days after surgery for a check of the sutures and then six weeks later. It is best if you can bring in a semen analysis to our laboratory a few days before the six-week check to see if there are sperm present in the ejaculate. Usually there are some sperm present in low numbers and with low motility, but do not despair if there are none since it can take up to six months for sperm to return. The count and motility usually improves with time and it can take between three to eight months for sperm quantity to become normal. If sperm have not appeared within six months, then the reversal has failed. In up to six percent of men who have return of sperm to the ejaculate, gradual scarring, called fibrosis, can occur at the reversal site with later loss of all sperm in the ejaculate. This usually occurs quickly after a reversal but has been reported up to two years later. If you are concerned about this possibility, then think about storing sperm once you get a good sperm count after the reversal.

The average time to a pregnancy is 12 months and almost all will occur within three years. If a pregnancy has not occurred within six months, especially if the woman is older than 35, then further investigations are indicated. This will involve sperm antibody testing and female fertility evaluation.

Although up to 80 percent of men will have sperm in their ejaculate following the reversal, not everyone will achieve a pregnancy. Often, presumably due to the back-pressure causing damage to the testis, the count is low and/or the motility is decreased. However, even if the semen analysis is normal, a pregnancy does not always occur and so it is sensible to look for sperm antibodies.

About 75 percent of men develop antibodies against sperm following a vasectomy and these can interfere with sperm transport in the female genital tract and also interfere with the process of fertilisation. Often people wonder about whether a blood antibody test done before a vasectomy reversal will help give some idea as to the chances of success from the procedure. Unfortunately, it does not predict the chance of success. It is antibodies on the sperm that correlate with chances of a pregnancy and so, this test is certainly worth doing if a pregnancy does not occur within six months of the operation.

Other Options

Often couples wonder if sperm can be retrieved from the testis and used for fertilisation, thus sparing the man an operation. Unfortunately, this is not as easy as it sounds because the sperm in the vas and epididymis have been present for a long time because of the blockage and are often old, degenerated and lacking in fertilising potential. Also, sperm numbers are too low to inseminate into the woman and so IVF technology has to be used.

However, if there are no sperm in the ejaculate, after a reversal, or the number of sperm are low, or a vasectomy reversal is not technically feasible, IVF with sperm microinjection (ICSI) offers as good a chance of pregnancy as any other couple doing IVF. A vasectomy reversal almost always gives rise to as good a chance of pregnancy as one IVF/ICSI cycle, and so a reversal is usually chosen as the first option.

Since the IVF/ICSI option entails sperm retrieval from the epididymis or testes, couples often consider having sperm retrieved and stored at the time of the vasectomy reversal (Micro Epididymal Sperm Aspiration - MESA), especially if the chances of success with a vasectomy reversal are lower than average because of the long duration from vasectomy. The MESA procedure should not compromise the chances of success from vasectomy reversal and would add only $500.00 to the cost. As already mentioned, a repeat vasectomy reversal also may give rise to a better chance of pregnancy than one IVF/ICSI/sperm retrieval cycle.

There are at least three causes of failure of vasectomy reversal. The commonest by far is due to a blockage at the reversal site. Sperm tend to leak out of the operation site on the vas when a reversal has been performed. If excessive, the leakage can give rise to scaring. The second cause of a failed reversal is where there has been a secondary blockage in the epididymis due to the back-pressure from the original vasectomy. Since some men, who have no sperm in the cut end of the vas at the reversal procedure, subsequently get sperm in their ejaculate over time, it is usually not possible to diagnose this secondary blockage at the time of the vasectomy reversal operation. An operation to bypass this blockage is called a vasoepididymostomy and can be associated with a 25 percent chance of a pregnancy.

Finally, in a very few men, sperm production in the testes may have ceased following vasectomy. If this is thought to be the cause in your case, then a testicular biopsy should clarify this.

An alternative option to vasectomy reversal and IVF/ICSI/sperm retrieval is of course the use of donor sperm and sometimes couples choose this option. Although much simpler and usually giving rise to a better chance of a family, there are many differences that must be clearly understood before couples choose this option. We have information available on this option.