Vasectomy Reversal Techniques to Fit Your Needs
Vasectomy reversal is a microsurgical procedure performed by a specialty-trained Urologist that reconnects the male reproductive tract after interruption by a vasectomy. Two procedures are possible at the time of vasectomy reversal: vasovasostomy (vas deferens to vas deferens connection) and epididymovasostomy (epididymis to vas deferens connection). There are a number of other vasectomy reversal techniques, which Dr. Larry Lipshultz can expertly provide from his Houston practice.
The patient is positioned supine (laying flat on his back). The choice of anesthetic used for vasectomy reversal is based on surgeon and patient preference. Local anesthetic and intravenous sedation may be utilized. However, general anesthesia or an epidural is preferable if (1) the patient is highly anxious, (2) the expected procedure length is greater than 3 hours, or (3) extensive dissection of the vas or epididymis is anticipated.
Instrumentation: Microscope, Tools, Sutures
The microsurgical approach is recommended and uses a high-powered microscope to magnify structures from 5 to 25 times their actual size. Use of an operating microscope provides better results, as it allows the urologist to manipulate stitches smaller in diameter than an eyelash to join the ends of the vas in 2 distinct layers.
The microsurgical instruments, from scissors to forceps and needle holders, should be customized to each surgeon’s hands and technique. 9-0 sutures (0.03 mm in diameter) and 10-0 sutures (0.02 mm in diameter) are used to sew the vas deferens together or the vas deferens to the epididymis.
The quality and quantity of fluid from the testicular end of the vas deferens is evaluated to help determine whether a vasovasostomy or epididymovasosotomy will be performed. During surgery, a drop of this fluid is then placed on a microscope slide and viewed under 400x magnification to look for the presence of whole sperm or sperm parts, and to evaluate sperm motility.
The pregnancy rate and likelihood that sperm will be present in the ejaculate are higher when the fluid appears watery (colorless, transparent, clear) or cloudy. If the fluid is thick and creamy, the rates diminish. The overall success rate is good when the fluid contains sperm (motile or nonmotile) or sperm parts. Some experienced microsurgeons prefer to perform a vasoepididymostomy if only sperm parts or no sperm are seen.
2- vs. 1-Layer Closure
The 2-layer closure brings together the inner (mucosal) layer of the vas deferens or epididymis with 10-0 sutures and the outer (seromuscular) layer with 9-0 sutures. A modified, 1-layer closure may be considered simpler, more expeditious, and may not require an operating microscope. A study directly and rigorously comparing the patency and pregnancy rates between 2-layer and 1-layer closures has not yet been performed, but it is generally believed that a 2-layer procedure performed by an experienced microsurgeon yields the best result.
If the patient wishes to bank sperm as determined through conversations pre-operatively, motile sperm identified in the fluid can be collected for cryopreservation. If whole sperm are identified, but none are motile, a testicular sperm extraction (TESE), in which tissue is removed from the testicle itself, can be performed at the end of the procedure.
A gentle pressure dressing and scrotal support are placed following the operation. An ice pack should be applied intermittently for 24 hours after surgery, and a scrotal support or briefs are encouraged for 2 weeks. Light physical activity is suggested for 3 weeks after the reversal, and patients are encouraged to abstain from sexual activity for 2 weeks. Oral analgesics are adequate for pain control. The urologist will request a semen analysis every two to three months after surgery until the sperm count either stabilizes or pregnancy occurs. While sperm generally appear in the semen within a few months after a vasovasostomy, it may take from 3 to 15 months to appear after a vasoepididymostomy.