Vasectomy Reversal | Vasectomy Reversals

Great question! What you are talking about is Intraoperative Vasal Fluid Microscopy. Here's a brief explanation...
At the time of the vasectomy reversal, the surgeon opens up the pipes and looks at the fluid coming out of the pipe that is coming from the testicle using a microscope at 400x magnification to look for the teeny tiny sperm to determine whether you need the More Simple or the More Complex "bypass" reversal to give you the best chances of getting sperm back in your ejaculate.

If your surgeon finds complete sperm (moving or not moving), then the pipes are obviously open ALL the way back to the testicle, and the surgeon knows that the More Simple reversal needs to be performed (Vasovasostomy - where the pipes are hooked up right where you had the vasectomy). In 1991, male fertility specialists looked at over 1200 patients who had the More Simple reversals (vasovasostomies) and found that the chances of getting sperm back in the ejaculate was 94% if moving complete sperm were found and 90% if there were complete sperm but they were not moving. They also found the pregnancy rates for these two groups were 63% and 54% respectively. This scenario of finding "complete sperm" makes sense and is pretty straight-forward.

The part that can get confusing and that requires a vasectomy reversal specialist who has had the proper experience and/or training with BOTH types of reversals is when there are NOT complete sperm. When sperm parts or no sperm are found, the surgeon must consider lots of other factors: How long has it been since the vasectomy? Is the amount of fluid coming out of the pipes a ton, enough or scant? Is the fluid clear, cloudy, creamy or pasty like toothpaste? Were the sperm parts just sperm heads or were there sperm with partial tails and then if so, were there a lot or just a few?

All those factors and questions must be considered because the More Simple reversal may actually NOT be the correct surgery for you. Some men may actually have developed a second area of blockage right behind the testicle in the refinery called the epididymis (click here for more details on an epididymal "blowout"). Your surgeon must take into consideration all these factors and decide whether you may actually need the More Complex "bypass" reversal (Vasoepididymostomy - sorry, not so easy to say which is why I call it the More Complex). One size does not fit all, and your surgeon must be ready to do either the More Simple or the More Complex on one or both sides. Remember, the correct surgery cannot be determined until your surgeon gets in there during surgery and considers all the factors when looking at the fluid coming out of the pipes.

Bottomline: If you want to get an idea if your surgeon is the right one for your vasectomy reversal, just ask them this question: What do you do if you find pasty fluid (like toothpaste) with NO sperm coming out of my pipes? The answer you are looking for is: "Boy, that would make me really concerned that you have another area of blockage that will require me to do the More Complex "bypass" reversal but that isn't an issue since I am very comfortable doing that type of More Complex reversal." Hope this helps...I know this is a lot to take in...but just talk to your surgeon and you will quickly get an idea if he or she is comfortable with determining what type of reversal you need and their comfort level with doing the More Complex surgery.

Reference: Belker et al. 1991 J Urol 145: 505; Kollettis 2011 SRM 9(4): p15

As the surgical technique for vasectomy reversal continues to evolve, microsurgeons strive to make the procedure as minimally invasive as possible in hopes of maximizing recovery and a man's post-operative comfort level. One area that has received attention is the size of the incision. Traditionally, incisions for the more simple vasectomy reversal (vasovasostomy) have been up to 3cm or larger. More recently, researchers in Canada have challenged this standard approach by looking at a novel "Mini"-Incision technique where the incision is less than 1 centimeter!

Dr. Grober and associates from Toronto, Canada in 2011 looked at 139 men who underwent bilateral vasovasostomies. Of these men, 55% had the "Mini"-Incision technique on both sides, 21% had the traditional incision on both sides, and 24% had the "Mini"-incision on one side with the traditional on the other side. They found that the "Mini"-Incision technique did not affect the chances of success or the semen parameters. Moreover, they found that the "Mini"-incision technique significantly reduced the severity of pain over the first 48 hours, and these men returned to normal activities 2 days earlier on average.

Bottomline: The "Mini"-Incision technique for the "more simple" vasectomy reversal on both sides reduces pain and helps men get back to normal activities sooner. The benefits of a smaller incision make sense and that is why we have been also using this minimally invasive approach at the Southwest Fertility Center for Men for the last several years. When looking into having a vasectomy reversal, the thought of a smaller incision can be quite captivating. While it is important, please remember that the "Mini"-incision technique only applies to the "more simple" reversal (vasovasostomy) when it is done on BOTH sides. If you end up needing the "more complex" bypass reversal (vasoepididymostomy) on any side, then this "Mini"-incision CANNOT be used. So don't forget about other critical factors when looking for a microsurgeon to do your vasectomy reversal: Do they do intra-operative vasal microscopy (looking at the fluid coming out the pipes during surgery to determine if the "more complex" bypass reversal is needed)? Are they comfortable and trained to do the "more complex" bypass if that is what is required to give you the best chances of getting sperm back? Remember that if it has been more than 3 years since your vasectomy, then there is a chance that you may need the "more complex" bypass so make sure your microsurgeon is ready to do this type of reversal if that is what you need and want. Thanks to Dr. Grober and his associates for great research that is making the vasectomy reversal experience more comfortable for men!!

Can I predict whether I will need the "more complex" bypass vasectomy reversal?

Reference: Grober et al. Urology. 2011 Mar;77(3):602-6. Epub 2010 Dec 24.

The goal of a vasectomy reversal is to have sperm return to the ejaculate. While the hope is to help couples conceive naturally ("good old-fashioned sex"), some couples may still require assisted reproductive technology (ART) using inseminations or in vitro fertilization (IVF) just like other couples where the man has not had a vasectomy. Is there a way to help couples predict whether their chances are higher for requiring ART after a successful vasectomy reversal?

Hsiao et al. from Cornell Medical College in New York reported their 2011 study on looking at the correlation of FSH and the need for ART after a successful vasectomy reversal. FSH is Follicle Stimulating Hormone and is a blood test that is a crude indicator of how well a man makes sperm. In general, a normal FSH roughly correlates with normal sperm production and a higher FSH correlates with poorer sperm production. (Please note: FSH is not a perfect test and should not be used in isolation. Seek the counsel of your male infertility specialist so they can look at all of your male fertility factors!).

They looked at 206 men who underwent a vasectomy reversal on average of 11-13 years after their vasectomy. The men were divided them up into two groups: 155 men with a normal FSH (average of 5.1 U/l) and 51 men with a high FSH (average 16.2 U/l). They found that the high FSH group used inseminations or IVF more frequently than men with normal FSH (78% vs 55%). It is important to see that couples may choose to use ART (inseminations or IVF) even if they choose to do a vasectomy reversal. Of the couples that they were able to follow, 47.8% got pregnant naturally or by using inseminations (using sperm in the ejaculate after a successful vasectomy reversal) and 40.7% got pregnant with IVF.

Bottomline: Every couple where the man has had a vasectomy must choose the reproductive option that best resonates with their reproductive needs and timetable. Some couples want to try natural conception first and choose to have a vasectomy reversal. Others are very comfortable with artificial conception or may not have the reproductive time to try naturally (advanced female age) and then choose IVF. What is important to realize is that it is NOT a binary decision. It is not just vasectomy reversal OR assisted reproduction like IVF. Some couples have a vasectomy reversal because they want a chance to conceive naturally, but talk to your partner. You may create a hybrid plan where you try to conceive naturally for a certain time period...6, 9 or 12 months...some number you both can agree on and at that time, if you haven't gotten pregnant, then agree together to pursue inseminations or IVF. Just because you choose IVF or inseminations, doesn't mean you will not conceive naturally for later kids. My point is that there are many options (vasectomy reversal, inseminations, and IVF). These options can be used in various combinations and various orders to help you build a family. Consult with your male fertility specialist to help you design the best reproductive plan for you and your partner (ideally, someone who does more than just vasectomy reversals, so that you can empower yourself with education about all your options).

Please note: Inseminations (where the sperm are washed and placed inside the woman's uterus at the time of ovulation) can only be used if the vasectomy reversal is successful and there are enough sperm in the ejaculate! I realize all this stuff is overwhelming and confusing so take the time to visit with a male fertility specialist. It will help to sit down with him or her and hash out all these details.

Reference: Hsiao et al. 2011 Journal of Urology 185: 2266

Ever wonder how many guys are having vasectomies in the United States? The National Centers for Health Statistics reported their most updated data from the National Survey of Family Growth and it was reviewed by Eisenberg et al. from Houston, Texas at Baylor University. From 2001 to 2007, it is estimated that over 1.9 million vasectomies were performed. The average is 322,838 vasectomies per year with the maximum being 512,277 vasectomies in 2006. The average age of men at vasectomy is 33 years old.

Bottomline: If you are looking at having a vasectomy reversal, then you are definitely not alone. Considering that up to 5% of vasectomized men decide to have a vasectomy reversal, that means that 16, 142 vasectomized men may seek out a reversal every year. When thinking about having a vasectomy reversal, definitely seek out a vasectomy reversal specialist near you. Ideally, they are fellowship-trained, can perform both the more simple and the more complex "bypass" reversal procedures and can help you optimize your fertility as a couple. Equally as important is to realize that there is probably someone you know who may have had one who can also be a great resource for you.

Reference: Eisenberg et al. 2011 Journal of Urology 185: 1541

Vasectomies are performed with the intent of "blocking off" the main pipes or “vas deferens”. The cut ends of the pipes are sealed off with heat, metal clips or surgical threads. 25% of the time, the end of the pipe that connects all the way back to the testicle is not completely sealed off. As a result, a small amount of sperm leaks out of that cut end and into the surrounding tissues in the scrotum.

Fortunately, the cut end of the pipe does not continue leaking sperm since your body seals off the area with a special type of scar tissue called a granuloma. Since it is scar tissue that surrounds sperm, it is called a “sperm granuloma.” If you have a sperm granuloma, it may feel like a firm bump that is about the size of a small marble. That is probably what your vasectomy reversal doc felt when examining you.

As you know, there are two types of vasectomy reversals: a more simple connection right where you had the vasectomy (the vasovasostomy) and the more complex "bypass" reversal (the vasoepididymostomy) where the main pipe or “vas” is plugged straight into the refinery behind the testicle (Click here to learn more). Men with sperm granulomas are twice as likely to need only the more simple connections. In 2004, Boorjian et al. from Cornell looked at 213 men who had underwent vasectomy reversals. Of the men who had sperm granulomas, only 14% required the more complex bypass reversal whereas 31% of men without sperm granulomas required that surgery.

Bottomline: If you have sperm granulomas, it’s a good thing. It means that you are twice as likely to need only the more simple connections. That’s good since these connections can be done through super-small openings via the “Mini-Incision” technique that allows us to work through an opening that is only 5 millimeters wide. With smaller incisions, your recovery tends to be faster which is always “a good thing”.

While tiny incisions are nice, it is more important that the proper type of reversal is performed. Just because you have sperm granulomas, there is still a 14% chance that you may require the more complex bypass reversal, so make sure your vasectomy reversal specialist is prepared and trained to do that more complex "bypass" surgery for you is the quality of fluid coming out of the pipe mandates a epididymal exploration and a vasoepididymostomy (Click here to see if you are likely to require the more complex reversal).

Reference: Boorjian et al. 2004. Journal of Urology. 171: 304-306.