What is a vasectomy?

To understand what a vasectomy reversal is, one must understand what the original procedure entails. A vasectomy is a short surgical procedure that involves cutting and sealing the two vas deferentia (singular: vas deferens) which are the tubes that carries sperm out of the epididymides (structures on the back of the testicles where sperm mature) during ejaculation. The procedure needs to be performed on both sides to be successful. A man with a vasectomy will still ejaculate, but there will be no sperm in the ejaculate, and therefore no sperm to fertilize an egg (to achieve conception). A vasectomy is thus a form of contraception that prevents pregnancy. Vasectomies are a more effective form of contraception compared to other male contraceptive methods such as condoms and spermicides. They are also sometimes referred to as “sterilization” procedures because they are an option for permanent contraception; however, this article will discuss how a vasectomy can be reversed.  

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Men can undergo vasectomy to prevent unwanted pregnancies, but there is a high level of variation in the frequency of vasectomy between countries. For example, for individuals aged 15-49 using contraception, 20 percent of couples rely on vasectomy in the United Kingdom, 19 percent in New Zealand, 15 percent in Canada, and 14 percent in Bhutan.ⁱ In the US, The National Survey of Family Growth estimates that 175,000 to 354,000 men undergo vasectomies each year.ⁱⁱ However, while the prevalence is quite high in certain geographic regions, in 2011, only 2.4 percent of men globally had a vasectomy.ⁱⁱⁱ

Can a vasectomy be reversed?

Following a vasectomy, a man may decide that he wants to be able to conceive again. This can happen later in life when an individual changes his mind, as in the case of a man with a new partner who wants children, or who wants more children than he anticipated at the time of the vasectomy. Based on evidence from review studies, it is estimated that up to 6 percent of men choose to have a vasectomy reversal.^iv,v

There are multiple methods for reversing a vasectomy. The two main reversal procedures are a vasovasostomy (VV) and a vasoepididymostomy (VE). VE is considered a more complex surgical procedure.^vi

Most men who have had a vasectomy are candidates for a vasectomy reversal surgery. In addition to wanting to restore fertility potential, men may also seek out a reversal in order to relieve pain experienced after the vasectomy (a rare condition known as post vasectomy pain syndrome, or PVPS).^vii It should be noted that while most men have the option to undergo vasectomy reversal, this does not necessarily guarantee future fertility as the reversal may not be successful.  

There is evidence to suggest that the success of a vasectomy reversal may be related to the length of time between the vasectomy and the reversal procedure. This is known as the “obstructive interval” (OI), which describes the amount of time the vas deferens was intentionally obstructed for. An older study by Dohl (2005) found that the rate of successful reversal (patency rate) was 89 percent when the OI was less than 5 years as opposed to 62 percent when the OI was greater than 15 years.^viii In sum, vasectomy reversals are more likely to restore fertility if less time has passed since the vasectomy was performed. In addition, if a longer time has passed between vasectomy and reversal, patients are more likely to require the more technically challenging vasoepididymostomy, as compared to vasovasostomy.^ix

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How does a vasectomy reversal work?

Vasectomy reversals are always performed by a urologist, often a urologist with special training in fertility procedures. If a patient is considering a vasectomy reversal, this is often discussed with a family physician, who can make a referral to a urologist. Some patients can see a urologist specializing in this type of surgery directly, without a referral from their primary doctor.

As mentioned previously, a vasectomy reversal consists of either a vasovasostomy (VV), or a vasoepididymostomy (VE). Both procedures involve reconnecting the vas deferentia, which were previously separated to prevent the passage of semen through the male reproductive system. In a VV, the cut ends of the vas deferens are reconnected to each other. In a VE, the cut end of the vas deferens is instead reconnected to the epididymis itself. A reversal procedure is typically performed on both sides to increase success. In some cases, a VV may be performed on one side and a VE on the other depending on certain surgical factors, which will be discussed below.  

Since the 1970s, many urologists have used a microscope to perform both VV and VE as this technique has been shown to improve the success of reversal over using natural (unmagnified) vision^x. More recently, some urologists have started using a specialized robot instead of a microscope, which is felt to have similar outcomes compared to the microscopic procedure^xi. A VV is the more straightforward procedure, while a VE is more technically challenging.^xii

The decision to perform a VV or VE is made intraoperatively depending on the composition of the fluid present within the side of the cut vas deferens that connects to the epididymis. The fluid is extracted and examined under a microscope at the start of the procedure. If there are whole sperm seen within the fluid, this indicates that the epididymis has an unobstructed connection to the vas deferens and a VV can be performed on that side. If there are no whole sperm seen within the fluid, only sperm heads or no sperm, there is concern that there is a blockage between the vas deferens and the epididymis, so the urologist may perform a VE on that side instead.^xiii Some urologists may also opt to cancel the procedure if they do not see any sperm or sperm parts of any kind in the fluid, due to the much lower success rate in this case.^xiv

Vasovasostomy

During a vasectomy, the vas deferens is cut and obstructed to prevent the passage of sperm to prevent conception. During a vasovasostomy, the two ends of the vas deferens that were separated and blocked are directly reattached to form an open, or patent tube. This reconnection is referred to as a “reanastamosis”. The two ends of the vas deferens are sewn together with tiny sutures.^xv

The operation can technically be performed using a macroscopic approach (with the surgeon visualizing the vas deferentia directly), or by a microscopic or robotic approach (surgeon visualizing using a microscope or robot). A study by Duijn et al of 8 305 patients found that the macroscopic approach had a patency rate of 80.5 percent, and a pregnancy rate of 47.7 percent. The microscopic approach was more effective, with a patency rate of 91.4 percent and a pregnancy rate of 73.3 percent.^xvi Because of the improved outcomes with the microscopic or robotic approach, many consider this technique to be the gold standard method. However, because this does require more training, cost, time and resources, some urologists perform the procedure either with natural vision or magnifying glasses given the known, but ^xviislightly reduced, success rate.^xviii

The term “patency” refers to the openness, or lack of blockage in the vas deferens tube – the goal of the vasectomy reversal is to make the surgically obstructed tubes open again so that sperm can enter the ejaculate. As such, restoring patency is a measure of success in vasectomy reversal.  

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Vasoepididymostomy 

For some patients, a vasoepididymostomy will be required on one or both sides. The key difference between the VE and the VV has to do with where and how the vas deferens tube patency is restored. While during a VV the two separated ends of the vas deferens are reconnected, this is not the case during a VE. Instead, one of the severed vas deferens ends is attached directly to an epididymal tubule within the epididymis (the structure on the back of the testicle where sperm matures). This requires the testes to be brought into the surgical field so the epididymis can be accessed.^xix VE is technically more difficult, as both the vas deferens and epididymal tubule structures are very small and there is a size discrepancy between the two anatomical parts. The vas deferens already has a very small diameter of 0.3-0.5 mm, while the epididymal tubule has an even smaller diameter of 0.15-0.2 mm.^xx

A VE is done instead of a VV if there is an obstruction of the epididymis or vas at a location other than at the original vasectomy site, which can be determined by examining the fluid within the vas deferens as noted above. In addition to a longer OI, indicators that a VE may be required rather than a VV include older patient age and if the procedure is a repeat attempt at vasectomy reversal.^xxi If a VE is required on both sides (bilateral VE), the success rate of vas deferens patency is lower at 40-60 percent.^xxii

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What happens after a vasectomy reversal? 

Since a vasectomy reversal is performed under general anesthesia, patients are asleep during the procedure. Following the procedure, patients are moved to a recovery room^xxiiiand can go home once they are able to tolerate eating and drinking and have effective pain management with oral medications.^xxiv Often, pain control is achieved without opioids, usually with ice, acetaminophen (Tylenol) and an anti-inflammatory such as ibuprofen (Advil or Motrin) or celecoxib (Celebrex).^xxv Some doctors do prescribe opiate pain medications after the procedure. After discharge from the hospital, patients are typically recommended to refrain from ejaculation and strenuous exercise for four weeks, sometimes more or less depending on surgeon preference.^xxvi

Following a vasectomy reversal, semen analyses are recommended every 2-3 months until sperm motility and concentration normalizes, or until pregnancy is achieved. Patency of the vas deferens indicates a successful vasectomy reversal and is defined as any motile sperm parts in a semen analysis.^xxvii While pregnancy is much more likely to result in the cases where semen analysis parameters are restored to normal or near-normal values, some studies have found that pregnancy is possible, though less likely, even if post-procedure sperm parameters are restored but remain abnormally low. For example, a study by Majzoub et al (2017) found that pregnancy was achieved post-vasectomy reversal in 21.3 percent of patients with (low) total sperm motility of <10 percent, in 15 percent with a (low) sperm concentration of less than 5 million/mL, and 14.8 percent with a (low) normal sperm morphology of <1 percent.^xxviii

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Does vasectomy reversal carry any risks?   

Vasectomy reversal surgery is usually safe but has rare complications including hematoma (bleeding leading to blood pooling within the scrotum), infection, and persistent pain (in patients undergoing the procedure to address post-vasectomy pain syndrome).^xxix The most common postoperative complication is the formation of a scrotal hematoma. This typically does not require treatment and usually self-resolves in 6-12 weeks. If the hematoma is not resolving, a tube can be placed within the scrotum to allow for the hematoma to drain or it can be surgically removed through a small incision.^xxx  

There is also a risk of re-obstruction of the vas deferens or epididymis following a previously successful vasectomy reversal. The risk of this is between 3-12 percent after VV, and 21 percent after VE. Re-obstruction of the vas deferens results in infertility again, as sperm become unable to enter the ejaculate and therefore conception cannot occur.^xxxi

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Alternatives to vasectomy reversal 

When a man with a vasectomy decides he wants to conceive a child, or restore his fertility, a vasectomy reversal is not the only option available. While vasectomy reversal is one option, patients may also opt to pursue in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) utilizing some form of sperm retrieval. There are different ways that sperm can be retrieved for ICSI, including testicular sperm extraction/aspiration (TESE/TESA) and Percutaneous Epididymal Sperm Aspiration (PESA).  Most of these procedures can be performed without general anesthesia utilizing either local anesthesia (injection of a medication such as lidocaine to numb the patient) or light sedation. A urologist may also offer to perform a sperm extraction at the same time as a patient’s vasectomy reversal. This way, if the reversal is not successful, the patient will also have banked sperm to be used in IVF and they will not need to undergo a second procedure to extract sperm. If the vasectomy reversal is successful and pregnancies result, the extracted and banked sperm can then be discarded.  

When comparing vasectomy reversal and IVF/ICSI with sperm retrieval, vasectomy reversal has the following advantages/disadvantages:^xxxii

Advantages

• Can improve post-vasectomy pain syndrome if present
• Only requires a single intervention, if successful, to fully restore fertility  
• Allows for conception at home
• May be less expensive than extraction combined with IVF/ICSI (though the reversal surgery itself is more expensive than sperm retrieval alone)
• Allows patient’s partner to avoid possible risks of IVF/ICSI if there are no concurrent female fertility concerns

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Disadvantages

• Requires a urologist who is trained in microsurgery
• If not successful, patient may then need sperm extraction procedure if this is not performed at the same time as reversal procedure

IVF with sperm retrieval has the following advantages/disadvantages:

Advantages

• Genetic disease screening possible on embryos created with IVF
• Can be used even if there have been multiple vasectomy reversal failures or if there are concurrent male fertility concerns such as known low sperm counts even prior to vasectomy or hormonal issues
• Useful if there is female factor infertility as well
• Lower surgical and anesthesia risk (extraction can be performed with local anesthesia or sedation compared to general anesthesia for reversal)
• Shorter time interval between procedure and attempt at conception (sperm can be used immediately for IVF as compared to several month wait to see if VV/VE restores fertility)

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Disadvantages

• Sperm extracted must be used with IVF/ICSI and cannot be used for home or intrauterine insemination (extracted sperm are not fully motile)
• More expensive overall in countries where IVF/ICSI are not covered services (though the extraction procedure itself is less expensive)
• May require multiple procedures if multiple pregnancies are desired and sufficient sperm are not extracted at the time of the first procedure (though in many cases a single extraction produces enough sperm for several cycles of IVF)
• Higher risk of multiple gestation pregnancies and maternal risks due to use of IVF which has increased morbidity/mortality
• Requires a specialist in reproductive endocrinology and infertility

The American Urological Association released a Best Practice Statement that recommends IVF/ICSI over vasectomy reversal if:^xxxiii

1. The female has diminished ovarian reserve (due to age or any other condition)

2. There are other coexisting female factors that decrease fertility  

3. A secondary condition is decreasing the male's fertility, aside from the vasectomy.  

4. There is a higher likelihood of success from IVF/ICSI rather than from vasectomy reversal alone

Overall, the gold standard treatment for male infertility due to vasectomy remains vasectomy reversal.^xxxiv  

Fertility after vasectomy reversal: measuring success 

Success of a vasectomy reversal procedure can be measured by semen analysis, in which ejaculated semen is collected and assessed under a microscope. As previously mentioned, patency is typically defined as the presence of any sperm in the postoperative ejaculate, which indicates a successful procedure.^xxxv

The time it takes for sperm to return in the ejaculate depends on the type of vasectomy reversal procedure. After vasovasostomy, the mean time for sperm to return is 1.7-4.3 months, while after vasoepididymostomy, the mean time is slightly longer at 2.8-6.6 months.^xxxvi

Failure of a vasectomy reversal may occur early on or at a later stage. While early failure is often due to an unrecognized obstruction that was not corrected during the vasovasostomy, late failure can occur due to narrowing of the anastomosis (where the vas deferens was reconnected or connected to the epididymal tubule). Late failure typically occurs 6-14 months postoperatively. The published  failurerate of bilateral VV or unilateral VV with opposite side VE is lower at around 13 percent (range 2-20 percent) , and higher for bilateral VE at around 50 percent.^{xxxvii,xxxviii}

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Vasectomy reversal vs sperm retrieval when trying to conceive 

The pregnancy rate for vasectomy reversal compared to that of IVF/ICSI with sperm retrieval is similar.^xxxix One meta-analysis of the pregnancy rate following vasovasostomy (which included older women) found that the pregnancy rate was 73.0 percent, and there was a higher pregnancy rate if the obstructive interval was <10 years.^xl After a vasoepididymostomy, the pregnancy rate was found to be lower at 31.1 percent.^xli In comparison, cumulative pregnancy rate after IVF/ICSI are 46.9-69.4 percent in women < 35 years old, 35.5-62.0 percent in women aged 35-40, and 18.2-34.0 percent in women > 40 years old.^xlii

While both vasectomy reversal and IVF/ICSI are options for achieving fertility, a study from Uvin et al (2018) found that the time to pregnancy was quicker in the IVF/ICSI group compared to a group that underwent vasectomy reversal. In this study of 163 males undergoing vasectomy reversal or IVF/ICSI, the time to pregnancy was 8.2 months in the IVF/ICSI group compared to 16.3 months in the vasectomy reversal group. The same study found that the cumulative delivery rate was similar between the IVF/ICSI group and the vasectomy reversal group. The IVF/ICSI group had a 43.8 percent cumulative delivery rate, compared to 40.0 percent in the vasectomy reversal group, and the difference between the two groups was not found to be statistically significant. Therefore, both options have a similar efficacy at restoring fertility.^xliii

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Conclusion  

While still intended to be a permanent sterilization method, most men who have had vasectomies in the past are able to reverse them, and potentially restore their fertility. The rate of success in restoring fertility depends on various factors, such as the length of time since the original procedure and age. There are also less invasive options to vasectomy reversal, namely sperm retrieval procedures (i.e., TESE, PESE) for use in IVF with ICSI. To determine which procedure is best for individual circumstances, patients should speak to their family doctor or a urologist.

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