Reversing Vasectomy

Vasectomy is considered a permanent method of contraception; however, since 1977 when principles of modern microsurgical techniques for performing vasovasostomy were popularized, the frequency of vasectomy reversals has progressively increased to become one of the most commonly performed surgeries for male infertility.^{1, 2} About 6% of the vasectomized men in the US seek reversal annually.³ 

The majority of the providers who perform vasectomy reversals are urologists.^{4, 5, 6, 7} The most common procedure for reversal is re-anastomosis of the cut ends of the vas, known as vasovasostomy. Occasionally vasoepididymostomy, or anastomosis of the vas directly to the epididymis, is done. Among the reasons men request vasectomy reversal are divorce from current partner, remarriage, loss of children, or desire for more children.^{8, 9, 10, 11} In some cases, vasectomy reversal has been recommended or performed to relieve postvasectomy pain syndrome, which may be related, at least in part, to epididymal engorgement with sperm or sperm granuloma formation due to back-pressure-induced rupture of epididymal tubules.^{12, 13, 14, 15, 16, 17}

Theoretically, there is no reason that fertility should not be restored following vasectomy reversal, because significant impairment of spermatogenesis after vasectomy is extremely uncommon.^{18, 19, 20, 21} Indeed, technical success (i.e. the reappearance of sperm in the ejaculate following reversal) is fairly high. However, in most cases, the desired endpoint of vasectomy reversal is pregnancy, and it must be emphasized that pregnancy rates are always lower than the rates of technical success. Technical factors in the reversal surgery itself present a challenge because the vas is thick-walled with a narrow lumen, and often the distal (testicular) end is dilated after vasectomy, leading to a pronounced difference in diameter of the proximal and distal lumens.^{9, 22} In addition, other factors, including time since vasectomy until reversal is performed; secondary changes in the epididymis such as obstruction due to granuloma formation; presence of partial obstruction following reversal surgery; permanent molecular and biochemical changes in the epididymis as reflected by changes in gene function, DNA, microRNA and specific proteins; levels of antisperm antibodies; and age of the female partner, may play a role in whether or not pregnancy is achieved following vasectomy reversal.^{23, 24}

In the past few years, nomograms to predict long-term outcomes following a microsurgical vasectomy reversal procedure have been developed, validated and adopted for use.⁵ Nomograms take into account significant pre- and intraoperative factors such as testicular volume, type of fluid found in the epididymis and presence of sperm in epididymis to predict the outcomes. They are used to guide the surgeon in the discussion of other options such as assisted reproduction for vasectomized men with a poorer prognosis of patency.^{25, 26}

Those involved in screening and counseling men for vasectomy should carefully evaluate them to determine whether they are seeking vasectomy as a temporary measure, because the restoration of fertility cannot be assured and efforts to do so can be costly. Men who have emotional problems or who desire vasectomy to improve an unstable marriage may be worse after the procedure and would be likely candidates to seek re-anastomosis. Changes in some economics factors such as unemployment rates have also been shown to directly correlate with vasectomy rates and inversely correlate with vasectomy reversal rates.²⁷ Careful screening, counseling, and client selection should reduce the demand for reversal. However, vasectomy should be performed by the surgeon in such a way as to consider the possibility that the man might seek reversal in the future.²⁸

Evaluation before vasectomy reversal should start with an interview with the client and, if possible, his female partner. Details regarding his original fertility status and details of the vasectomy, including date, procedure used (if the operative report is available or discussion with the original surgeon is possible), and complications, may provide important information regarding the chances of successful restoration of fertility. Important historical information should be obtained, including injuries or infections of the testicles or epididymis and general health problems such as urinary tract infections or diabetes. Physical examination should include palpation of the site of vasectomy. Nodularity in the convoluted vas or epididymis could diminish the possibility for successful reversal. The examination should evaluate the size, shape, and consistency of the testicles.

When appropriate, the female partner should be advised to undergo a fertility investigation. The gynecologist should communicate with the operating surgeon regarding the female partner’s status and her chances of pregnancy. Sometimes a man requests restoration of fertility for his own reasons, regardless of his partner or when he has no partner. As with vasectomy, such requests should be honored if there are no medical or other contraindications. The surgeon must be sure that the client understands that restoration of sperm to the ejaculate does not guarantee pregnancy and that the success of the technical procedure may not satisfy the ultimate desires of the couple.

Other options for achieving pregnancy should also be discussed with the patient before a decision is made to perform the reversal procedure. Most men who have had vasectomy prefer vasectomy reversal rather than assisted reproduction which is more costly, and subjects the woman to some invasive procedures.²⁹ Conversely, in situations where the female partner is confirmed to have other conditions that may adversely affect the desired outcome such as infertility as a consequence of bilateral tubal occlusion or advanced age, it is advisable for the couple to be counselled accordingly and if they consent, initiate a work up for assisted reproduction.^{30, 1, 31} Other options for non-biologically related children such as adoption or sperm donation can also be discussed depending on circumstances. It is during this time of counselling, when the surgeon also discusses the different surgical approaches that would be performed for the reversal including risks and success rates duration of the surgical procedure, period of recovery postoperative care and follow-up.³⁰

Local, regional and general anesthesia may be used for the procedure, however, with increasing adaptation of more demanding microsurgical techniques, regional and general anesthesia are preferable.^{31, 32}

Over the past several decades a number of techniques, including macroscopic and microsurgical approaches, have been used to perform vasectomy reversal. Regardless of what specific technique is used, the key to success is to accurately appose the two ends of each vas to establish a watertight anastomosis that prevents sperm leakage and subsequent granuloma formation as well as allows for unobstructed flow of sperm.

Although patency and pregnancy rates may be high following macroscopic reversal when performed by some experienced providers, low rates have also been reported, and the current consensus is that results with microsurgical approaches are superior to those with macroscopic techniques, with or without the use of a magnifying loupe.^{22, 32, 7} Table 1 shows reported patency and pregnancy rates following macroscopic and microsurgical vasectomy reversal.

Table 1. Patency and pregnancy rates following vasectomy reversal

*Patency as demonstrated by sperm in the ejaculate. The timing of assessment and exact definition (e.g. presence of any sperm, presence of motile sperm, no details provided) varied among studies.

The two main methods of microsurgical reversal are two-layer anastomosis and modified one-layer anastomosis.⁵¹ Both involve placement of interrupted sutures using an operating microscope. Sutures should be fine and nonirritating (e.g. 9–0 or 10–0 nylon). With two-layer anastomosis, sutures are first placed in the mucosal layer, and then a second set of sutures is placed in the muscle layer. The modified one-layer approach involves placement of several full-thickness sutures, followed by additional sutures through the muscle layer only, which are placed between the full-thickness sutures.⁵² Similar results have been reported using the two-layer and modified one-layer approaches (Table 2). The modified one-layer approach may be beneficial in that it takes less time. However, the two-layer approach allows for better apposition of the cut ends of the vas in cases in which there is a large difference in the diameters of the cut ends.

A three-layer anastomosis technique has also been developed and tested with outcomes comparable to the two-layer and modified one-layer techniques (Table 2). The anastomosis is performed with an end-to-end technique. The first layer is the mucosal layer, which is apposed with 10–12 non-absorbable 10-0 sutures. The second layer involves apposing the muscle layer with approximately ten 9-0 non-absorbable sutures. The sutures in the muscle layer provide tension relief to the more fragile internal layer. Finally, for the third layer, approximately ten 8-0 sutures are placed in the adventitial connective tissue surrounding the duct, which prevents tension on the internal mucosal layer. Some of the advantages of the three-layer technique as reported by Schwarzer et al. are that there is a tension-free anastomosis achieved with the use of connective tissue, better vascularization of the duct and an improved ability to address luminal disparity than with modified one- or two-layer reversal.⁵⁰

Other modifications to the above-described technique(s) include the use of mini-skin incision to reduce postprocedure morbidity. The approach described by Jarvi et al. adopts the use of instruments recommended for no scalpel vasectomy and therefore an incision length of less than 1 cm is adequate for good exposure compared to the standard or recommended 2–3 cm length of the incision.^{53, 54}

Table 2. Patency and pregnancy rates for three-layer, two-layer and the modified one-layer microsurgical vasectomy reversal

^a Differences are not significant

During vasectomy reversal procedures, the surgeon should perform a microscopic examination of the fluid obtained from the testicular end of the vas. Temporary muscle spasm may prevent the initial exudation of fluid. In some cases, gently massaging the vas, probing the lumen, or irrigating with saline may initiate the flow. The character of the fluid may provide some indication of the likelihood of success of the reversal and may also influence the decision to do a vasoepididymostomy as opposed to a vasovasostomy. If sperm (either motile or nonmotile) or even just sperm heads are present in the intraoperative vas fluid, then vasovasostomy is the preferred method for vasectomy reversal.⁵¹ This usually indicates a good prognosis and early appearance of sperm in the ejaculate. In some instances, depending on the preference of the couple, sperm may be collected for preservation and immediate or later use in ART. If sperm are not present in the vas fluid but the fluid appears watery (i.e. clear, colorless, and transparent), vasovasostomy should still be the procedure of choice, because sperm often reappear in the ejaculate with time in these cases.^{8, 58} When sperm are absent from the vas fluid and the fluid appears cloudy or is creamy or paste-like in consistency, then vasoepididymostomy may afford a higher chance of success.^{52, 59} 

Vasoepididymostomy is a technically demanding microsurgical procedure, in part because it may be difficult to identify the proper epididymal tubules that lead to the testis and because of the large difference in diameter between the vas and epididymal tubule.⁴⁶ Since it is unlikely that the need for vasoepididymostomy can be determined before the surgery it is recommended that only surgeons skilled in both vasovasostomy and vasoepididymostomy perform vasectomy reversals.⁵¹ Although success rates are lower than those for vasovasostomy, reasonable success can be achieved following vasoepididymostomy. Patency rates have been reported to range from 55% to 85%, with pregnancy rates being in general much lower.^{22, 59, 60, 61, 62, 63} Although pregnancy rates following vasoepididymostomy have been reported as high as 84%,²² most often they around 50% or less.^{46, 47, 59, 60, 61, 62, 63, 64} Unlike vasovasostomy, if no sperm are seen intraoperatively from fluid or a touch preparation obtained from the epididymis during vasoepididymostomy, the chance of successful reversal is minimal.^{63, 65, 66, 67} It is recommended that the surgical team should explore for evidence of blockage and select a different section of the tubule where epididymal fluid and possibly sperm is present and perform the anastomosis at that point. The detection of such fluid may be done by aspiration.^{1, 68}

Postoperative recovery typically takes 2–3 weeks. Use of a scrotal support and ice packs is also encouraged to prevent hematoma and edema. The use of antibiotics is at the discretion of the surgeon. Patients are advised to avoid strenuous exercises and sex for several weeks; some surgeons recommend refraining from sex for at least 2 weeks postoperatively while others recommend refraining for up to a period of 4 weeks after the procedure.^{1, 32, 68} Use of non-steroidal anti-inflammatory drugs or steroids have also been recommended for better outcomes.³¹ Postoperation follow-up includes serial semen analysis from as early as 6 weeks up to 21–24 months; return to fertility could take up to 2 years after vasectomy reversal.⁶⁹

Intra- and postoperative complications are rare, the frequency ranging between 2 and 3%. Complications include scrotal hematoma, granulomas, persistent pain, bleeding, infections, obstruction, and surgical failure. Reported rates of obstruction following vasovasostomy range from 3 to 12% and about 21% for vaso-epididymostomy.^{1, 31, 32, 68, 54}

Time between vasectomy and vasectomy reversal

Silber⁵⁸ first reported that one of the most important factors influencing return of fertility after vasectomy reversal was the duration of time the vasa deferentia had been obstructed. The longer the interval between vasectomy and reversal, the less likely the reversal was to be a success.

The Vasovasostomy Study Group reported that if the interval was less than 3 years, patency occurred in 97% of cases and pregnancy in 76%; with a 3–8 year interval, patency occurred in 88% and pregnancy in 53%; with a 9–14 year interval, patency occurred in 79% and pregnancy in 44%; and with a 15 year interval or more, patency occurred in 71% and pregnancy in 30%.⁸ Other researchers have also seen decreasing pregnancy rates with increasing time since vasectomy, with reported pregnancy rates in general less than 50% when vasectomy was performed 15–25 years before reversal.^{22, 44, 45, 47, 48, 70, 31}

The most likely explanation for the effect of time since vasectomy on the success of reversal is that with increasing time the chances are greater that back pressure from the site of the vasectomy will lead to rupture of epididymal tubules, with subsequent development of sperm granulomas and obstruction of the epididymis.^{71, 72}

Age of female partner

Another important factor affecting the success of vasectomy reversal is the age of the female partner, with pregnancy rates after reversal declining as female partner age increases.^{11, 22, 47, 73, 31} In fact, of all the factors analyzed (type of anastomosis, duration of time since vasectomy, postoperative sperm count, and age of female partner) in a series of over 1700 couples having vasectomy reversal, the factor that had the most significant impact on pregnancy rate after reversal was female partner age: pregnancy occurred in 94% of couples when the female partner was less than 30 years old compared to only 60% when the female partner was 40 years or older.²² Others have reported even lower pregnancy rates, ranging from 14 to 20%, following vasectomy reversal when female partners are over 40 years old.^{47, 73} This is not surprising given the decreasing ovarian reserve and oocyte quality seen with advancing age in women, resulting in fertility declines with increasing age.^{74, 75, 76}

Antisperm antibodies

The production of antisperm antibodies after vasectomy (see Long-Term Risks of Vasectomy) may have implications for the success of reversal. Several investigators have reported a clear association between seminal plasma antisperm antibodies and reduced pregnancy rates after reversal,^{40, 45, 77, 78} whereas others have questioned the importance of antisperm antibodies in reduced fertility after reversal.^{22, 79, 80} In vitro, antisperm antibodies have been shown to impair sperm motility and cervical mucus penetration.^{81, 82, 83, 84} In addition, using computerized semen analysis, sperm from men with antisperm antibodies was shown to have significantly lower percentages of motility, velocity, and linearity compared with sperm from men without antibodies.⁸⁵ With videomicrographic semen analysis, the percentage of motile sperm was found to be significantly lower among men with greater quantities of sperm surface antibodies postvasectomy.⁸⁶

Although there have been differing reports and the exact effect of anti-sperm antibodies on fertility is not clear, in the past, the presence of  high levels of anti-sperm antibodies was considered as one of the factors that would inhibit fertility after vasectomy reversal.⁸⁷ However, several authors have reported no correlation between high anti-sperm antigen titers and return of fertility post vasectomy reversal.^{32, 88, 89} Further, no correlation has been reported between IgA or IgG anti-sperm antibodies and pregnancy rates following vasectomy reversal.⁸⁹ It is not possible to accurately predict results of vasectomy reversal based on pre-reversal anti-sperm antibody levels in serum, and reversal surgery itself can induce the production of anti-sperm antibodies.^{90, 91} Medical guidelines on vasectomy reversal therefore do not recommend routine use of anitsperm antigen titres as a predictor of the vasectomy reversal outcomes, although the titers may be relevant when the couple is considering assisted reproductive technology.³²  

Partial obstruction

Partial obstruction of the vas at the site of the vasectomy reversal has been proposed as a factor contributing to failure of vasectomy reversal.^{22, 80, 92} Sperm may leak out at the site of vasovasostomy, leading to sperm granuloma formation and partial obstruction of the vas. Although these cases may be technical successes (i.e. sperm are present in the semen), the sperm may be poor quality in terms of concentration and motility.

Partial obstruction plays a role in infertility following vasectomy reversal, even though men may also have antisperm antibodies.⁹³ In men with partial obstruction (defined as epididymal fullness on palpation) and moderate levels of antisperm antibodies who underwent a repeat microsurgical vasectomy reversal, motility improved from a mean of 4% to 52%, and mean sperm concentration increased from 17 × 10⁶ to 36 × 10⁶ sperm/ml. One half of the men and their partners achieved a pregnancy after the repeat surgery. Good results in terms of both patency and pregnancy have been reported by others following repeat vasectomy reversal surgery.^{8, 58, 92, 94}

Average testicular volume

Average testicular volume also influences the success of vasectomy reversal. Hsiao et al. reported that average testicular volume had a significance effect on long-term patency following vasectomy reversal. Patients with testicular volumes of 20–25 cm³, had the highest patency rates. Further, men with smaller testicular volume and those with a testicular volume larger than 25 cm³ had lower patency rates. The reason(s) why men with such characteristics have lower patency rates is unknown.^{6, 26, 1, 2} 

Retrieval of sperm from the epididymis or the testis, followed by intracytoplasmic sperm injection (ICSI), has been used successfully to produce offspring in cases where men do not want a vasectomy reversal, where they have had one or more unsuccessful reversal surgeries, or if their female partner has had a bilateral tubal occlusion or has some other form of infertility. Success rates have been shown to be comparable to those following ICSI with ejaculated sperm.^{95, 96, 97} Sperm can be retrieved from the epididymis using microscopic or percutaneous aspiration. Success rates in terms of retrieving sperm that can be used for ICSI following epididymal sperm aspiration are generally in the neighborhood of 80% or higher.^{98, 99, 100} Pregnancy rates following ICSI are reported to be between about 20% and 40%.^{98, 99, 100, 101, 102, 103} Percutaneous epididymal sperm aspiration (PESA) has advantages over microsurgical epididymal sperm aspiration; it is simpler, requires less time and no specialized equipment, causes less discomfort, and can be performed under local anesthesia.

Occasionally some couples presenting for vasectomy reversal may have a strong desire for children and when counselled for the reversal procedure, they opt to have vasectomy reversal and also ICSI as they wait for fertility to return, a period that may be as long as 2 years.¹

Pregnancy rates following ICSI with sperm aspirated directly from the testis or from testicular biopsy specimens range from 17% to 36% and have been reported to be as good as those following microsurgical epididymal sperm aspiration^{97, 101, 104} and PESA.^{98, 105} Reported results on the effect of time since vasectomy on the success of ICSI have been conflicting. Several studies have found that similar to the case with vasectomy reversal, a negative correlation appears to exist between pregnancy rates and time elapsed from the vasectomy until ICSI.^{47, 49, 70, 106} However, others have reported no association between the time since vasectomy and the outcome of ICSI.^{100, 103, 107, 108}

Vasovasostomy and vasoepididymostomy have been shown to be equally successful and less costly than ICSI following epididymal sperm aspiration.^{47, 49, 106, 109, 1} Thus, surgical reversal appears to be a better first choice for vasectomized men who wish to have children.^{22, 62, 109, 110, 111} This is the case even in men who are undergoing repeat vasectomy reversal surgery due to a previous failed reversal.^{94, 112} In addition, vasectomy reversal may also be a option even in men with previous failed PESA and ICSI. In a small series, four of eight couples achieved pregnancy following vasovasostomy or vasoepididymostomy after unsuccessful PESA and ICSI.¹¹³ 

There are advantages and disadvantages to both vasectomy reversal and assisted reproductive technologies.^{30, 114} Vasectomy reversal has very low morbidity, involves procedures on only the male partner and has pregnancy rates at least as high as those following assisted reproductive technologies. It is likely to be less expensive than assisted reproductive technologies. However, contraception is necessary after vasectomy reversal if the couple does not want to conceive (or after they have reached their desired family size). Additionally, it could take up to 2 years for fertility to return after vasectomy reversal.

Treatment with assisted reproductive technologies can begin immediately with the possibility for conception sooner than with vasectomy reversal and these techniques also allow for treatment of specific male and female infertility factors such as tubular occlusion or immunological infertility.  However, disadvantages of assisted reproductive technologies include potential morbidity for the female partner related to use of hormones or the procedures involved, the risk of multiple pregnancies, and higher cost compared to vasectomy reversal.^{30, 114}

One of the main advances in vasectomy reversal and in the field of urological microsurgery in general is the adoption and use of robotics assisted surgery for vasectomy reversal procedures. However, the robotic systems are not specifically designed for microsurgery and to this end improvements to the systems are ongoing to ensure more recent versions incorporate higher magnification capabilities and use of more specialized microsurgical instruments. The other advantage of robotics microsurgery is the elimination of the need for a highly skilled surgical assistance.^{1, 115}

Research continues on new and improved methods of vasectomy reversal that may be easier to perform or that may provide better success rates than current approaches.¹¹⁶ In addition, new assisted reproductive technologies that are being explored may some day be applied in cases of vasectomized men who are interested in having children. However, there is no guarantee that pregnancy will occur following vasectomy reversal or use of assisted reproductive technologies, and these procedures are expensive, technically demanding, and not always widely available. It should, therefore, be emphasized that vasectomy is meant to be a permanent method of contraception and that reversibility with the endpoint of pregnancy cannot be guaranteed.