Vasectomy is a surgical birth control method for men that cuts and seals the vas deferentia, the tubes that connect the left and right epididymis to the ejaculatory ducts to move sperm. Each tube is almost 12 inches long. Although this form of birth control was thought to be permanent, nearly 6% - 10% of the 500,000 men who have had a vasectomy will want it reversed. The reasons for this change of heart are thought to be the high divorce rate followed by remarriage or after the death of a child, among others.

Vasectomy reversal is a more complicated procedure than the vasectomy itself. It can range in cost from $5,000 to $12,000 and is not covered by insurance. When choosing a physician the American Society for Reproductive Medicine (ASRM) advises that the best results are achieved by surgeons with experience in microsurgery due to the accuracy and delicacy needed for this technique. As with any surgery you and your partner will want to meet with the physician before deciding to go forward to discuss the procedure, surgical risks, and possible complications.

There are multiple factors that influence the decision to have the surgery as well as the chances of achieving pregnancy after a vasectomy reversal. The female partner should be evaluated to rule out any fertility problems and should not be of advanced age. If she does require in vitro fertilization (IVF) then microsurgical sperm aspiration, a less invasive method of procuring sperm, may be preferred for financial reasons. Another predictor of success is the time between the vasectomy and vasectomy reversal. It has been shown that the likelihood of finding sperm within the vas deferens decreases as the duration of the obstruction increases. ASRM recommends that this time interval should be less than 15 years. Finally, approximately 60% of men develop circulating antisperm antibodies (antibodies that can work against the body by interfering with the reproductive process) after a vasectomy which some suggest can decrease pregnancy rates. The relatively high conception rates (50%-70%) after vasectomy reversal lead others to question this correlation.

The vasectomy reversal is typically done on an outpatient basis under general, epidural, spinal or local anesthesia. There are two procedures used to reverse a vasectomy. They are:

Vasovasostomy: A procedure in which the surgeon sews the ends of the vas deferens back together. This is the less complicated and less expensive procedure.

Vasoepididymostomy: A procedure in which the surgeon sews the vas deferens directly to the epididymis. This procedure is indicated when the sperm flow is blocked due to breaks or blockages in the vas deferens.

Once the surgeon has opened the vas deferens he/she will examine the fluid that comes out visually and also under the microscope. The fluid is graded based on the presence of sperm as well as the sperm motility (if they are moving) and sperm morphology (how they look.) Ideally, there will be motile sperm in clear fluid, an indication that there are no blockages. If the consistency of the fluid is thick and there are no or only parts of sperm, a vasoepididymostomy may be the preferred procedure. If the physician does find sperm he/she may advise freezing the sperm in case the surgery is unsuccessful for later use in IVF.

Post-operative complications are rare. Physicians recommend that a scrotal supporter is worn for three to four weeks. Heavy physical activity is restricted for three to four weeks and sexual intercourse should be avoided for two to four weeks. Semen analyses will be required every two to three months until the sperm count and motility return to normal and then every four months until a pregnancy occurs. Most pregnancies occur within 24 months.

The Vasovasostomy Study group studied 1,247 patients. Their results suggest that the less time that has elapsed from the vasectomy to the reversal the better the chances of pregnancy. They looked at the return of sperm to the semen and pregnancy rates respectively and reported the following:

• Less than 3 years: 97% return of sperm; 76% pregnancy rate
• Three to eight years: 88% return of sperm; 53% pregnancy rate
• Nine to 14 years: 79% return of sperm; 44% pregnancy rate
• 15 years or longer: 71% return of sperm; 30% pregnancy rate

If the reversal is not successful a repeat vasectomy reversal is an option for certain patients however success rates are decreased compared with first-time reversal procedures. The decision to attempt another surgery should be based on the duration of the obstruction, the original reversal, the experience of the surgeon and again female factors. A couple may prefer to do IVF using sperm aspirated directly from the epididymis and intracytoplasmic sperm injection (ICSI), a technique used to inject a sperm directly into an egg rather than have another surgery. All of these factors as well as a cost analysis should be discussed with your health care provider to determine which option offers the best chances for pregnancy.

For more information on this topic visit these websites:

Johns Hopkins Urological Institute: http://urology.jhu.edu/infertility/vasectomy.php

Mayo Clinic: http://www.mayoclinic.com/health/vasectomy/HQ01049

Fertility Journey: http://www.fertilityjourney.com/testinganddiagnosis/malediagnosis/
vasectomyreversal/index.asp?svarqvp2=0

References:
ASRM Practice Committee Report: Vasectomy reversal. Fertil Steril 2006; 86: (Suppl 4): S268-71.

ASRM Practice Committee Report Management of Obstructive azoospermia. Fertil Steril 2006; 86: (Suppl 4): S259-63.

Belker A. Microsurgial vasectomy reversal. In: Lytton B, Catalona W, Lipshultz L, McGuire E, ed. Advances in urology. Chicago: Year Book Medical Publishers, 1988: 193-230.

Belker A, Thomas A , Fuchs E, Konnak J, Sharlip I. Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J Urol 1991; 145: 505-11.

Belker A, Fuchs E, Konnak J, Sharlip I, Thomas A.. Transient fertility after vasovasostomy in 892 patients. J Urol 1985; 134: 75-6.

Hollingsworth M, Sandlow J, Schrepferrman C, Brannigan R, Kolettis P. Repeat vasectomy reversal yields high success rates. Fertil Steril 2007; 88: 217-19.

Karpman E, Williams D, Lipshultz L. Vasectomy reversal: new techniques and role in the era of intracytoplasmic sperm injection. Can J Urol 2006; Suppl 1: 22-27.

Linnert L, Hjort T, Fogh-Anderson P. Association between failure to impregnate after vasovasostomy and sperm agglutins in semen. Lancet 1981; 1: 117-19.

Meng M, Greene K, Turek P. Surgery or assisted reproduction? A decision analysis of treatment costs in male infertility. J Urol 2005; 174: 1926-31.

Pavolich C, Schlegal P. Fertility options after vasectomy: a cost effectiveness analysis. Fertil Steril 1997; 67: 133-41.

Thomas A, Pontes J, Rose N, Segal S, Pierce J. Microsurgical vasosasostomy: immunologic consequences and subsequent fertility. Fertil Steril 1981; 35: 447-50.