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   DIVISION OF MALE REPRODUCTIVE MEDICINE AND SURGERY                   
 Microsurgical Vasectomy Reversal (Vasovasostomy and Epididymovasostomy)
Setup:
Preparing the anastomosis (connection) between the two ends of the vas.
Suture Placement:
The first three inner layer sutures.
Suture Placement:
The remaining three inner layer sutures.
Completion:
The outer sutures sealing the anastomosis.

How often do men seek vasectomy reversal? Why?
Approximately 6% of all men who undergo vasectomy will later desire reversal. Often it is because they have a new partner, while in many cases the couple has simply decided that they would like more children.

How should I choose where to get a vasectomy reversal?
While many clinics offer and advertise vasectomy reversal, it is important to consider that the success of the operation is heavily dependent on the surgeon’s experience, surgical precision, intraoperative decision making skills, state-of-the-art equipment, and support team. One should not be deceived by billboards and marketing.

Why should I come to Johns Hopkins?
Dr. Rao performs many vasectomy reversals for men from all around the country and world, and often brings success when patients have had failed operations elsewhere. Moreover, prior to offering vasectomy reversal, he performs a careful preoperative evaluation to avoid common pitfalls that patients may encounter elsewhere. Finally, he believes that preoperative counseling and prudent patient selection is critical to helping patients decide the best course for them and helping them reach their ultimate family goals.

Using thoughtful preoperative evaluation and meticulous intraoperative approaches, Dr. Rao has achieved leading success rates among the small community of academic urologists adhering to the highest standards of treatment for male infertility and vasectomy reversal.

What if I cannot make it to Baltimore?
Dr. Rao would be happy to help guide you to a member of the academic urological community adhering to the highest standards of treatment for male infertility in your region.

Where are sperm made, and what is their normal path?
Sperm production occurs in the testis. From the testes, sperm travel to the epididymis. The epididymis is a continuous, tightly coiled tube approximately 15-18 feet in length, which leads into the vas deferens.  In the epididymis, the sperm mature and develop motility. Thus, sperm that have not passed through the epididymis are generally not able to fertilize eggs under normal conditions.  The vas deferens is responsible for directed and propelling sperm into the urethra, where it joins with fluid from other glands to form the ejaculate.

What happens during a vasectomy?
During a vasectomy, the vas deferens (the tube that carries sperm into the ejaculate) is divided or interrupted by one of many methods, including removal of a tube segment, placement of clips on the vas, or using electric energy to cause scarring and closure of the tube. For more detail, please click here.

What is done during a vasectomy reversal procedure?
Vasectomy reversal reestablishes an open tube, or “lumen”, of the vas deferens to allow the sperm to reach the ejaculate once again. 
To accomplish this, the vas deferens is connected to a healthy segment of vas deferens (vasovasostomy), or to a tubule of the epididymis (vasoepididymostomy).

Which is preferred, vasovasostomy or vasoepididymostomy?
The path or “lumen” within the vas deferens is around one third of a millimeter in diameter. The lumen of the epididymis can be one third to one half of this size. Thus, when possible, vasovasostomy is preferred.

Why would a surgeon perform vasoepididymostomy?
The decision of whether to perform a vasovasostomy or a vasoepididymostomy depends upon the quality of the fluid from the vas deferens at the time of surgery, patient characteristics such as time since vasectomy, and surgeon experience. Sometimes the sperm can be blocked in a region separate from the vasectomy site – often in the epididymis after a prolonged time since vasectomy. In these cases, bypassing the vasectomy site with vasovasostomy will not suffice to allow sperm to reach the ejaculate. Using intraoperative findings, an experienced surgeon will be able to decide the appropriate procedure. Since this decision is made during the surgery, it is important to have a surgeon who is experienced, confident, and prepared for either operation.

How do some clinics perform vasectomy reversal with very low cost?
Using suboptimal magnification equipment can drastically cut the cost of the procedure. However, optimal magnification has been shown to improve outcomes. In addition, when a proper surgical microscope is used, general anesthesia is usually preferred. However, many clinics using lesser magnification will perform the operation under local anesthesia to cut costs. Others cut costs by performing only vasovasostomy to limit the time of the operation, even when vasoepididymostomy would be preferred by an experienced surgeon. Finally, using optimal suture adds to the cost of the procedure; the suture used is practically invisible to the naked eye, and it’s critical to the success of the operation.

At Johns Hopkins, due to the structure of our academic institution and operations, we are able to combine the optimal procedure with the optimal surgeon and equipment for a cost well below most providers.

How is vasovasostomy performed?
While there are many methods for performing a vasovasostomy Dr. Rao prefers a strict, two-layer, watertight procedure utilizing microscopic sutures and the latest microsurgical equipment. Another commonly used method is the single-layer closure, and the choice is best dictated by the experience of the surgeon.

The illustration below shows the concept of a two-layer closure. One layer of suture approximates the inner tube (or lumen) of the vas deferens. And outer layer seals the wall of the vas deferens on the outside, making it watertight.

 

vasectomy reversal 3

 

This intraoperative photo taken through a microscope shows three inner layer sutures of vasovasostomy.  The connection, or "anastomosis", has already been completed on the back wall.

vasectomy reversal



How is vasovasostomy performed?
Vasoepididymostomy (or epididymovasostomy) requires even more experience and surgical precision for optimal results. As mentioned, the decision to perform vasoepididymostomy is made during the operation, so it is imperative that the surgeon is prepared and experienced in this technique.

To perform vasoepididymostomy, a single epididymal tubule is carefully dissected and mobilized. It is then incised in a location upstream from the suspected obstruction. The fluid is checked for sperm and, if none are present, a more proximal transection is made.  The anastomosis (connection) is then performed with two layers of extremely fine suture under the operating microscope.

Dr. Rao performs a “microsurgical end to side intussusception technique” for epididymovasostomy/vasoepididymostomy.  In this procedure, sutures are placed in a manner that pulls the open epididymal tubule into the lumen of the vas deferens. This concept is illustrated in the illustration below. On the left, the sutures are placed and the tubule is incised. On the right, the sutures are tightened, and the connection is made.

vasectomy reversal 4

How is success measured after vasectomy reversal?
Success after a vasectomy reversal can be measured in two ways: patency and pregnancy rates.  

Patency refers to the connection being open for sperm passage. While many community urologists consider any sperm in the ejaculate to represent success when reporting their results, Dr. Rao prefers a more strict definition, in which motile sperm are required to define success. Sperm that are not moving could indicate old dead sperm versus sperm that are injured during transport.

Since male and female factors are important in creating a pregnancy, the most straightforward way to measure success is patency. However, most would agree that the pregnancy rate is the most important.

What are the success rates of vasectomy reversal?
During the procedure, the vas deferens is opened at a location just prior to the blockage created by vasectomy. The decision between vasovasostomy or vasoepididymostomy is then made primarily based on the  characteristics of the fluid found at this site.

Importantly, when motile sperm are found at this site, Dr. Rao’s success rate is nearly 100%.

More detailed information about success rates are shown in the table below:

JHU Vasectomy Reversal Success Rates 

Intraoperative Findings

 

Results

Sperm Present

Fluid Quality

Procedure

Patency Rate

Pregnancy Rate

Yes, and Motile

Good

Vasovasostomy 

>99%

~75%

Yes

Good

Vasovasostomy

>95%

75%

No

Good

Vasovasostomy

60%

50%

No

Poor

Epididymovasostomy

50%

45%

 

 

Good fluid quality = large amounts of clear fluid.

Pour fluid quality = small amounts of fake or pasty fluid.

Where is vasectomy reversal performed?
The location of surgery is chosen to minimize the cost for the patient. First, our representatives will carefully check whether patients qualify for any financial assistance from their insurance providers. If so, the procedure is done in the hospital setting, usually at Johns Hopkins Bayview. If the insurance company does not assist, it is more affordable for the patient to do the procedure at an ambulatory surgery center. In this case, it is performed at The Greenspring Station Surgicenter or The Johns Hopkins Hospital Outpatient Center.

What should I expect on the day of vasectomy reversal surgery?
You will be asked not to eat or drink anything the night before surgery, as a measure to decrease the chance of complications with anesthesia. You will then present to the facility and meet with the anesthesia team and touch base with Dr. Rao. The procedure is done under general anesthesia, meaning the patient is completely asleep. It is an outpatient surgery, so patients return home or to a nearby hotel without actually being admitting directly to the hospital. This saves considerable expense and makes the overall experience much more pleasant.

How long does the vasectomy reversal surgery take?
Vasovasostomy or epdidymovasostomy usually take approximately 2.5-4 hours, although it can be significantly longer in certain cases. Compromises are made with regards to patient safety or the anticipated success of the procedure.

What is the vasectomy reversal recovery process?
We prefer that out-of-town patients stay in the Baltimore area for at least 1-2 days after surgery. Postoperative follow-up includes an evaluation of the healing wound at 2-3 weeks, although many foreign patients forego this visit for convenience purposes.

Please click here for Dr. Rao’s recovery instructions.

When do you check for success after vasectomy reversal?
Semen analysis is usually first checked between two and three months after surgery. Semen analyses are then obtained for approximately 4-6 months, or until the sperm count stabilizes.  It can take up to 6-12 months for sperm to return to the ejaculate following a vasovasostomy and longer following an epididymovasostomy. However, in the vast majority of patients, sperm will be seen in the ejaculate three months after vasovasostomy. If semen quality is less than expected, anti-inflammatory medications may be prescribed to decrease scar formation that can block the surgery site.

Are there alternatives to vasectomy reversal?
Adoption and the use of donor sperm with assisted reproductive techniques (ART) are entirely acceptable options. If a man does not want bursectomy reversal, testicular or epididymal sperm extraction can be used to obtain sperm for IVF or ICSI. In many cases, depending on he female partner’s age, ART might be advisable instead of natural conception. In this case, sperm retrieval might make more sense for the couple than vasectomy reversal.

What backup approaches are available in case the vasectomy reversal is not successful?
Cryopreservation of sperm (sperm banking) can be performed at the time of vasectomy reversal. Sperm can be acquired by testicular sperm extraction (TESE) in most patients, and from epididymal or vasal fluid in some patients.

Because vasectomy reversals may infrequently scar over time despite good initial results, cryopreservation may also be performed on ejaculated specimens early in the course of recovery. However, since most couples are hoping to conceive naturally, and since the surgery is usually successful, most couples choose to later pursue TESE only if necessary.