Somewhere between one and two percent of men who have a vasectomy make the decision to change their mind and undergo a vasectomy reversal. In order to understand a reversal one needs to first understand how sperm gets into the ejaculate and then what a vasectomy accomplishes.
Sperm form in the testicle and are carried by tubes called efferent ducts into the epididymis. The Epididymis is itself a very thin and long, coiled tube that sits on the surface of the testicle. Sperm mature as they travel through the epididymis until they reach their destination of the end of the (cauda) epdidymis and the first part of the (convoluted) vas, where they are stored until ejaculation. With ejaculation, sperm is propelled through the straight vas through the ejaculatory ducts and then into the ejaculate. The straight vas is the tube divided during vasectomy and the ends are sealed. A piece of the vas is also typically removed. (See image of vasovasostomy)
After administration of anesthesia, the first step of a vasectomy reversal is to remove the sealed end of the testicular end of the vas. Fluid is expressed from it and a drop is placed on a microscope slide to examine for the presence of sperm. If sperm are present, microsurgical techniques, using suture finer than hair, are used to reconnect the abdominal end of the vas to the testicular end. This is called a “vasovasostomy”. This can be performed with a very high chance of return of sperm to the ejaculate.
Different techniques are used by different surgeons. I use a multiple layer technique using 10-0 and 9-0 nylon sutures for the inner and outer layers of the reconnection, also known as the “anastomosis”.
If sperm are not present and the quality of the fluid is poor, then a second blockage is likely present in the epididymis. This happens with increasing likelihood as the time after vasectomy increases; in other words, vasoepididymostomy is more likely to be performed if it is more than ten years since the vasectomy as compared with just a few years. In this situation, the vas needs to be reconnected to the epididymis above the blockage. This is called a “vasoepididymostomy”. This is a more difficult procedure and has a somewhat lower chance of success though recent changes in the technique called “longitudinal intussusception” have resulted in better results. 10-0 and 9-0 nylon sutures are utilized for inner and outer layers of this reconnection as well.
Following the surgery, my patients are advised to use ice as they can tolerate for two days. Patients need to refrain from heavy lifting, sports and sex for two weeks. A scrotal support is also worn for two weeks. The first semen analysis is performed six weeks after surgery.
