Vasectomy reversal – methods

Vasectomy reversal

Vasectomy reversal means restoring the presence of sperm in the ejaculate after a previous vasectomy. After a vasectomy, the cut ends of the vas deferens can be sewn together, thereby restoring the presence of sperm in the ejaculate. Unfortunately, this operation does not always succeed.

Within the first 3 years after the procedure, the return of sperm is achieved in over 90% of cases. With a longer interval since the vasectomy, this percentage falls: for example, 15 years after a vasectomy the success rate is around 70%.

Reversal technique

The vasectomy reversal takes about 3.5 to 4.5 hours. It is performed under local anaesthesia similar to that used for vasectomy, but with longer-acting anaesthetics. The continuity of both vasa deferentia is restored through a single small opening of about 15 mm. The procedure is performed either with a microscope or with special very high-power loupes, such as those used by cardiac surgeons to join small coronary vessels. 

The day after the procedure, a soft drain is removed from the wound, and the small opening closes by itself within 1-2 days.

After the procedure

Seven days after the reversal, the patient may return to light work. If the work is physical (lifting loads over 10 kg), it should also be avoided for the following week. The same applies to sports training.

Detailed instructions on preparation before and recommendations after the reversal can be found here in a PDF file (in Polish). 

Cost of vasectomy reversal (vasovasostomy)

The fee for a minimally invasive outpatient vasectomy reversal is PLN 12,000.

Before the procedure the patient pays a deposit of PLN 2,000.

The fee for the reversal is justified by the large quantity of very expensive microsurgical materials used and by the fact that the procedure takes about 10 times longer than a vasectomy. However, if it is found during the operation that joining vas to vas (V-V) has a very low chance of success, the costs to the patient can be significantly reduced. 

Why might the cost of the reversal be reduced?

If no sperm are found intra-operatively in the lower, testicular segment of the vas, the vas-to-vas anastomosis is not performed. In such cases the vas on the other side is checked. If there are no sperm there either, the procedure is not continued and the patient bears only the cost of the deposit, i.e. PLN 2,000. If sperm are present in one of the vasa, the patient pays half the fee, i.e. PLN 6,000 + half the deposit, giving a total of PLN 7,000. Allowing for the deposit, they pay an additional PLN 5,000.
In the case of a bilateral absence of sperm – which would indicate a “blockage” of the lower, testicular segment of the vas somewhere below (most often in the epididymal duct) – there are two options for further management. Namely:
1.) anastomosing the vas to the very thin epididymal tubule. The VASO-EPIDIDYMOSTOMY (V-E) operation. It is performed in a hospital operating theatre under general anaesthesia with an anaesthetist in attendance. This operation is much more expensive and its success rate is lower than joining vas to vas.
2.) an in vitro fertilisation procedure – IVF using sperm obtained surgically directly from the epididymides or testicles.

Payment schedule

The deposit of PLN 2,000 and the signed reversal agreement must be delivered to our clinic no later than 7 days before the planned reversal. This is a condition of keeping the procedure date.

If the patient cancels 28 days before the planned date, they will receive a refund of PLN 1,800. The same applies at shorter notice in case of illness of the patient himself (this does not apply to illness of a family member). In that case it must be documented with a medical certificate. 

The remaining fee (PLN 10,000) must be paid immediately before the procedure.

The ZdrOva practice does not offer credit options, but we accept VISA and MasterCard credit cards, which the patient repays according to the convenient plans offered by banks.

If any medical problems ruling out the procedure are revealed during the examination immediately before it, the patient receives a full refund.

Reversal candidates from outside Warsaw

We perform vasectomy reversals only at our Warsaw practice at ul. Floriańska 6, unit U-4.

Patients arriving by plane should fly into Warsaw 1 day before the procedure and can board a plane 2 days after it.

On the morning of the day after the procedure, the patient comes for a follow-up visit and drain removal. So if a patient is from outside Warsaw and comes by car or train, they must spend one night in Warsaw. If they plan to return by plane, they must spend 3 nights in Warsaw.

Success rates of vasectomy reversal

Since few vasectomies are performed in Poland compared with other developed countries, even fewer reversals are performed. Reliable statistics from Poland therefore do not exist, and we must rely on data from countries where many of these procedures are done. Nationwide American statistics on reversal success are readily available. The most frequently cited article is the report of the Vasovasostomy Study Group, published in the Journal of Urology in March 1991 (J Urol 145: 505-511, March 1991). The most important parameter determining the success of the operation is the number of years since the vasectomy. Within the first 3 years after a vasectomy, reversal results in the return of sperm in over 97% of cases. From 3 to 8 years, about 90%; from 9 to 14 years, about 80%; and over 14 years, about 60%. 85% overall, counting all patients seeking a vasectomy reversal. 

Pregnancy rates (without fertility assistance) also fall slowly with time (from about 86% in the 3-year group to 35% in the > 15-year group). 

Some patients achieved a pregnancy (impregnated their partners) even after 30 years! As with any operation, not all end in success. 

For a couple, the ultimate goal is the birth of a healthy child. The path to that leads through a chain of independent conditions.

1. The man must be fertile (have healthy sperm in his ejaculate) 
2. The woman must be fertile (ovulating, with patent reproductive tract, in a hormonal balance optimal for pregnancy).
3. Not every pregnancy ends with the birth of a child (pregnancy losses happen)
4. not every child born is healthy.

Even a successful reversal operation is only one of the necessary links in this chain. That is why success cannot be guaranteed. 

Microscope or loupes for a reversal

We are fully aware that other websites claim that the optics obtained with loupes are inferior to those of a microscope. 

Many experienced surgeons who used microscopes for years are switching to very high-quality, high-magnification loupes. 

Many scientific publications indicate that for a V-V reversal (sewing the cut ends of the vas together), the microscope has no advantage over high-quality loupes. 

Whether with a microscope or loupes,
4-6x magnification is used. Loupes allow the operating field to be viewed not only vertically from above (as with a microscope) but also from every side, at any angle. 

A microscope is absolutely necessary when joining the vas to the much thinner, highly coiled epididymal duct (V-E = vaso-epididymostomy), an operation performed when there are no sperm in the lower segment of the vas.

Success rates might be better if reversals were performed under general anaesthesia, in an operating theatre, using an operating microscope, in a centre prepared to perform a V-E immediately. 

Some American centres suggest the need for an immediate vasoepididymostomy (V-E) when there are no sperm in the fluid from the testicular end or when the fluid is thick and creamy. 

A V-E requires taking the entire testicles out of the scrotum. 

Available data show that when sperm are absent from watery (thin) fluid on both sides at the time of the reversal, sperm reappear in the ejaculate after some time in 53% of patients. When the fluid is thick and creamy, the chances of sperm returning to the semen are so minimal that we do not continue the V-V anastomosis (nor charge the full fee). However, bilateral thick creamy discharge from the testicular end of the vas is found in only about 5% of patients. 

In most cases this avoids operating theatre fees while still achieving proper connections of both ends of the vas. The office-based reversal technique (Approach no. 3) does not create post-operative scarring that would hinder a future V-E operation. Only the patient can decide whether the availability of an immediate V-E is worth the difference in cost and the organisational effort involved.

The biological response after vasectomy and different reversal strategies

After a vasectomy, sperm continue to be produced. Some methods by definition block the outflow of sperm from the testicles. With other methods (with an “open end” of the testicular segment), a blockage may occur spontaneously at various levels (including lower down). 

If sperm cannot drain from the epididymis, where they mature, their build-up can lead to chronic inflammation via an immune reaction. Every inflammation leads to scarring. Scarring inside a very thin duct can block it. In short: even a minor, symptomless inflammation well below the vasectomy site can block the sperm outlet so permanently that sewing the ends of the vas together near where they were cut during the vasectomy will not bring sperm back into the ejaculate. The chances of pregnancy then remain close to zero. 

In such a case, sperm usually still enter at least the initial part of the epididymis, from where they can be retrieved for an IVF procedure. The alternative is a more complicated operation: sewing the thick, stiff segment of the vas (the one leading to the penis) to the many times thinner, flaccid epididymal tubule. This operation is called a vaso-epididymostomy (V-E). It is performed under general anaesthesia in an operating theatre, and the patient must remain immobilised for much longer afterwards than after a vasovasostomy (V-V).

Causes of scarring and blockage below the vasectomy site

Under normal conditions (in a healthy, fertile man who has not had a vasectomy), white blood cells in the epididymides absorb and remove old, abnormal and trapped sperm. This process, however, occurs on a small scale. Excessive, prolonged white blood cell activity is by definition chronic inflammation. The causes of inflammation can vary: various systemic diseases, toxins, hypersensitivity, sperm congestion (e.g. after a vasectomy) or infections. An infection may be persistent, existing for years and progressing symptomlessly in a latent form since before the vasectomy. An infection may also appear as a new one after the vasectomy. 

Inflammation and reversal

Inflammation can lead to scarring, and scarring in a very thin tube like the epididymal tubule can cause blockage. 

For example, inflammation of the liver (hepatitis) can cause liver scarring (cirrhosis); inflammation of the joints (arthritis) can cause scarring with stiffness and restricted range of motion. The longer the inflammation lasts, the greater the likelihood of scarring and blockage – and this can occur in the epididymides just as in any other organ.

An alternative explanation for epididymal blockage after vasectomy is that, with a deliberate or spontaneous (method-independent) high blockage of the vas, pressure in the epididymis rises and can cause a blowout in the tiny epididymal tubules, causing sperm leakage and local inflammation leading to blockage.

Whatever the cause of epididymal obstruction (scarring or rupture), its probability is roughly proportional to the number of years since the vasectomy. In the 1-3 year range, the epididymides are rarely (though not never) blocked, but after 20 years the probability of secondary bilateral obstruction can exceed 30%. 

In such a case, sewing the two vasa together (V-V) at the site of the previous vasectomy will not correct the secondary blockage in the epididymis. This requires a more complicated procedure called a vaso-epididymostomy (V-E). 

V-V versus V-E

Vasovasostomy (V-V) and vaso-epididymostomy (V-E) are two very different operations. The aim of a V-V is to permanently reconnect the vas at the point where it was cut during the vasectomy. It is a true “vasectomy reversal”. A V-V can often be performed by bringing the vasa out through a small single opening in the middle of the scrotum, similar to the minimally invasive no-scalpel vasectomy technique. 

At the vasectomy site there is either a gap (a missing fragment) or a nodule. Either way, the aim is to “refresh” both ends of the vas on either side of the vasectomy site and sew them back together. The left and right sides can usually be repaired through a single vertical opening of 12-25 mm in the midline of the scrotum. The entire procedure is performed under local anaesthesia in a medical procedure room. 

The cut ends of the vasa are joined under the control of very high-magnification, high-quality optical loupes or an operating microscope. On each side in turn, the two ends are sewn together with 10-18 microsurgical sutures. The whole procedure takes 3-4.5 hours. 

Vaso-epididymostomy (V-E)

Vaso-epididymostomy (V-E), i.e. sewing the thick-walled, stiff end of the vas to the much thinner and flaccid epididymal tubule, differs greatly from vasovasostomy. 

1. Because the epididymis is attached along its entire surface to the testicle, a very large incision must be made in the scrotum so that the whole testicle can be taken out. 
2. Having to bypass the lower segment of the vas lengthens the gap between the upper end of the vas (leading to the penis) and the planned attachment site on the epididymal duct. The attached epididymis, with the testicle fixed to it, will therefore pull on (stretch) the remaining upper segment of the vas. To free the upper segment and bring it downwards, the surgeon must make two long incisions on both sides of the scrotum towards the groin.
3. As mentioned above, the wall of the vas is thick, hard (muscular) and has a very narrow lumen (through which the sperm travel). The diameter of the vas ranges from 2-4 mm. The lumen is very narrow, usually about 0.2-0.5 mm in diameter. The vas is thus a tube with a thick, stiff wall and a narrow channel. 

The epididymis, in turn, consists mainly of a single epididymal duct. It is a single tube with a tangled course resembling a ball of wool. This tube is of similar thickness to the lumen of the vas (0.2-0.6 mm). If straightened, the epididymal duct would be about 4 m long. Its lumen increases along its course; at medium filling it is about 0.2-0.3 mm in the body, at strong filling 0.4-0.6 mm. 

The wall of the epididymal duct consists of a single-layer epithelium resting on a thin basement membrane, surrounded externally by smooth muscle; this muscle is arranged in four to eight circular layers; its contraction can move sperm along. The muscle is enclosed by a layer of connective tissue. The wall of the epididymal duct is thus very thin and flaccid, and the duct itself is highly coiled. 

The vaso-epididymostomy operation (sewing the vas to the epididymal duct) is performed under a microscope. This connection is never as strong and durable as a vas-to-vas connection (V-V), and likewise the success rate of a V-E is not as high as that of a V-V. 

A V-E is a more complicated operation, with an effectiveness of about 60%

Most doctors agree that taking both entire testicles with their epididymides out of the scrotum goes beyond the scope of outpatient procedures and that general anaesthesia should be used in a hospital or ambulatory surgical centre with an operating theatre. 

Moreover, since the success rate of a V-E is about 60%, the operation should be considered in a facility that also offers the intra-operative possibility of retrieving, properly preparing and storing the sperm obtained. This includes: 

1. microscopic assessment of the sperm, 
2. their preparation for freezing. This involves complex processing in special media, centrifugation, chemical removal of water from inside the sperm (during freezing, sharp ice crystals would destroy the sperm’s DNA) and 
3. cryopreservation (freezing). Such a facility should therefore run a tissue bank or have the technical means to transport material to one. All this so that, if the V-E fails, the sperm obtained during the operation can be used in the future for an IVF procedure. It should be mentioned that the V-E procedure itself can cause such scarring of the epididymides that attempts to obtain sperm by epididymal biopsy may fail.

With a V-V (vas-to-vas anastomosis), “banking” sperm for the future is less important. Sperm obtained from the lower segment of the vas are usually (initially) immotile and therefore unsuitable for freezing and IVF use. The success rate of a V-V when sperm are visible during the procedure is high enough that the costs of retrieval, processing and storage are not worth it. If a V-V – or a V-E – fails, sperm can later be obtained by biopsy. Biopsy of previously untouched epididymides is highly effective. With a V-E, as mentioned above, scarring and adhesions often form after the operation, and the chance of obtaining good sperm is lower than after a V-V.

The table below shows the differences between the vasovasostomy and vaso-epididymostomy methods

	V-V	V-E
Testicles	Not even visible	Must be taken out of the scrotum
Distance between suture sites	Usually short	Usually long
Incision	Usually no scalpel, short, single, in the midline	One or 2, much longer, usually on both sides of the scrotum, sometimes reaching the groin.
Magnification	High-quality surgical loupes or operating microscope	Operating microscope required
Anaesthesia	Local	General preferred
Location of the procedure	Medical procedure room or operating theatre	Operating theatre
Sperm storage	Not practical	Recommended
Cost	Surgeon	Operating theatre, surgeon, anaesthetist, sperm retrieval and processing (a working laboratory next door), transport and storage of sperm (tissue bank).
Anatomical conditions after the procedure	Natural – almost identical anatomical conditions are restored.	Unnatural. Sewing together ducts of incompatible structure (thick and stiff with thin and flaccid). The effect of a taut string under the weight of the testicle.

Which men need a V-E?

That is a difficult question. It is known that the longer the interval in years between the vasectomy and the planned reversal, the higher the probability of secondary blockage of the epididymal duct. However, in some men secondary obstruction is found after only two years. In others, even after 30 years the epididymal duct is patent. Wouldn’t it be good if we could determine with certainty which men need a V-E before they undergo surgery? Unfortunately, we cannot – neither physical examination, nor ultrasound, CT or MRI can give us that answer.

Reversal – examining the patient (in medical terms, the physical examination)

There are a few clues that can be obtained during the physical examination before a reversal:

1. The epididymis. If it is greatly enlarged, hard and tender (painful to the touch), this suggests obstruction (blockage) more than when it is small, soft and painless to the touch.

2. The presence of a nodule at the vasectomy site. A palpable nodule may in fact be a sperm granuloma – a site where sperm leaking from the lower end of the cut vas are recycled. If the inflammation associated with sperm recycling occurs high up at the vasectomy site and does not extend downwards, it spares the epididymides. This protects the coiled epididymal duct from damage due to rising pressure 

So finding a lump at the vasectomy site on palpation of the scrotum is a good prognostic sign, but not all palpable lumps are granulomas… some are just suture knots or clips used during the vasectomy. 

Some surgeons believe that a high vasectomy site (far from the testicles) is also a good sign… a longer testicular segment of the vas may better cushion the rise in pressure in the event of a blockage at the vasectomy level, whether intentional (depending on the method used) or spontaneous. 

Intra-operative examination – what can be established during the operation.

The initial part of the reversal consists of dissecting the cut ends of the vasa and cleaning and refreshing the lower, testicular segment of the vas. After examining the vasectomy site, the fluid that may flow from the lower, testicular end is examined. Its macroscopic appearance (to the naked eye) and microscopic appearance are important prognostic clues. 

If the fluid contains sperm, the probability of a blockage lower down in the epididymal duct is very low, and the probability of sperm returning to the ejaculate after a V-V is very high. If the fluid contains no sperm, especially if it is thick or creamy and contains white blood cells (pus cells), the probability of a blockage somewhere lower in the epididymal duct is very high, and the probability of sperm returning to the ejaculate after a V-V reversal is very low. 

If no fluid at all flows from the lower segment, that is a relatively poor prognostic sign. The presence of watery fluid without sperm is a relatively good sign. 

Reversal strategy

There are three approaches to a vasectomy reversal: 

REVERSAL – APPROACH ONE

The surgeon may perform a bilateral V-V through a single incision, in the office or in an operating theatre, regardless of concerns about whether the quality of the fluid from the lower segment of the vas bodes well, because: 

a. most patients have good-looking fluid from the lower, testicular end of the vas anyway and will not need a V-E,
b. in some patients with poorly prognostic fluid from the lower segment, sperm nevertheless appear in the ejaculate after some time and a spontaneous pregnancy occurs,
c. a V-V is technically less demanding. With a successful V-V it is more likely that the vasa will remain permanently open than with a V-E. The latter operation suffers from the taut string effect – often, after some time, the sutures give way and the connection either breaks or scars over.

REVERSAL – APPROACH TWO

The surgeon may begin the reversal under general anaesthesia, through two incisions, in an operating theatre, with a laboratory standing by to receive, process and freeze the material obtained. Take both testicles out of the scrotum and thereby work with excellent exposure. With favourable fluid, perform a high V-V on both ends of the vasa, or with poorly prognostic fluid, proceed directly to a V-E on one or both sides.

The problem with approach no. 1.

The problem is that when there is epididymal obstruction on both sides (which happens on average in about 17% of cases), the reversal will fail. The patient has paid the full fee for a procedure from which they gained no benefit. Moreover, if the patient later decides on a V-E, the previous V-V will have caused some scarring and shortening of the upper segment of the vas. This makes a later V-E reversal even more difficult and reduces its chance of success.

The problem with approach no. 2

One problem with approach no. 2 is that every patient must pay for the operating theatre and the anaesthetist, as well as for the laboratory standing by for a sample that must be processed immediately. Most of these patients would have succeeded in a procedure room with a minimally invasive reversal. Even applying the most liberal criteria for choosing a V-E over a V-V (as a recently published study showed), 75% of men in the operating theatre still had the simpler V-V performed on both sides, and 8% of men had a V-V on one side and a V-E on the other. Since the vasovasostomy (V-V) techniques used in the office and in the operating theatre are almost identical, those 83% of patients could have enjoyed the return of sperm to their ejaculate at a much lower cost. This matters for procedures not reimbursed by most insurers. Another problem with approach no. 2 is that after larger bilateral incisions and the sewing together of dissimilar tissues (thick and hard to thin and flaccid), patients need more recovery time. After a single opening, often made without a scalpel, the time before patients can return to work is shorter. Since scrotal wounds heal quickly and well, skin healing should not be a major problem even with a V-E

REVERSAL – APPROACH THREE

The third approach attempts to solve both of the above problems. The procedure is performed using a minimally invasive method in a procedure room. First, a small opening (12-25 mm) is made without a scalpel in the midline of the scrotum. 

The first step of the procedure is to assess the upper segment and clean the lower segment of the cut vas and evaluate the fluid (with the naked eye and under a microscope). If the fluid assessment is favourable, proceed to a V-V. If the results are very unfavourable (no fluid, or thick, creamy fluid without sperm), the procedure is not continued on that side, and for that side the patient pays half of the deposit (PLN 1,000) as an exploration fee. The upper end of the vas and the epididymis remain untouched, scarring is minimal, and the patient can undergo a V-E operation in the future, with sperm retrieval in the operating theatre on that occasion. If the fluid from the testicular segment of the vas is inconclusive (watery but containing no sperm or sperm fragments), the patient and doctor can jointly decide whether to proceed with a V-V on that side. The other side is treated the same way. Most patients, regardless of the interval between vasectomy and reversal, will have favourable fluid. Most will have a V-V on both sides and will see the return of sperm to their ejaculate. 

Approach no. 3 is most applicable to men with short intervals (under 10 years) and no adverse findings on physical (palpation) examination. Why spend much larger sums on an operating theatre and anaesthesia when the probability of success in the simpler outpatient procedure is so high? 

Reversal – approach no. 2 (readiness to proceed immediately to a V-E) may make sense when the interval is very long.

Whichever reversal approach is used, the operation to restore sperm to the ejaculate takes about 3-4 hours. After the operation, the dressing is held in place with an athletic supporter. Slight oozing from the post-operative wound may persist for one to 3 days, allowing blood to escape and thus preventing swelling.