The Treatment of Post-Vasectomy Infertility:
IVF or Vasectomy Reversal?
This article from the American Infertility Association 2003 newsletter Over the years there has been much misinformation spread regarding vasectomy and vasectomy reversal. In the last decade an alternative treatment, in vitro fertilization, has evolved to help those couples wishing to continue family building after permanent sterilization. While it is always good to have multiple treatment options, couples need to be informed of the real chances of success, pros, cons, risks, complications and consequences of their potential choices. In this article, the myths and misconceptions regarding vasectomy reversal and IVF in the treatment of post-vasectomy infertility will be briefly explored.

Common Myths About Vasectomy and Vasectomy Reversal

Myth 1: Men usually stop making sperm after a vasectomy
The first commonly held myth I heard when I began my vasectomy reversal practice was from a healthy young patient who consulted with an “old-timer” urologist. The urologist wanted to perform a biopsy of the patient’s testicles to check if he was still making sperm after his vasectomy, prior to considering his reversal. The patient was told that men usually stop making sperm after a vasectomy and that a sperm donor would be his best bet at having another child. If that wasn’t acceptable then he should forget having more children with his new wife and just be happy with his children from his prior marriage. This shocked me because we have known for a long time that men continue to produce sperm after a vasectomy regardless of how many years ago the vasectomy was performed. With that most important myth being dispelled it is clear that most men can become biological fathers again after vasectomy and testicular biopsies are not routinely needed to check if sperm are being produced.

Myth 2: Vasectomy reversals don’t ever work.
Once again, this information is clearly not accurate. So where does this incorrect idea come from? We need to explore the history of vasectomy reversal and see how a reversal is performed to address this misconception. The vas deferens is a tube with an inside diameter of one third of a millimeter (the size of a pen dot). This would be extremely difficult to sew back together without the aid of a powerful operating microscope to magnify the vas 10-15 times and without the aid of very small microsutures called 10-0 nylon (half the thickness of a hair). These tools were not routinely available until the 1980’s so reversals done prior to that time were not performed in an optimal fashion. Because the vas is so small and delicate, great skill is required to perform the reversal surgery. This special expertise takes a minimum of one year of special microsurgical training beyond urology residency to acquire and much practice to maintain. Most urologists in the United States do not have this training or skill. It would be logical to assume that much of the reversal surgery over the years was not performed microsurgically and has not met with success. The referring physicians lost confidence in sending patients for the procedure when it is not the concept of reversal itself that is at fault. Newer microsurgical techniques have resulted in much better results for reversals. It has been shown that the skill and technique of the surgeon is the single most important factor in successful reversal.

Myth 3: Vasectomy reversals don’t work if the vasectomy was performed over ten years ago.
This is another misconception that is frequently told to patients. While there is truth to the fact that in general, the chances of success with a reversal are lower the longer a man waits, there is not a direct one-to-one correlation with age of the vasectomy and success of the reversal. Nothing magically happens to the sperm after ten years that prevents them from working. The way that age effects reversal has to do with a possible second blockage occurring in the tiny tubules of the epididymis, the organ responsible for storing the sperm. The epididymis is located above and behind the testicle and is made up of fragile tubules whose walls are one cell layer thick. The sperm mature as they pass through the epididymis and the epididymis eventually thickens and becomes the vas. When a vasectomy is performed, it blocks the vas and prevents sperm from leaving the epididymis. Pressure can build up in this now closed system and if that pressure becomes greater then the resistance of the walls of the epididymal tubule, the tubule will rupture. This causes a scar to form and that leads to a second blockage. This blockage in the epididymis prevents the sperm from reaching the vasectomy site so reconnecting the vas to the vas (a procedure known as a vasovasostomy) will not work. A harder procedure called vasoepididymostomy must be performed to connect the vas to the epididymal tubule upstream from the second blockage in the epididymis. This connection is even smaller and more delicate than a vasovasostomy, is harder to perform and as such has a lower success rate. The decision to perform a vasovasostomy or vasoepididymostomy is made at the time of surgery and is based on whether there is sperm present in the fluid of the vas. It is important that the surgeon checks the fluid under a light microscope during the vasectomy reversal and that they can perform a vasoepididymostomy if necessary.

The success of a vasectomy reversal can be categorized into patency rate (chances of having sperm present after reversal) and pregnancy rate. For most skilled microsurgeons the patency rate for a vasovasostomy if sperm were present in the vasal fluid should be about 98%. Patency rates for vasoepididymostomy should be greater than 60%. The pregnancy rate varies widely from 30 to 70% depending on which procedure is performed, age of the female partner, and other factors. A recent study evaluating the pregnancy outcome for vasectomy reversals performed 15 years or more after vasectomy showed that the pregnancy rates for intervals 15-19 years, 20-25 years and greater then 25 years were 49%, 39% and 25%, respectively (Fuchs et al, 2002).

Myth 4: A woman won’t get pregnant after her husband has a vasectomy reversal because of antisperm antibodies.
Antibodies are molecules produced by the immune system to fight off anything that the immune system perceives as being foreign. After a vasectomy many men begin making antibodies to their sperm that can be detected in their bloodstream. When present in the semen, antibodies can attach to the sperm and prevent them from moving (decrease motility) or from penetrating an egg. It has become clear that only antibodies present on the sperm may cause a problem in certain situations. Very few men actually have antibodies detected on their sperm after a reversal. A study of men with poor semen parameters after reversal showed that it was actually a partial blockage and not antisperm antibodies that was responsible for the problem (Carbone et al 1998). In my experience, antisperm antibodies can cause problems after a reversal but it happens in less then 5% of my patients so it is not common and has little to do with the age of the vasectomy.

Myth 5: In-vitro fertilization is the best way to conceive after a vasectomy.
While this is a position advocated by many fertility specialists, it is not necessarily accurate. IVF does have certain advantages over reversal but it also has drawbacks. The good points to IVF are; 1) retrieving the sperm from the testicle or epididymis is much easier than a reversal and has a quicker recovery time 2) time to pregnancy has the potential to be faster with IVF than reversal, 3) it doesn’t make a difference how long ago the vasectomy was performed or whether there are antisperm antibodies. The drawbacks of IVF include 1) potential need for multiple cycles to achieve pregnancy and deliver a baby 2) need for procedures on both partners, 3) complications from injection of fertility medicines, 4) 25-30% chance of multiple births (twins or triplets), 5) questionable small increased health risk to children conceived through IVF and 6) significantly higher costs then reversal. Several cost-effectiveness studies have been published comparing reversal and IVF and all have concluded that microsurgical vasectomy reversal is the most cost effective way of conceiving. The average cost per delivery with reversal was $25,475 for a delivery rate of 47% versus $72,521 per delivery with IVF for a delivery rate of 33% (Pavlovich and Schlegel, 1997). It was also concluded that reversal has the highest chance of resulting in delivery of a child for a single procedure.

So then what is the best way to conceive after vasectomy? This is a question I am asked multiple times every day and it is a difficult one to answer. The reason is because the answer can be different for each couple and there is no right or wrong choice except in retrospect. All the data seems to support vasectomy reversal as the first choice except for couples where there is a female factor present that would impair pregnancy or when it seems as if a reversal would be unsuccessful. Treatments need to be individualized based on the couples’ circumstances because the optimal treatment for one couple is not necessarily good for another couple. The most important thing is to educate people with factual information and allow them to make a choice they are comfortable with.

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