Vasectomy Reversal

Approximately 500,000 men request vasectomies each year and it is recognized that 5% of them will change their minds, usually due to remarriage, death of a child or improved circumstances allowing for more children. Over the past 20 years, the surgical technique of vasovasostomy provided excellent results, permitting a man to re-establish his fertility. The surgery is performed on an outpatient basis with over 99% success for those men who have sperm at the time of surgery.

Within the aspect of medicine or life, good judgment is based on experience and experience is based on poor judgment. Therefore, you, as the patient, look to find the physician with the greatest experience and most skill in performing these operations. Multiple outcome studies have shown that the single most important factor in success of a vasectomy reversal is the skill and experience of the microsurgeon. This is where the Center for Male Reproductive Medicine can help. We have been in existence for 30 plus years and were original pioneers in microsurgical vasectomy reversal in the 1970’s. Dr. Rothman has been considered by many as one of the “fathers of urological microsurgery”. Dr. Werthman, after completing his microsurgical fellowship training was hand picked and trained by Dr. Rothman to carry on his practice and pass on his microsurgical skills, techniques and experience. Dr. Werthman has refined many of the procedures over the years and expanded the practice as well. Dr. Werthman has performed over 3000 microsurgical cases and now holds the distinction of helping a man father a child 57 years after his vasectomy (vasectomy performed in 1945 and child born in 2002). Unlike many of the reversal clinics that are now popping up and advertising all over, we have been here since the beginning and you can be assured of our experience.

For those couples experiencing infertility due to a man’s vasectomy, there are the alternatives of T.D.I. (therapeutic donor insemination) or IVF/ICSI (in-vitro fertilization with intracytoplasmic sperm injection), but restoration of a man’s fertility by reconnecting the tubes at the site of the previous vasectomy appears to provide couples with the most optimal and least expensive option for building a family.

How is Vasectomy Reversal Performed?

With the patient under anesthesia, a 1-2 inch incision is made in the scrotal skin over the old vasectomy site. The two ends of the vas deferens are found and freed from the surrounding scar tissue. A drop of fluid from the testicular end of the vas is placed on a glass slide and examined using a light microscope. This is a crucial part of the operation because the information obtained is used to decide what type of microsurgical reconstruction needs to be performed. Since the testicle continues to produce sperm after a vasectomy, the fluid in the vas should contain sperm. There are 3 possible scenarios that may be encountered when examining the vasal fluid. The first and best scenario is that the vasal fluid contains whole sperm. The second possible finding is that the fluid is thin and copious and contains only sperm parts or no sperm. The third is that the fluid is thick, pasty and contains no sperm. This last scenario usually means that a “blow out” or rupture has occurred in the epididymis. Sperm leak out if the pressure in the tubule becomes greater than the resistance in the wall of the tubule, similar to the way a pipe breaks in the basement when the water pressure gets too high. The body tries to heal this tubule and a scar forms. This causes a second blockage in the epididymis, which needs to be bypassed to allow the sperm to get out into the vas. If this second blockage is present and is not recognized then the operation is doomed to failure.

Micro Surgical Vasovasostomy

If the vasal fluid contains sperm then the two ends of the vas deferens can be sewn together. This procedure is known as a vasovasostomy. The associated pictures were taken through the operating microscope during a vasovasostomy performed by Dr. Werthman. An artist drawing is depicted to the right for illustration purposes. The lumen or channel inside the vas deferens through which the sperm swim is only 0.2 to 0.3 millimeters in diameter (about the size of a pen dot). An operating microscope is used to magnify the operating field up to 16 times. The vas can then be better visualized and the sutures can be precisely placed. You can now easily understand that without the use of the microscope this operation would be very difficult, if not impossible to perform successfully. All studies have demonstrated that microsurgical vasectomy reversal is more successful than those procedures performed without the microscope or with loupes (magnifying glasses worn by the surgeon).

The technique we prefer is a two or three-layered closure using 10-0 and 9-0 suture (half the thickness of a human hair). We place 6-8 interrupted sutures in the mucosa or inner layer of the vas to ensure that the repair is water-tight (figure 2). This is very important because one reason that vasectomy reversals fail is that sperm leak out from the vas at the surgical site and cause inflammation and a new blockage. The muscular layer of the vas is then re-approximated adding strength to the repair (figure 3). The surrounding connective tissue is also brought together as a third layer to take any tension off of the repair site. The skin incision is then closed.

Photographs taken though the operating microscope during a vasectomy reversal performed by Dr. Werthman

The back walls of the vas have been brought together – microsutures are seen connecting the inner layer posteriorly.
The diameter of the inside channel is 0.3 millimeters.

All the mucosal (inner layer) sutures have been precisely pre-placed every 45 degrees. This assures a water tight seal.

The inner layer sutures have been tied and a micro needle is seen going though the muscular layer of the vas deferens.
The second layer adds strength to the repair.

The muscle layer is closed over the inner layer. The picture shows the completed vasovasostomy.

Microsurgical Vasoepididymostomy

If an epididymal blowout has occurred then this second blockage must be bypassed. To do this, the epididymis is closely examined and a tubule is opened and the fluid checked for the presence of sperm. If sperm are found then the vas can be sewn to the open epididymal tubule (pictures above). This is called a vasoepididymostomy. A vasoepididymostomy is a technically more difficult procedure to perform than a vasovasostomy because the epididymal tubules are very thin and delicate. The results of vasoepididymostomy are not as good as with vasovaostomy. It is for this reason that if the vasal fluid looks good or has sperm parts, then a vasovasostomy is performed. Motile sperm can also be collected from the epididymis right at the time of surgery and frozen for later use if the vasoepididymostomy fails. Not all vasectomy reversal surgeons are able to perform this more difficult procedure nor can it be performed precisely under local anesthesia with the patient moving around. It is important to make sure that the surgeon you choose can perform this successfully, if needed.

The vas deferens (stained blue) is brought into close proximity to the epididymal tubles in preparation for the connection.

Sutures have been placed through an epididymal tubule and an opening has been cut to allow the sperm to pass though.

The epididymal tubule has been connected to the vas and sutures have been tied.

The muscle of the vas is closed over the outer covering of the epididymis to add strength to the surgical repair. The finished connection is seen in the drawing.

Re-do Vasectomy Reversals
Vasectomy reversals typically fail either because of scarring at the surgery site, imprecise suture placement or because a blockage in the epididymis was present and not recognized i.e. a vasovasostomy was performed when a vasoepididymostomy was indicated. Because a vasectomy reversal has failed does not mean all hope is lost. Re-doing the surgery using meticulous and proper technique can produce success in more than 80% of cases.

At the Center for Male Reproductive Medicine, we specialize in re-do vasectomy reversals. Ten percent of the reversals we perform are re-operations on patients who had failed surgery elsewhere.

Dr. Werthman currently performs 2 to 4 vasectomy reversals per week. Many of our patients travel from outside the Los Angeles area and our staff are able to help you with accommodations. The initial evaluation can be performed a day prior to the procedure and the patient may return home one day after the procedure minimizing the stay in LA to 3 days.

THE BOTTOM LINE is that we offer patients all the possible option and combinations of treatments so you can choose what is best for you not what we might want you to do because of our limitations. For more information on vasectomy reversals, or to speak with Dr. Werthman, please call the Center for Male Reproductive Medicine. We will be happy to send out an information package.
Schedule an appointment – If you’d like to request information about reversals or make an appointment, you can call us or complete our online Action Request Form and we will then contact you.