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Factors for a good prognosis in patients undergoing vasectomy reversal

By Edward Karpman, MD, FACS
California Vasectomy and Reversal Center Mountain View, CA
Medical director of the Men’s Health Program at El Camino Hospital, Los Gatos, CA

There are two ways we can consider success after vasectomy reversal, sperm returning to the ejaculate of the man (surgical success) and pregnancy (overall success). We have very little control over the latter since this is very dependent on the female partner. However, we do have control over the former since this is a result of patient selection, experience and technique.

So what are the factors that we can influence in order to get the best results for patients undergoing a vasectomy reversal? There are actually two different surgeries for vasectomy reversal: vasovasostomy (vas to vas) and epididymovasostomy (vas to the epididymis). The surgical approach any patient needs can only be determined at the time of surgery. Selecting a surgeon who is well-skilled in BOTH of these operations is an important factor for success. The need for the more complex epididymovasostomy increases with the time since a patient has had a vasectomy and, overall, 30% of men will require this approach.

Some surgeons can only perform the vasovasostomy procedure and will gamble with the patients whose vasectomy was performed less than 10 years ago that they can reverse the vasectomy. Studies have shown that the likelihood of requiring the more complex epididymovasostomy is lower but not unlikely less than 10 years after the vasectomy.1 Unfortunately, as with most gambles, they don’t always pay off and the wrong operation is performed leading to further surgery and costs for the patients.

The time since the vasectomy was performed has always been considered a determinant for surgical success for vasectomy reversal.2 Our own research has shown that even men who have had vasectomies for greater than 10 years can have a very highly successful surgery more than 90% of the time.3 Other factors such as the presence of a sperm granuloma and the length of the testicular end of the vas deferens have also been shown to have an impact on success.4

Another important factor is technique. Vasectomy reversal can be performed in the doctor’s office or in a surgery suite. It can be done under local anesthesia or general anesthesia. It can be done with loupe magnification (x2) or a high-powered microscope (x 24). It can be done with very fine microsurgical suture (9-0 or 10-0) or it can be done with more crude sutures (5-0 to 8-0). It can be done as a single-layer, modified single-layer or two-layer technique.5 All of these variables are associated with differences in success rates and costs of the operation.

Finally, experience does matter. microsurgical vasovasotomy and epididymovasostomy are considered some of the most technically challenging surgeries in the field of urology. As with everything in medicine and life, the more you do something, the better you are at it. The concept of a center of excellence holds true for this field as well. But it is not just the number of years a surgeon has ben practicing medicine, but the number of actual vasectomy reversals they perform. Microsurgical vasectomy reversal is a skill acquired during specialized fellowship training. Finding a fellowship-trained vasectomy reversal surgeon can ensure that your doctor is performing the best possible operation.

References

1 Nomogram to preoperatively predict the probability of requiring epididymovasostomy during vasectomy reversal.Fenig DM, Kattan MW, Mills JN, Gisbert M, Yu C, Lipshultz LI.J Urol. 2012 Jan;187(1):215-8. doi: 10.1016/j.juro.2011.09.026. Epub 2011 Nov 17.

2Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group.Belker AM, Thomas AJ Jr, Fuchs EF, Konnak JW, Sharlip ID.
J Urol. 1991 Mar;145(3):505-11.

3Vasectomy reversal outcomes among patients with vasal obstructive intervals greater than 10 years.Grober ED, Karpman E, Fanipour M.Urology. 2014 Feb;83(2):320-3. doi: 10.1016/j.urology.2013.09.016. Epub 2013 Nov 6.

4The post-vasectomy length of the testicular vasal remnant: a predictor of surgical outcome in microscopic vasectomy reversal. Witt MA, Heron S, Lipshultz LI. J Urol. 1994 Apr;151(4):892-4.

5Vasectomy reversal: new techniques and role in the era of intracytoplasmic sperm injection.Karpman E, Williams DH, Lipshultz LI.Can J Urol. 2006 Feb;13 Suppl 1:22-7. Review.

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