119 I.5.2 Vasectomy Reversal A. Belker Key Messages I.5.2.2 ■ The most common reason vasectomy reversal Contraindications is requested is the remarriage of a divorced man. The usual contraindications to surgery, such as bleed- ■ Either vasovasostomy or vasoepididymostomy ing diatheses and general severe health problems, apply may be required to reverse a vasectomy. to vasectomy reversal. A reversal procedure is also con- ■ The surgeon’s choice of vasovasostomy or traindicated if urinary tract infection or scrotal skin in- vasoepididymostomy depends upon many fection are present. If the female partner has bilateral factors such as the quality of sperm in the fallopian tube obstruction, reversal of both the fallopi- intraoperative vas fluid, the gross appearance an tube obstruction and the vasectomy is possible. of the vas fluid when sperm are absent from However, sperm retrieval for in vitro fertilization (IVF) thefluid,andthepresenceorabsenceof with intracytoplasmic sperm injection (ICSI) (Kolettis epididymal induration. and Thomas 1997) would be a less expensive method to ■ Microsurgical procedures obtain results that achieve a pregnancy. In most centres, this alternative are markedly better than the results of wouldbeaslikely,ifnotmorelikely,toproduceapreg- nonmagnified procedures. nancy than for both partners to undergo a reversal pro- ■ The success rate of vasectomy reversal cedure. I.5 decreases as the duration of the obstructive If physical examination reveals that the patient has interval increases. developed bilateral testicular atrophy, the cause of atro- ■ The success rate of vasectomy reversal is phy must be determined (see Chap. II.2.5). If the cause related to the intraoperative sperm quality in is testicular disease, correctable pituitary or hypotha- the vas fluid. lamic disease, vasectomy reversal would be contraindi- ■ Sperm retrieval for IVF/ICSI is an alternative cated. to vasectomy reversal that should be consid- ered in certain situations. I.5.2.3 Vasectomy Reversal Techniques I.5.2.1 I.5.2.3.1 Indications Vasovasostomy The most common reason for vasectomy reversal is the Vasovasostomy is the technical name for anastomosis desire of a man to have a child, or children, in a second of the severed ends of the vas. The procedure may be or subsequent marriage. In such situations, the male performed without optical magnification (see Chap. partner usually has had children in a previous relation- II.4.1), but almost all authorities now agree that the re- ship and it is the desire of the female, who usually has sults of vasovasostomy performed with the aid of mi- not previously had children, that prompts the male to crosurgery are better than the results of those proce- seek a vasectomy reversal. Less often, both partners dures performed without optical magnification. A two- have had children and simply desire to have a child in a layer method of microsurgical vasovasostomy (see new relationship that will be “theirs”, rather than “his” Chap. II.4.1) creates precise approximation of the mu- or “hers” in that relationship. A relatively rare reason cosaledgesandoftheoutermuscularlayeredgesofthe for vasectomy reversal is the death of a child and the de- vas. sire of a couple to have another child because of that loss. Another infrequent reason for vasectomy reversal I.5.2.3.2 is the development of testicular or epididymal pain re- Vasoepididymostomy sulting from the vasectomy. Obstruction of the vas de- ferens,subsequentlyreferredtoassimplythevas,may During a vasectomy reversal procedure, fluid from the be discovered to be the cause of azoospermia during testicular end of the vas is examined with a laboratory theevaluationofamanwhopresentsforafertilityeval- microscope. If spermatozoa are present in the fluid, uation. The obstruction of the vas in such situations al- vasovasostomy is performed. The absence of sperma- most always is the result of bilateral injury to the vas tozoa may indicate that epididymal obstruction has de- that occurred during bilateral inguinal hernia repair veloped after the vasectomy (see Chap. II.4.1). In this performed during infancy. situation, the epididymal obstruction must be by- 120 I.5 Problem: Male Contraception passed by performing vasoepididymostomy, or anasto- Postoperative infection and bleeding, which may occur mosis of the abdominal end of the vas to the epididy- after any surgical procedure, fortunately are rare occur- mal tubule at a level in the epididymis above the point rences after vasectomy reversal. The pain that follows of obstruction. Older nonmicrosurgical methods of va- vasectomy reversal, whether vasovasostomy or vaso- soepididymostomy relied on the creation of a fistula epididymostomy is required, is of brief duration and between openings in several loops of the epididymal rarely requires more than oral analgesia. There has tubule and the vas lumen (see Chap. II.4.1). A micro- been no report of a change in sexual performance after surgical method of vasoepididymostomy creates a di- vasectomy reversal. rect connection of the edges of the epididymal tubule to the edges of the vas mucosa, with subsequent connec- I.5.2.6 tion of the muscular layer of the vas to the edges of the epididymal tunic (see Chap. II.4.1). Results As the duration of the obstructive interval, which is Numerous factors determine the success of vasectomy the elapsed time since the vasectomy, increases, an in- reversal. The most important preoperative factor that creasing percentage of men develop a back pressure-in- determines success is the duration of the obstructive duced rupture of the epididymal tubule (Silber 1977). interval (Belker et al. 1991). The rates of return of The subsequent leakage of spermatozoa from the epi- sperm to the semen and of pregnancy in the female didymaltubulecreatesaspermgranulomawithinthe partners, respectively, are 97% and 76% for an ob- epididymis (Silber 1979). Because the epididymal tu- structive interval of under 3 years, 88% and 53% for bule is a single, continuous tube, the obstructing sperm 3–8years,79%and44%for9–14years,and71%and I.5 granulomapreventsthepassageofspermatozoabe- 30% for 15 years or longer (Belker et al. 1991). Results yond the point in the tubule at which the granuloma is of the microsurgical one-layer (Schmidt 1978) and two- located. layer (Belker 1980) techniques are comparable (Belker The absence of spermatozoa from the intraoperative et al. 1991). vas fluid does not necessarily indicate that an epididy- An intraoperative factor that determines the success mal obstruction is present. When spermatozoa are not of vasovasostomy is the sperm quality in the fluid that seen in the vas fluid, the surgeon must inspect the epi- is obtained from the testicular end of the vas. Success didymis. If a point of obstruction is clearly identified by rates are progressively lower for vasovasostomy when observing dilation of the epididymal tubule above that the intraoperative fluid contains mainly motile sperm, level and collapse of the tubule below that level, then mainly nonmotile sperm, mainly sperm heads (with- vasoepididymostomy is required. If no point of ob- out tails), only sperm heads, or no sperm at all (Belker struction can be identified, then the surgeon may be et al. 1991) (see Chap. II.4.1). If microsurgical vasoepi- guided by the gross appearance of the fluid that ema- didymostomyisrequired,therateofreturnofspermto nates from the testicular end of the vas (Belker et al. the semen postoperatively ranges from 60% to 85% 1991) (see Chap. II.4.1). and the rate of pregnancy ranges from 20% to 44% (Matthews et al. 1995; Kim et al. 1998; Kolettis and I.5.2.4 Thomas 1997). The success rates of both vasovasostomy and vaso- Postoperative Care epididymostomy are better when those procedures are After both vasovasostomy and vasoepididymostomy, it performed microsurgically compared to the results of is recommended that a scrotal support be used and procedures performed without optical magnification. heavyphysicalactivitybeavoidedfor4weeks.Sexual However, microsurgical performance of both proce- intercourse should be avoided for at least 2 weeks post- dures requires formal laboratory training and subse- operatively. Semen analyses are advised at 2- to 3- quent practice before optimal results can be expected. month intervals until semen parameters are stable or until a pregnancy has been achieved. The average inter- I.5.2.7 val until a pregnancy occurs after vasovasostomy is 1 year (Belker et al. 1991), but information about the Conclusions average interval until a pregnancy occurs after vasoepi- Vasectomy reversal may require either vasovasostomy didymostomy unfortunately is not available at this or vasoepididymostomy. The intraoperative decision time. regarding which procedure is required is made inde- pendently on each side. Thus, some patients may re- I.5.2.5 quirevasovasostomyononesideandvasoepididymo- Complications I.5.3 Male Contraception 121 stomy on the other side. The results of vasectomy rever- Kim ED, Winkel E, Orejuela F, Lipshultz LI (1998) Pathological sal have been improved considerably since the intro- epididymal obstruction unrelated to vasectomy: results with duction of microsurgical methods to perform both vas- microsurgical reconstruction. J Urol 160:2078–2080 Kolettis PN, Thomas AJ Jr (1997) Vasoepididymostomy for va- ovasostomy and vasoepididymostomy. sectomy reversal: a critical assessment in the era of intracy- toplasmic sperm injection. J Urol 158:467–470 Matthews GJ, Schlegel PN, Goldstein M (1995) Patency follow- References