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If you have any questions, you may call us at (314) 576-1400.
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Video:
Dr. Silber explains vasectomy reversal in detail: what works, what doesn't work, and why. |
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Two of Dr. Silber's patients relate their experiences receiving care at the Infertility Center of St. Louis. |
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Vasectomy reversal discussed on Tom Snyder's show. |
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A technical video of microscopic vasectomy reversal. |
Vasectomy Reversal is a procedure which allows men who have previously undergone vasectomy to become fertile again. The vas deferens is microsurgically reconnected and the epididymal blowouts are microsurgically bypassed, allowing sperm to travel out of the epididymis and into the ejaculate.
Microsurgical Vasectomy Reversal Technique (For Simpler Cases)
The outer diameter of the vas deferens (sperm duct) is about 1/8 of an inch, but the diameter of the inner canal which carries the sperm is about 1/70 to 1/100 of an inch, or roughly the size of a pinpoint. This inner canal has a lining of mucosa which is about 3 cells thick. In order to achieve a non-obstructed reconnection, it is necessary to accurately stitch this inner lining in a leakproof fashion, using thread that is invisible to the naked eye (approximately 1/1000 of an inch in diameter). Then the relatively thick muscular wall (1/16 of an inch on each side) is similarly stitched to insure proper muscular contraction for moving sperm into the ejaculate.
This is all performed under a microscope with very high magnification, using delicate instruments and suture which I designed specifically for this surgery.
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Precise microsurgical alignment of the inner canal of the vas lining with ultra-fine monofilament surgical thread that is invisible to the naked eye performed under the microscope with high powered magnification usually results in a normal channel for sperm to travel through and gives the best chance for a pregnancy.
(see video clip)
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There are less precise techniques for vasectomy reversal. For example, a single-layer of stitching that pierces through the thicker muscular wall and the delicate inner lining all in one bite will not obtain as precise an approximation, and runs the risk of actually sewing the tiny inner canal shut.
In most cases, attempting to reverse the vasectomy simply with 'vasovasostomy' or 'vas-to-vas reconnection' is simply not adequate because over a period of time, blockages occur in the epididymis, i.e. closer to the testicle. This epididymal damage must be bypassed and is much more difficult microsurgically than simply reconnecting the vas.
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| Relatively crude surgical techniques like those depicted above will occasionally be successful, but this usually results in scarring down with a poor channel for sperm to go through leading to poor sperm quality and no pregnancy. Eventually such a crude channel scars down completely and the patient has very few or no sperm coming through. |
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Failure Of Previous Reversal Attempts
The technique is equally successful in cases where previous attempts at vasectomy reversal elsewhere have failed. In these circumstances, scar tissue from the previous operation does make repeat surgery more difficult, but that poses no problem with results. In my experience, previous failed surgery has never interfered with obtaining an accurate reconnection. I do not recommend that you go through the expense and discomfort of a less meticulous attempt at vasectomy reversal the first time. Nonetheless, if you have had a previous unsuccessful operation elsewhere this will not hurt your chances for success if you come here for a repeat operation.
In fact, 40% of my patients come here after having had failure of a vasectomy reversal attempt elsewhere. The cause of these failures is always obstruction. In many cases, obstruction is at the site of the previously attempted reconnection. However, in most patients there is also obstruction in the much more delicate ductwork closer to the testicle, called the "epididymis."
The Need For Epididymal Repair (More Complex Cases)
The epididymis is a coiled, 20-foot long, fragile, microscopic tubule that carries sperm from the testicle into the vas deferens. The delicate wall of this tubule is a thin, filmy membrane 1/1000 of an inch in thickness. The diameter of the tubule is 1/300 of an inch, or roughly 1/3 the size of a pinpoint. After vasectomy, the testicle continues to produce sperm and fluid normally. This causes a build-up of pressure within the vas going all the way back to the epididymis. In most individuals this pressure causes a "blow-out" in the epididymis, similar to a leak in the thinnest part of a tire that has more pressure than it can handle. Sperm then leaks into surrounding tissue and causes scarring and obstruction.
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| The above diagrams depict the very delicate microscopic technique that we use for connecting the healthy end of the inner canal of the vas directly to the opening we make in the incredibly delicate epididymis in order to bypass the epididymal blockage. |
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Thus the patient has obstruction not only at the original vasectomy site, but also closer to the testicle, at the epididymis' blow-out site. In this situation, reconnection of the vas deferens alone would not restore fertility. Such patients require a more precise reconnection of the vas deferens to this much more delicate epididymis.
The majority of vasectomized men have such epididymal blow-outs. The longer the duration of time since your vasectomy, the greater the chance that you will have epididymal obstruction. However, it is important to understand that epididymal blow-outs can occur anytime following your vasectomy. If this has happened to you, these blow-outs will need to be repaired at the time of your reversal to maximize your chance of regaining fertility.
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| Above, we see the final connection being made from the outer wall of the vas deferens to the epididymis. |
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Diagram of steps in the very delicate microscopic surgical process for bypassing epididymal blowouts, necessary for obtaining high pregnancy rates with vasectomy reversal.
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Microsurgical Vasectomy Reversal Is Not Just Vasovasostomy
Vasectomy reversal is often incorrectly thought of as simply a reconnection of the severed vas deferens. In fact, the term many doctors mistakenly use for the reversal of vasectomy is “vasovasostomy”. But vasovasostomy just means reconnecting the vas. Simply “reconnecting the vas” is not enough to restore fertility to most vasectomized men. The reason for so many failures of vasectomy reversal, even with “microsurgery”, is that in over 80 per cent of cases the pressure buildup inside the vas (caused by the original vasectomy) results in microscopic “blowouts” and “concretions” in the more delicate ductwork closer to the testicle (called the “epididymis”) which is where the sperm leave the testis on their way to the vas. If this complex, truly more delicate pathway, the epididymis, is not microscopically bypassed, the vasovasostomy will not work, because the sperm still cannot get to the site of the vas reconnection. They are blocked from even reaching the vasovasostomy site because the more delicate ductwork closer to the testicle remains blocked. So the routinely performed vasovasostomy was destined never to work no matter how accurate the reconnection.
The reason for this most commonly practiced error is that repair of the epididymis is very difficult, and requires years of very specialized practice and experience. Most urologists would be lost in the epididymis. So they might very earnestly apply what they think are “microsurgical skills” to perform a vasovasostomy, just hoping that there are no proximal blowouts in the epididymis. They might even tell the patient that they saw “sperm” in the vas fluid at the time of the vasovasostomy, increasing their hope that vasovasostomy is enough in their case. They will do anything to avoid trying to repair the usually obstructed epididymis because it is so difficult for the less experienced.
The problem is that there will always be creamy thick fluid in the vas deference on the proximal side of the vasectomy site, which has been stored in that obstructed site for years, and there might even be decayed old dead sperm or sperm parts in that fluid, and so it might be mistaken for epididymal continuity. But if the vas does not have translucent fluid with normal intact motile sperm, then you can be sure that no fresh new sperm have reached this area for many years, because of epididymal blockage more proximally. So you might leave the clinic with “wait and see” advice from the doctor even though there is no chance of the “vasovasostomy” working. It may not be until a year later with consistently negative semen analysis results, that you realize you had the wrong operation.
This problem of epididymal blowouts is much more common now than 20 or 30 years ago, and occurs much earlier after vasectomy, as early as 6 months even. The reason is that urologists are performing the original vasectomy much more tightly, allowing no leaks whatsoever of sperm. Therefore, it is important for the microsurgeon to perform this more delicate vasoepididymostomy procedure [technical video] in over 80 per cent of cases, when there is secondary epididymal blockage.
Sperm Production And Sperm Quality After Vasectomy & After Reversal Of Vasectomy
For many years people had wondered what happens to the sperm after vasectomy. Our studies, reported at meetings of the American Fertility Society and the American Urological Association show the following:
- After vasectomy, sperm production continues normally, but sperm transport slows down dramatically in response to the build-up of pressure. This pressure build-up eventually leads to blow-outs in the delicate ductwork which drains sperm from the testicle to the vas deferens, causing blockage not only at the vasectomy site, but also much closer to the testicle. Both sites of blockage must be corrected for the vasectomy reversal to succeed.
- In order for sperm transport to recover properly, this high pressure must be reduced to normal by a technically accurate reconnection of the two ends of the vas. If there is a partial obstruction, or an inadequate channel, sperm transport will not return to normal. For maximum fertility an unobstructed channel must be reconstituted. A scarred-down, partially open channel will slow down the transport of sperm, and lead to only older sperm with poor motility eventually reaching the ejaculate.
- Sperm counts do not reach normal values until 3 to 8 months after the reversal operation. This is the time required for recovery of sperm transport mechanisms. Sometimes sperm recovery requires longer however, and the uncertainty surrounding such a wait is usually less emotionally traumatic when you know that a technically perfect repair has been performed.
- Some have speculated that "sperm antibodies" prevent a successful outcome. Our studies have clearly disproved that theory. Failure of vasectomy reversal is not due to antibodies, but rather to obstruction either at the site of the vas reconnection or at the site of blow-outs in the delicate ductwork of the epididymis.
Poor Sperm Counts After Less Precisely Performed Vasectomy Reversal
Sometimes patients may think they have had a successful vasectomy reversal because there are some sperm in the ejaculate, but the sperm count is terribly low and they are not really fertile. With imprecise surgery an adequate channel is not established, scarring constricts the site of reconnection, impeding sperm transport, and this causes the sperm count to be too low. Also, unrepaired epididymal damage reduces the quality and quantity of sperm getting through. Pregnancy is not likely with that sort of result.
Large Segment of Vas Removed At The Time Of The Original Vasectomy
The length of vas removed at the time of vasectomy and the type of vasectomy originally performed should not have any effect on the results. Whether or not the convoluted portion of the vas is involved is of no consequence. The vas can be microscopically stitched just as precisely in the convoluted as in the straight portion. If a large segment of vas has been removed, the gap can always be bridged by careful microsurgical dissection.
It is impossible to determine prior to surgery just how much vas deferens was removed at the time of your vasectomy. It is never an important concern. The success rate should not be any lower in cases where large or even huge portions of the vas have been removed.
Difficulty Of Operation
This surgery requires a great deal of practice, because of the delicate manipulations involved. I practiced on over 1,000 rats for three years before performing my first human case. I have now performed over 6,000 cases on humans. I do not recommend this procedure to be tried on humans without adequate and continuing practice.
In addition to enhancing the likelihood of success, performing this surgery delicately allows there to be less pain and swelling postoperatively, with a quicker and more comfortable recovery. In fact, the pain postoperatively should be minor IF proper attention is paid to all these details.
Fertility And Pregnancy Results
The statistics reported in this information are based strictly on surgeries performed by myself on over 6,000 patients and do not reflect results of other surgeons. These statistics are not estimates, or guesses, but represent an accurate tabulation of the results in those patients I have already operated on.
- In patients with no epididymal obstruction, 98% develop normal sperm count and sperm motility, indicating fertility. 88% achieve pregnancy without further treatment.
- Contrary to general myth, the duration of time since vasectomy does not significantly affect the success rate.
- The success rate for those patients who have had previous unsuccessful surgery elsewhere and come here for a re-operation, is no different from patients who are undergoing vasectomy reversal here for the first time.
Cost Effectiveness of Vasectomy Reversal Compared To Sperm Retrieval With ICSI
- The cost of these approaches is similar, but the pregnancy rate after a single microsurgical vasectomy reversal is over 80%, and with ICSI is about 35% per treatment cycle.
- Therefore the first choice is vasectomy reversal. Sperm retrieval and ICSI is only a "back up", which hopefully won't be needed.
Comparing Microscopic Vasectomy Reversal vs. Sperm Retrieval and ICSI: Dr. Silber's conclusions
It is highly possible that you have heard of a new technique called Intra-Cytoplasmic Sperm Injection (ICSI) which was developed by me and my Brussels' colleagues, Dr. Andre Van Steirteghem and Dr. Paul Devroey. Since we are the team that invented this procedure, we naturally have the most extensive experience and success in performing it. The ICSI procedure involves direct aspiration of sperm from the husband combined with the injection of a single, weak or non-moving sperm into the cytoplasm of the wife's egg, resulting in fertilization. This procedure requires surgery for both the husband and the wife. We routinely perform sperm aspiration and ICSI for patients who have congenital absence of the vas or for those in whom there is no possibility of surgical repair.
For anyone who has had a vasectomy, or even one or more previous failed vasectomy reversals, the simplest, most cost-effective approach, as well as the best chance for a pregnancy would still be for me to reconnect your ducts microsurgically. This involves no greater surgical discomfort than the sperm aspiration and gives a 95% chance for a successful return of fertility, as compared to a 40% pregnancy and delivery rate per treatment cycle with sperm aspiration and ICSI. However, by having the ICSI option available as backup, you have virtually a 100% chance of success so long as the wife is fertile. Therefore, we do make sure to offer you the benefit of both vasectomy reversal and ICSI. This is how we do it.
At the time of your vasectomy reversal, our program has the capability to freeze and store sperm retrieved from your epididymis or vas. We do not enter your testicle for this, and so there is very little discomfort. This frozen sperm can be used as a backup if your wife is unable to achieve a pregnancy with your ejaculated sperm following your reversal, (which occurs in a small percentage of cases). By freezing your sperm at the time of your surgery, we will still have the opportunity of doing the ICSI procedure for your wife in the future, if necessary, without your ever having to go through another surgical procedure. We were the original developers of the ICSI procedure, and we can, therefore, provide you with the best possible results with sperm retrieval and ICSI. But, nonetheless, a microscopic vasectomy reversal is actually your least painful and most successful option.
Another alternative you may have recently heard about is "needle aspiration" in combination with an IVF/ICSI procedure. Needle aspiration is generally offered by doctors or clinics that do not have access to an operating room or delicate microsurgery. The only option these doctors can offer you is to stick a needle into your testicle. However, this type of aspiration, though easy for the doctor to perform, can result in testicular damage and a great deal of swelling and pain. Then your wife has to go through an involved and costly IVF/ICSI procedure requiring three or four months of injections, many trips to the clinic, and a huge drain on both her time and yours. This is a difficult procedure for her, is more costly than vasectomy reversal, and only gives a 40% pregnancy rate per each treatment attempt. Microsurgery for vasectomy reversal, properly performed, results in minimal pain and gives a 95% success rate. Therefore, microsurgical vasectomy reversal is still the simplest, most cost-effective first choice option for fulfilling your desire to have children.
Scientific paper on Vasectomy Reversal by Dr. Silber.
See also:
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Click Here to Learn More about Vasectomy Reversal from Chapter 15 of Dr. Silber's book, "How to Get Pregnant." |
If you have any questions, you may call us at (314) 576-1400.
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