Vasectomy Reversal Failure Explained by World-Leading Specialist Dr. Sherman Silber
Dr. Silber explains vasectomy reversal in detail: what works, what doesn’t work, and why.
Two of Dr. Silber’s patientsrelate their experiencesreceiving care at the Infertility Center of St. Louis.
Vasectomy reversal discussed on Tom Snyder’s show.
A technical video of microsurgical end-to-side vasoepidymostomy.
Why do Vasectomy Reversals Fail So Often?
There are many reasons that patients experience failure of vasectomy reversal:
- Incompetent microsurgical skill;
- Large length of vas missing due to the original vasectomy which the surgeon does not know how to free up and lengthen so as to avoid stretch on the reconnection site;
- Pulling up of the testicles high into the scrotum rather than resting where they should at the bottom of the scrotum; and
- Most commonly, the original vasectomy formed a tight seal, not allowing any escape of sperm or fluid, and thus resulting in pressure buildup in the vas and the more delicate ductwork (called the epididymis) that connects the testicle to the vas deferens and leads the sperm out of the testicle into the vas. The buildup of microscopic pressure in the epididymis caused by the original vasectomy results in blowouts and blockages not only at the vasectomy site, but also in the epididymis (again, the very extremely delicate network that leads the sperm out of the testicle into the vas). So even a “perfect” vas reconnection cannot possibly result in a successful return of fertility, because there is still blockage that has not been corrected or bypassed closer to the testicle itself.
Most physicians who do vasectomy reversal, do not have extensive training or experience with it, and never pay attention to epididymal blowouts. Yet epididymal blowouts occur in 80 per cent of modern cases of vasectomy because of the tight seal and rapid pressure build up, and large segment of vas that most urologists take out when they do a proper vasectomy.
In fact most physicians doing vasectomy reversal in an office based setting or small clinic, only do “vasovasostomy”, that is, they just try to reconnect the vas, and consciously neglect the obstruction still present in the epididymis in 80 per cent of cases.
Most physicians in an office based setting do not even have the capability to free up the missing vas, and so the testicles are pulled up high into the scrotum and there is tension on the suture line. So the “vasovasostomy” either falls apart or the testicles remain uncomfortably high. But even if the “vasovasostomy succeeded to reconnect the vas, in 80 per cent of cases, there would still be now sperm in the ejaculate postoperatively because of the neglected epididymis.
How Is It That We Can Correct Previous Failures of Vasectomy Reversal?
Our technique for microsurgical vasectomy reversal is very 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 and time consuming on our part. But that poses no problem with results. In my experience, previous failed surgery has never interfered with obtaining an accurate reconnection, and our results are just as good in correcting failed vasectomy reversals as in standard cases where there was no previous messed up surgery. 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.”
We are able to free up the most miserable scar tissue from terribly performed or attempted vasectomy reversals, create enough length so there is no longer any tension on the suture line, and the testicles can hang at the bottom of the scrotum where they should. Then when we find epididymal blockage (usually the case) that was originally neglected, we can make an extremely delicate reconnection of the healthy vas to the epididymal tubule just beyond the area of the true blockage, which is in the epididymis. And so the failed vasectomy reversal is thus corrected.
I was the one who originally wrote all of this up in the scientific journals, and all my work, to this very day, is carefully audited and peer reviewed. When we give you success rates, it is not baloney our clinic made up or guessed at. It has been audited and published in scientific journals after careful and detailed editorial and peer review.
Shouldn’t There Be a Lot of Pain From Such An Extensive Procedure?
Our technique results in very minimal pain, no more than would require a Tylenol for full relief. Why is that so? How can that be? There are several reasons:
- I do this procedure in a true operating room, not some office. I can free up an inordinate amount of scar and stop all bleeders simply and readily with expensive electro cautery equipment. The patient is asleep and we can therefore extend the dissection to lengthen his shortened vas without any pain. It is not an amateur set up as is the usual case in some beautiful office somewhere. Where I operate, it is the real thing.
- I keep you in the hospital overnight with “drains” to avoid any swelling. The lack of swelling results in minimal pain. Then you leave the next day, and are remarkably pain free.
- There is no swelling and no tugging on the reconnection that would otherwise be pulling your testicle high up into your scrotum.
- I also inject a local anesthetic approved by the FDA which last for four days. It is just amazing how little pain men have after such an extensive re-reversal of their previously botched operation.
What If There Has Been A Long Time Since the Original Vasectomy?
There is no damage whatsoever to sperm production (spermatogenesis) no matter how many decades ago the vasectomy might have been performed. The problem is you can be sure there will be secondary pressure induced epididymal blowouts and blockage. 30 years ago, this secondary blockage rarely occurred before 5 years, and occurred in only 50 per cent of the cases by 10 years. But that has all changed.
Since urologists in the last three decades have been much more thorough with their vasectomies, taking out a large piece of vas, and sealing the ends of the vas very tight and securely, there is a much more rapid build up of high pressure, and blowouts now occur at any time, even just one year, after the vasectomy. Time since vasectomy never had any effect on sperm production in the testicles, but did affect the likelihood of epididymal blowouts. But now epididymal blowouts are just as likely to occur (80 per cent) with recent vasectomies as with vasectomies that were performed many years ago.
None of this should affect our success however with vasectomy reversal IF it is done properly, freeing up the vas adequately, and bypassing epididymal blowouts.
Failed Vasectomy Reversal Options
If your vasectomy reversal was done by some office based physician who just did vasovasostomy and charged you a bargain basement price, then it is obvious, you just need a proper re-reversal, as described above. If your doctor was truly accomplished and failed at the reversal, then he SHOULD HAVE FROZEN SOME OF YOUR SPERM AT THE TIME OF HIS “REVERSAL”. If he did not do that, then he really is completely incompetent, and you just need to have a proper “re-reversal” operation, and consider the money you spent just lost money. Just come to us and we will do a re-reversal for you.
On the other hand, if he froze your sperm at the time of surgery, and he knew what he was doing, and froze it in a proper adjacent lab where they are experience with freezing sperm, then you have two choices:
- You could still have a re-reversal if your preference is to avoid ICSI-IVF. OR
- you could have your wife go through ICSI-IVF using her eggs and your stored sperm.
- You should know that even we have a 5 per cent failure rate (don’t believe for a second claims of 99 or 100 per cent), and therefore we always freeze the sperm when we do vasectomy reversal so there is a “backup” opportunity to have an ICSI-IVF procedure without your husband having to go through any further surgery to retrieve sperm.
- The one most cost effective and easiest way to have a baby is with a successful vasectomy reversal procedure. But if even in our hands that fails occasionally, then you want to be sure to have frozen sperm for backup, which rarely do the office based amateurs who offer cut rate prices for vasectomy reversal ever do.
Vasectomy reversal failure is very common in most hands, particularly those who advertise great results with a simple office-based procedure under local anesthetic.
Even if such an amateurish procedure has failed for you, that is not the end. We can redo the failed reversal and we can even do ICSI-IVF with retrieved sperm, and there is no reason the fertile wife cannot get pregnant with her husband.
Click Here to Learn More about Vasectomy Reversal from Chapter 15 of Dr. Silber’s book, “How to Get Pregnant.”
Microscopic Vasectomy Reversal 30 Years Later: A Summary of 4010 Cases by the Same Surgeon. Journal of Andrology, Nov/Dec 2004.
- Male Infertility
- “Fertility: stop all the clocks” from The London Daily Telegraph Sunday Magazine
- Fertility expert Dr. Sherman Silber gives hope to infertile men and women
- Innovation: Dr. Sherman Silber St. Louis Business Journal article
- Intra-Cytoplasmic Sperm Injection (ICSI)
- Tubal Ligation Reversal
- Sperm, Egg, Embryo, and Ovarian Tissue Freezing
- Sperm Aspiration