Vasovasotomy & Epididymovasostomy
Vasectomy-induced obstructive azoospermia is a treatable cause of male infertility. In the United States, 500,000 to 750,000 vasectomies are performed annually; up to 10% of these men may later request reversal. Technical success of the operation or patency—defined as the presence of sperm in semen postoperatively—is dependent on surgical technique and skill of the operating microsurgeon, time interval since vasectomy, quality and nature of vasal fluid, and presence of epididymal obstruction.
Vasovasostomy is the most common technique for vasectomy reversal. During this three-hour procedure, the cut ends of the vas deferens are sewn back together using a high power surgical operating microscope and sutures finer than a human hair (9-0 and 10-0 sutures). These sutures are so small that they cannot be seen well with the naked eye. We use an operating microscope at 30-40X to ensure that the operation is done well and the tissue is handled meticulously. We perform both one and two layered anastomoses (reconnection of the previously severed tubes) as the existing data do not demonstrate the superiority of one procedure over the other. (Figure 1)
This procedure involves dissection of the vas deferens, identification of the obstructed segment from the vasectomy, incisions to cut the vas deferens above and below this blockage, and then the placement of six to ten very fine sutures to reconstruct an intact tube. Prior to placing any of the sutures we examine the fluid coming from the testicular end of the vas under the microscope. We only perform this procedure if fluid is still present in the vas deferens at the time of surgery; if no fluid is present, we perform an epididymovasostomy.
Epididymovasostomy is a more complex version of the vasovasostomy. This procedure is chosen if the blockage of sperm is at the level of the epididymis. This procedure is one of the most complex microsurgical procedures performed. We typically use the “intussusception technique”, which was developed by Dr. Richard Berger, one of Dr. Hotaling’s mentors at the the University of Washington. This technique involves placing two or three 10-0 sutures in the distended epididymal tubule and then connecting them to the vas deferens before opening the tubule. This makes the procedure significantly easier as the surgeon can place the sutures in the enlarged distended tubule rather than the open deflated tubule. Once all the sutures are placed, the tubule is opened with a microsurgical knife and the sutures are sequentially tied down.
These procedures are highly successful in the hands of fellowship-trained microsurgeons who regularly perform them. If we are able to perform a microsurgical vasovasostomy on each side, men can expect a >95% chance of having sperm return to their ejaculate. If we perform the vasoepidiymostomy, there is a 70-90% chance of having sperm return to the ejaculate. The main advantage of these microsurgical techniques is that they allow men to conceive without the need for in vitro fertilization.
It is important that patients have a frank discussion with their partner in order to determine whether these procedures make sense for them. Factors, such as advanced maternal age, may make natural conception impractical for some couples, and in these cases, the couples are often better served by having a procedure to extract sperm, which can be used for assisted reproductive techniques such as in-vitro fertilization. This decision must be made on a case-by-case basis.
We also offer men the option of banking sperm at the time of their vasectomy reversal. This procedure is performed through the same incision as the vasectomy reversal and involves making a small incision in the testicle to remove some of the seminiferous tubules. This incision is then closed with very fine suture. The tubules are taken to the andrology lab where sperm are extracted and then frozen. The sperm is placed in liquid nitrogen and can remain there indefinitely. The advantage of this is that, in the rare instances that sperm does not return to the ejaculate or if female factors necessitate the use of in-vitro fertilization, the man does not have to undergo another procedure for sperm extraction as the sperm that was obtained at the time of vasectomy reversal can be used.
These procedures are performed under general anesthesia in the outpatient setting with patients returning home same day. The procedure is performed through one or two small incisions over the scrotum or a small midline incision, and patients typically have minimal pain that is well controlled with a mild analgesic and applying an ice pack (we recommend a pack of frozen peas) 20 minutes out of every hour. Post-operatively we ask that patients do not have sex or masturbate for two weeks and avoid lifting anything heavier than a gallon of milk for two weeks as well.
Douglas T. Carrell, Ph.D.Locations
|Andrology & IVF Laboratories||(801) 581-3740|
Specialties: Andrology, Reproductive Endocrinology & Infertility, In Vitro Fertilization