Episode Transcript
Interviewer: For men who have had a vasectomy to prevent pregnancy, one day they might change their mind for one reason or another, and they might opt to have a vasectomy reversal. But while a vasectomy can be a pretty simple procedure, reversing it can have some extra complications a patient should take into account.
Dr. John Smith is a board-certified urologist and has performed his fair share of vasectomies. Dr. Smith, let's start off with the basics.
What is a Vasectomy Reversal?
Dr. Smith: Yeah, you bet. So a vasectomy reversal, if you go in and look at the $500 word for vasectomy reversal, it's vasovasostomy. Pretty much we take the tubes that were cut and put them back together. There are a couple of different ways they do that. They either put them together face-to-face, or end-to-end they call it, or end-to-side where you hook it into the side. Both of them have high success rates of 90% to 95% success rate.
Success Rates and Expectations of a Vasectomy Reversal
Interviewer: Wow. I didn't know that, because usually when you go in and get a vasectomy, they go out of their way to go, "Are you sure?" And then they might even . . . I could've sworn they told me it's not reversible, or you don't want to get it reversed.
Dr. Smith: Well, I usually tell people, "I don't do this to be reversed," when I do my vasectomy, but you can get it reversed. And don't be fooled. When I tell you a 90% to 95% success rate, that means you've got sperm in the tube afterward. So when we do a post-analysis three months later, 90% of people will have sperm there. Doesn't mean you're going to get a baby out of it. So pregnancy rates from that are a different story. They're around 60%, 65%.
So if you're looking at success as a baby out of it, which is why most people undergo the procedure . . . There are a couple of other reasons people do have the procedure. But if the end goal is, "I have a new partner, we want to have a child together, and I'm getting this procedure for a child," you're in the 60%, 65% range of getting a child out of it or having a viable pregnancy. The success rate of having sperm in the ejaculate is 90%, 95%. So, I mean, it's not misleading, but you've got to make sure you get all the information.
Interviewer: Right. And so that 60% of being able to have a baby, is that a lower number than had the person not got the vasectomy in the first place? Is there something inherent in having gotten it and having it reversed that decreases your chances of having a child?
Dr. Smith: Well, if you didn't have fertility issues prior to the vasectomy, then your chances are higher. If you were someone who had to use IVF or you had difficulty with conception or something before getting a vasectomy, just for safety's sake, you got a vasectomy to make sure that there wasn't a slip-up, then your chances are probably on the lower end. But yeah, most of the time your chances are better prior to.
Interviewer: So same guy, pre-vasectomy, post-vasectomy, the chances after the vasectomy could be a little bit lower, because they did have the vasectomy and the reversal?
Dr. Smith: Yeah. I mean, if you're looking one-to-one, most of those we don't do scientific studies based on one person, like, "Oh, we took this dude and we did this thing and . . ." That's not how we do it. We usually take groups of people who come from . . . all-comers of, "Hey, who had this procedure between the ages of 25 and 70 who were looking to have fertility afterward? And what percentage got pregnant?" kind of a thing. "What percentage had sperm in their ejaculate? What percentage had a baby?"
So it's hard to do the one-to-one. I mean, most people, if you have sperm in your ejaculate afterward and you were fertile before, the odds are . . . But the numbers that I'm going to tell you when you come to my office are 60%, 65% pregnancy rate.
Factors Influencing Vasectomy Reversal Success: Age, Surgical Techniques, and Timing
Interviewer: And then what are some of the factors that contribute to the success of a reversal? Does age impact it or the surgical technique or anything like that?
Dr. Smith: Absolutely. So at the University of Utah where I practice . . . I actually want to preface I don't do this procedure currently. I did it when I was a fellow, and currently, I don't do it because we have two microscopic surgeons that perform this procedure on a regular basis.
The reason we do that is to keep their volume high. When these surgeons' volumes are high, we get better outcomes. And that's one of the things that's going to make this be better, have a higher success rate. You want the people who do this on a regular basis who are very proficient, and do this procedure quite a bit. That is one of the biggest factors.
Another factor is how long between your vasectomy and the surgery. So the further out you get, the less success you find you have. However, there is some literature that says, "Even out to 10 years afterward, there are great success rates for having sperm in the ejaculate."
So some of that stuff may be debunkable with more evidence, but what we have right now looks that the further out you are from your vasectomy, it does make it a little bit less successful.
Interviewer: Okay. And the success, again, being judged in having a baby.
Dr. Smith: The success is having sperm in the ejaculate.
Interviewer: Oh, okay.
Dr. Smith: That's where there is that kind of fine line of success for a vasectomy reversal is we're trying to get sperm back through the tubes that we previously had cut. And 90% to 95% of people will have sperm there. Of those people who have that, you're going to have those folks who are going to have a child.
Surgical Techniques for a Vasectomy Reversal
Interviewer: If you go to the University of Utah Health website for vasectomy reversal, there's a lot of great information there, and you can get some details about the different techniques used. You mentioned at the top that there are two techniques.
Dr. Smith: Well, there are more than two techniques, but those are two that they use to put the tubes together. There's a little bit more nuance to a lot of this because you can put the tubes together or you can put a tube and sew it to the epididymis.
Interviewer: Yeah. So, really, this is a conversation. You could do all the research on your own that you want, and get some great information like you could at our website, but really, that conversation is pretty critical it sounds like.
Dr. Smith: Exactly. So like I said, I don't do this procedure, but I also see people preoperatively for this because I know the ins and outs of it and I refer to our surgeons because we want to keep their volume high.
You have the vasovasostomy, which is the tubes going back together, and a vasoepididymostomy, which again is a mouthful, but that's sewing the tube directly to the epididymis.
And now if we look anatomically, we have the testicle that makes the sperm, the epididymis is where the sperm matures, and then from the epididymis, it goes into the vas deferens. And so the epididymovasostomy, you've got to be careful not to mess that one up, is also a procedure, and success rates with that are a little bit lower than the vasovasostomy because of scarring that can occur.
Interviewer: Sure. And your conversation with your doctor would determine in your particular instance which one of those would probably be the best.
Dr. Smith: Yes. And sometimes you don't know until you get to surgery. So you give people the information of, "Hey, we're going to try to do a vasovasostomy. If the scarring or where they cut the tube is right next to your epididymis, when we go in and clean that area up, we may need to sew it to the epididymis."
I always coach people on all the risks that could occur, and then if something does occur, they at least understand what's going on once the surgeon kind of talks to them about that after the surgery. Because you never know what you're going to get into sometimes.
Post-Vasectomy Reversal Monitoring
Interviewer: And then how soon after the vasectomy reversal will a patient know if there's sperm making it through again?
Dr. Smith: Yeah, we give people three months. We say to get a three-month semen analysis. It's the first time that we have them look at the ejaculate. We look at the volume, we look at the amount of sperm that are possibly there, their motility, and then kind of judge things based on that and move forward with kind of secondary testing if the levels look lower than we expected. Or if the numbers look great, then we kind of go from there.
Interviewer: If the numbers are lower, is there anything you can do at that point to increase those or to help?
Dr. Smith: So sometimes we'll use clomiphene, which is an off-label use for testosterone therapy, but it has also been known to improve semen parameters and sperm parameters. And so we'll use that sometimes.
And then sometimes just time. Sometimes they needed an extra few months to get things rolling again, to be honest. And that's one of the biggest things, is nobody wants to wait, but sometimes time is the thing that we need.
Interviewer: So it takes three months. You can go and get the test, see what kind of sperm production you've got, if it's coming through. Could somebody actually start attempting to conceive before then, and how soon could they actually start that if they really did want to get going?
Dr. Smith: So we usually tell people the three months is where we're going to look at our success for this procedure. You can kind of move forward in whatever direction you want whenever you want, but until we kind of do that testing at three months, we can't give you any idea of what we think. But folks do go back to intercourse before that, and so there is a possibility.
Intimacy After Vasectomy Reversal
Interviewer: When's the soonest that you can go back to intercourse after a vasectomy reversal?
Dr. Smith: So that depends on each surgeon. Some of them will tell you to wait a few weeks. Some of them will tell you to even wait up to a month. I haven't read any literature that says one is better than the other.
But in general, I would just consult with the surgeon who's going to perform the surgery for you, because obviously, they're going to give you their success rates based on the way that they do things postoperatively and during the operation. So some of that is variable.
Interviewer: Yep. And some of it, I'd imagine, is just recovery. When you get a vasectomy, you're not supposed to have intercourse for a while because you need to heal.
Dr. Smith: Right. Well, I tell people after I do my vasectomy that they can kind of resume sexual activity whenever they're comfortable. Some of my colleagues tell people to wait a full week before having intercourse just to allow for healing and scarring of the tubes. So again, some of it does depend on your surgeon and their comfort level, and then obviously, they want it to be successful and they're going to give you their recommendation.
Interviewer: So it's a good idea to follow that recommendation is what you're saying?
Dr. Smith: I would follow what your surgeon invites you to do simply because that's your best case of getting success. They've been doing it that way, and if they have a good track record, then yeah, I mean, you're going to get the best bang for your buck by listening to them.
Choosing the Right Surgeon for Your Vasectomy Reversal
Interviewer: What are some questions that you should ask that surgeon that could potentially be performing your vasectomy reversal to make sure that you've got the person that's going to do a good job for you? If you want to talk to a couple, what are some of the questions you should be asking everybody?
Dr. Smith: When you come in, you sit down. I mean, they should ask who's doing this procedure. A lot of the people who do them at the university are fellowship trained in a men's health fellowship where they do a lot of this microscopic surgery, so you want to look for someone who has the credentials that you're looking for.
It's never a bad idea to ask how frequently they do this procedure. I know that some people can get a little edgy about stuff like that, but those are perfectly within your rights to ask, like, "Hey, is this something you do on a regular basis? Or is this something that you wished you did more of but you don't do very much of it?" And so asking those questions is great.
You can ask about success rates. Again, most of these surgeons don't have a paper they can hand you, "Hey, I did a research paper, and here are my success rates for my last thousand patients." But anecdotally, they'll know how well they're doing. And so those are the things that you want to make sure of.
You can ask them how they do the procedure, the timing. Usually, the procedure takes a couple of hours. It's done in the operating room under general anesthesia. There are folks around the country who do it under local anesthetic. So some of those things may be important to ask and ascertain the answers to.
And then cost. Ask them what they charge. Insurance does not cover this procedure. I don't know any that do. So making sure that you have your ducks in a row in that way.
Vasectomy Reversal Costs and Insurance Coverage
Interviewer: And then what about the costs or insurance considerations with the vasectomy reversal?
Dr. Smith: So I don't know of any insurance that covers the vasectomy reversal. I may be incorrect on that, but I haven't seen any. And so vasectomy reversals are not cheap. You're going to be anywhere from $6,000 to $10,000. I know there are some places that say they do it less expensive or they'll do it under local anesthetic for less, but on average, that's what you're going to spend in most cases to get one, depending on your area of the country. That's what you'll see.
Exploring Options Beyond Vasectomy Reversal
Interviewer: And are there options then if the reversal doesn't work, or is that pretty much it if somebody's trying to have kids?
Dr. Smith: No, I think you can find ways. There are always ways to look. So let's say you had a vasectomy so we know that you had sperm before if you had children previously. There are people who get a vasectomy and haven't had kids, so that may be a little bit more difficult to ascertain depending on if they had any banked sperm or anything before.
So some patients have banked sperm before they get their vasectomy, which they could use. In the case of a vasectomy reversal, obviously, they haven't had success with that or they've utilized that for IVF purposes or something already.
But there are other things you can do. Testicular sperm extraction is a way where we go in and we extract sperm directly from the testicles and we utilize that for in vitro fertilization. There are ways to continue to get sperm for pregnancy. Again, those are going to be out-of-pocket costs because most fertility stuff isn't covered by insurance.
Interviewer: Right. Is vasectomy kind of the most cost-effective way to do that, or the other procedure that you mentioned where they go right into the testicles and get the sperm? Is that comparable in cost?
Dr. Smith: So usually the testicular sperm extraction is much less expensive than a vasectomy reversal, but you have limited quantities of sperm that you're able to extract at that time.
Interviewer: Yeah. So again, a conversation. There are upsides and downsides to all of these.
Dr. Smith: Exactly.
Interviewer: Yeah. Are there any options that you would recommend before a reversal?
Dr. Smith: I think a lot of that just depends on the conversation between the patient and their partner and what their goals are. I try to have a conversation of, "Hey, here are the options. I know you're coming in asking for this, but let's give you some information so that you understand what's available to you because this may or may not be what you want in the end."
Interviewer: Any final thoughts if somebody's listening to this and they're considering a vasectomy reversal?
Dr. Smith: I think if you're thinking about doing it, look for some folks who do quite a bit of it. I'd look for people who do a good volume of it. And then obviously be aware that the cost is not insignificant. I mean, like I said, it's $6,000 to $10,000. You may want to ask around and visit a couple of people because even if you're paying out of pocket for a consult of a couple of hundred dollars, it's going to save you $5,000 on the cost of the procedure to go and see somebody who does just as much volume and has just as good of a success rate as someone else.
All in all, my biggest thing is to find someone you're comfortable with. If you're comfortable with the surgeon and you've asked your questions and you're comfortable with it, I think that's when you can make that decision in the most appropriate manner.