-
What is vasectomy reversal?
-
What are the chances of success?
-
Why are "surgical success" rates higher than pregnancy rates?
-
What's different about Dr. Gould's reversal?
-
How likely is it that I will need a vasoepididymostomy?
-
Can sperm be frozen at the time of a vasectomy reversal?
-
What happens on the day of surgery?
-
What are the risks of surgery?
-
What should I expect after surgery?
-
How long will it take to get pregnant?
-
What if we do not want to get pregnant right away?
-
After a reversal, will the semen quality deteriorate over time?
-
Are birth defects more common after vasectomy reversal?
-
What options do I have other than vasectomy reversal?
-
What if I had a previous, unsuccessful vasectomy reversal?
-
If we fail to get pregnant, what else can we do?
-
What financial arrangements can be made?
-
Will I need a postoperative semen check?
1.
What is
vasectomy reversal?
A vasectomy reversal,
or vasovasostomy, is a
surgical procedure to
reconnect the tubes that
are cut during a
vasectomy (Figure 1).
These tubes (called the
vas deferens) are each
about the size of a
strand of spaghetti, and
the channels in the
tubes that conduct sperm
are barely visible to
the naked eye. Sperm
production continues
after a vasectomy, but with no place to go the sperm are
reabsorbed.
During the reversal,
the vas deferens is cut
above and below the site
of the previous
vasectomy, and the two
ends are precisely
aligned. Dr. Gould
always uses an operative
microscope and performs
a "three-layer"
connection (Figure 2).
Less precise procedures
are performed by some
doctors because they
take less time and do
not require as much
surgical skill.
In the United States,
physicians are currently
performing about 500,000
vasectomies per year.
About 1 percent of men
(1 out of 100) who have
had a vasectomy will
decide to undergo a
reversal. The technique
used for the vasectomy
is largely irrelevant to
the success of the
reversal. The vas
deferens is a long tube
and it is very rare to
be unable to accomplish
a reconnection.
return to
top
2.
What are the
chances of success?
"Success" may be defined in several ways. If success is the
physical re-connection of the vas deferens, then success is
virtually 100 percent. More commonly, success is defined as (1)
the return of sperm cells to the ejaculate or (2) pregnancy. The
following table shows "success" rates
after vasectomy reversal:
|
Years
Since the
Vasectomy
|
Sperm in
the
Ejaculate |
|
<5
5-10
10-15
>15 |
97 %
90-95 %
85-90 %
80-85 % |
Pregnancy rates are
never as high as the
"surgical success" rates
shown in this table. The
pregnancy rates that
result from intercourse
at home will generally
be
lower, and are significantly dependent on the age of the woman.
For most couples who opt for the reversal within five years of
the vasectomy, “home” pregnancy rates range from 65 to 75
percent; reversals 10 to 20 years from the vasectomy result in
pregnancies in 55 to 65 percent of cases. However,
pregnancy rates can be
made even higher if a
couple is willing and
able to undergo
advanced fertility treatments.
return to
top
3.
Why are
"surgical success" rates
higher than pregnancy
rates?
There are three main
reasons for this:
- Surgery restores sperm cells to the semen but the sperm
may be
weak or low in
number
- Good numbers of strong sperm are found after surgery
but "antibodies" that attack sperm may be present
- There are
unanticipated
problems with the
fertility of the
female partner
There are two important points
to make about the
"success" table:
- The pregnancy
rates reflect the
results of sexual
intercourse at
home. The
advanced fertility treatments in
the laboratory (in
vitro) can be used
when the surgery
results in weak
sperm or low
numbers of sperm.
These techniques
can increase the
pregnancy rates for
those unable to
conceive after a
reversal.
-
If epididymal obstruction is not recognized and
corrected at the time of the reversal, the success rates
will be lower.
 Let's
discuss this last point
in more detail. We know
that certain findings at
the time of the
vasectomy reversal will
give us more information
about the chances of
success. When the
reversal is done, the
vas deferens is cut
between the testis and
the vasectomy site. The
fluid that comes out of
the vas deferens can be
examined with a
microscope in the
operating room (Figure
3).
We know that if the
fluid is thick and does
not contain sperm, the
chances of success
with a standard reversal is poor. Thick fluid
without sperm is almost
always a sign that the
delicate tubes on the
side of the testis
(called the epididymis)
have become blocked. It
is possible to bypass
the epididymal block by
performing a
vasoepididymostomy
(don't try to pronounce
this word!).
A vasoepididymostomy is
a surgical procedure in
which the vas deferens
is hooked up directly to
the epididymis above the
blockage (Figure 4).
Generally, the success
rate of
vasoepididymostomy (as
defined by sperm in the
ejaculate after surgery)
is about 75-80 percent.
This is very significant
compared with the 10
percent rate of success
following a standard
vasectomy reversal when
the fluid is thick and
devoid of sperm.
So keep in mind that
the success rates in the
table above will be
higher if the surgeon is
prepared to perform a
vasoepididymostomy if an
epididymal block (thick
fluid) is suspected at
surgery.
Dr. Gould will always attempt to identify cases with epididymal
obstruction. (See next question).
One final point:
The fluid findings
at surgery may be
equivocal for epididymal blockage. For example, the fluid may be
thick but nonetheless contain sperm or sperm fragments.
Alternatively, the fluid may be thin or scant but may not
contain sperm or sperm fragments. In these cases, it is
not clear if the epididymis is blocked or not. Dr. Gould will
weigh all of the relevant factors and perform the type of
connection with the highest chance of success. In
some cases, it may be
necessary to perform the
delicate
vasoepididymostomy on
one side and the
"standard" vasectomy
reversal on the other.
return to
top
4.
What's
different about Dr.
Gould's reversal?
There are big
differences!
! 1) Dr. Gould does not use general anesthesia. He uses
“conscious sedation”, much like that used for wisdom teeth or
colonoscopy. Patients are asleep but they are neither paralyzed
nor put on a ventilator. 2) Unlike Dr. Gould, many urologists
will only do a standard vasectomy reversal. Some do not even
examine the fluid with a microscope during surgery. Some have
never attempted a vasoepididymostomy. 3) Having performed these
reversals since the late 1980’s, Dr. Gould has experience at
this surgery that few can rival.
During the performance
of the vasectomy
reversal, if Dr. Gould
determines that an epididymal blockage is
likely and that a
vasoepididymostomy would
be beneficial, he will
perform that procedure
on one or both sides. In
other words, if the
fluid at surgery looks
favorable, he will
perform a standard
vasectomy reversal
procedure. If the fluid
is unfavorable, he will
perform a
vasoepididymostomy. If
the vasoepididymostomy
is necessary, it will
not increase the cost of
your surgery.
return to
top
5.
How likely is
it that I will need a
vasoepididymostomy?
On the average, Dr.
Gould performs one
vasoepididymostomy for
every 10 to 15 standard
vasectomy reversals (vasovasostomies).
However, the longer it
has been since your
vasectomy, the more
likely it is you will
need this procedure.
return to
top
6.
Can sperm be
frozen at the time of a
vasectomy reversal?
It is very rare to
find large numbers of
active sperm at the cut
end of the vas deferens
during a reversal. It
would be possible to
expose the epididymis,
"nick" a tubule and
recover active sperm,
but this increases the
risk of obstructing the
epididymis at the site
of the "nick". For this
reason, we generally do
not recommend freezing
sperm during a
vasovasostomy.
However, if a
vasoepididymostomy is
required,
freezing sperm becomes quite feasible. During the
course of a vasoepididymostomy, the
epididymal tubule is
"nicked" to check for
active sperm.
In this setting, it is very reasonable to collect and freeze
epididymal sperm. Two
important points should
be clearly understood:
- freezing sperm
cells is optional
and if chosen will
add additional
costs.
- the quantity of
sperm obtained is
not enough for
simple
insemination. In vitro fertilization (IVF) would be
necessary to assist the fertilization process (see last
question).
In vitro
fertilization (IVF),
with micro-injection of
sperm, (Intracytoplasmic
Sperm Injection - ICSI)
would be necessary to
assist the fertilization
process.
return to
top
7.
What happens on
the day of surgery?
You must fast (not
eat or drink) the day of
your surgery. You will
arrive at the surgical
unit at an appointed
time and an IV
(intravenous) line will
be started. You will
then be taken to an OR
(operating room) and
placed on a well-padded
table. Your scrotum will
be shaved and cleansed
and a sedative will be
administered through
your IV.
While you are sedated a local anesthetic will be used to make
your surgical area completely numb. A small
opening will be made on
each side of your
scrotum to gain access
to the vas deferens and
the re-connection will
be performed.
Typically, the surgery takes about three
hours for a standard
reversal and about four
hours if you need a vasoepididymostomy. The
sedative will probably
make you sleep for most
of the procedure. When
your surgery is
finished, you will spend
a short time in the
recovery room before you
are sent home. You will
be given printed
postoperative
instructions regarding
activity restrictions
and follow-up.
return to
top
8.
What are the
risks of surgery?
It is very rare to
have a serious
complication from a
vasectomy reversal. The
most common
complications are:
- Bleeding
(bruising is
common; an internal
collection of blood
or a "hematoma"
occurs in
less than 5
percent of
patients)
- Infection
(occurs in less
than 5 percent of
patients and
usually clears with
oral antibiotic
treatment)
- Nerve damage
(occurs in less
than 5 percent of
patients and
manifests as
numbness at the
incision sites or chronic pain)
There is no reason
why this type of surgery
should affect either
urination or erections.
return to
top
9.
What should I
expect after surgery?
Contrary to popular
belief, most men are not
in severe pain after
surgery. Some men tell
us that the vasectomy
was much worse! Ice is
applied to the scrotum
for about 36 hours
following surgery and a
pain pill may be used as
needed. Warm soaks are
started after 72 hours.
Walking and light
activity are resumed
quickly but heavy
lifting and vigorous
exercise are restricted
for four weeks. Sexual
intercourse is avoided
for ten days. Most men
are able to return to
work after only a few
days.
Following the
surgery,
the semen can be checked for sperm by Dr. Gould or a laboratory. Sperm are
commonly seen at one
month if a standard
reversal was performed.
If a vasoepididymostomy
was performed, it may
take several months
before sperm are seen.
return to
top
10.
How long will
it take to get pregnant?
Dr. Gould has had patients conceive within two weeks of surgery!
However, data collected
on large numbers of vasovasostomy patients
show a mean (average)
time between surgery and
pregnancy of about 6 to 12 months, depending on female age and
time since vasectomy.
return to
top
11.
What if we do
not want to get pregnant
right away?
Since pregnancies do
not usually occur right
away, most couples will
not want to delay
surgery. If you do not
plan to conceive for
several years, then a
delay might be
reasonable.
return to
top
12.
After a
reversal, will the semen
quality deteriorate over
time?
There are data that
show a deterioration of
semen quality over time
in 5 to10 percent of men
after vasovasostomy and
in 10 to 20 percent of
men after
vasoepididymostomy.
Sperm banking may be
considered but this does
not guarantee success.
return to
top
13.
Are birth
defects more common
after vasectomy
reversal?
There is no evidence
that vasectomy reversal
increases the risk of birth defects or miscarriage. Problems
such as these appear to
occur at the same
frequency as in the
general population.
return to
top
14.
What options
do I have other than
vasectomy reversal?
It is now possible to
extract sperm cells from
the testicle or
epididymis. However, we do not recover enough sperm to produce a
pregnancy by simply inseminating the woman. Instead, the sperm
are used in the laboratory to fertilize eggs removed from the
female partner (in vitro fertilization - see last question).
These lab techniques are
much more costly than
the reversal itself
but they do represent a viable option with good success rates
for couples who can afford them.
Therefore, in most
cases, a vasectomy
reversal is more cost
effective and the best
first option.
return to
top
15.
What if I had
a previous, unsuccessful
vasectomy reversal?
If you had a previous
vasectomy reversal and
now have no sperm, a
"re-do" reversal may be
a reasonable option.
Success rates for re-do
reversals are still very
good, declining by only
about 5 percent compared
with the "first try". If
sperm were ever seen
after the first attempt,
this is a good sign that
a re-do could restore
sperm to the ejaculate.
return to
top
16.
If we fail to
get pregnant, what else
can we do?
There are several
techniques that can help
to produce a pregnancy
if it doesn't occur at
home. Intrauterine
insemination (IUI) of
sperm can be performed
in some situations (if
the sperm count is
adequate). With this
procedure, the woman's
cycle is monitored to
detect the time of
ovulation. At the
appropriate time, a
sperm sample is
collected, washed, and
concentrated. The sample
is then placed into the
upper uterine cavity by
means of a small
catheter.
Depending on the
quality and quantity of
sperm, some couples will
require in vitro
fertilization (IVF) in
order to conceive. IVF
is a technique where
eggs are removed from
the woman's ovaries and
placed in a lab dish
with sperm. Success
rates depend upon
the age of the woman and
the quality of the
resulting embryos.
If the sperm count is
very low, an assisted
fertilization procedure
may be necessary. This
procedure, known as
intracytoplasmic sperm
injection (ICSI) is
utilized in an IVF cycle
and consists of
injecting a single sperm
into each egg. For those
men who do not have any
sperm in the ejaculate
after vasovasostomy or
those who elect not to
have a reversal, sperm
may be obtained
surgically by
percutaneous sperm
extraction (with needle) or open
sperm extraction (with minor surgery).
Adoption or
insemination with donor
sperm are also other
options for couples who
are unable to conceive
following a vasectomy
reversal.
Summary
Making the decision
to reverse a vasectomy
is a big step.
Considering all of the
options currently
available, vasectomy
reversal represents the
most cost effective
option for having your
own biological child in
most cases. Dr. Gould
will make every effort
to make your experience
as comfortable and
convenient as possible.
Please ask questions! We
look forward to meeting
you!
return to
top
17.
What financial arrangements
can be made?
We are currently able
to offer one global fee
for vasovasostomy
(vasectomy reversal) and
if necessary,
vasoepididymostomy
(correction of
epididymal obstruction).
The total fee is
$6,900.00. This global
fee covers all aspects
of the reversal
including the "pre-op",
surgery fees
(professional and
facility fees), and two
postoperative semen
checks. The global fee
does not cover the sperm
freezing option as
discussed earlier.
Most of our patients
find that their
insurance company will
not pay for the
reversal. You may wish
to submit a claim to
your insurance company
and we would be happy to
assist you in doing so.
We are extremely
proud that this global
fee is much lower than
comparable fees around
the United States. Other
programs offer this same
arrangement for as much
as $20,000.00. Remember
that this global fee
will cover not only a
bilateral vasectomy
reversal but will also
cover the more delicate
correction of epididymal
blockage if it is found.
The $6,900.00 global fee
is due no later than the
day of surgery.
Please call our
office if you have any
questions about the
microscopic vasectomy
reversal program. Free
telephone consultations
are available on
request.
return to
top
18.
Will I need a
postoperative semen
check?
You may want to have
your semen checked after
surgery. This can be
done anytime; most
people wait about 4-8
weeks after surgery if a
standard vasectomy
reversal was done on
either one or both
sides. If a
vasoepididymostomy was
done on both sides, it
is preferable to wait
8-12 weeks after surgery
before the semen is
checked. Abstain from
ejaculation for about
2-3 days prior to any
type of post-operative
semen testing. There are
3 options for the
post-operative semen
check:
- Make an
appointment to see
Dr. Gould in his
clinic in
Roseville. At your
appointment you
will be asked to
collect a semen
sample, and you
will be able to
look at the sample
under a microscope
with Dr. Gould. At
this appointment we
will only check for
the presence of
sperm; we will not
calculate an exact
sperm count or
motility
assessment. There
is no charge for
this visit.
However, Dr.
Gould’s clinic
appointments are
usually only in the
morning and often
only one or two
days per week. This
may not be
convenient for you.
For option #1
call 916 773-2229
and ask for a
post-op appointment
with Dr. Gould.
- Make an
appointment to have
the Northern
California
Fertility Medical
Center (NCFMC) lab
in Roseville check
your semen. There
is a $50.00 charge
for this service.
Dr. Gould will call
you to discuss the
results within a
few days. The
advantage of this
option is that you
will have much more
flexibility in
scheduling your
appointment. Also,
the lab will
provide an exact
sperm count and
motility
assessment. In the
future Dr. Gould
may advise you to
call the option #2
phone number below
to schedule more
detailed semen
tests: full semen
analysis ($125.00)
or antisperm
antibody test
($175.00). Do not
request these more
expensive tests
without talking to
Dr. Gould first.
For option #2
call 916 773-2229
and ask for a
$50.00 post-op
sperm check with
the laboratory.
- Make an
appointment with
any laboratory in
your area to have a
full semen
analysis. Costs
vary for a full
semen analysis, but
an average cost is
$125.00.
For option #3 call
Dr. Gould at 916
773-5529 and
provide the phone
number and fax
number of the lab
you wish to use for
the semen
evaluation. He will
contact the lab and
order a semen
evaluation.
return to
top
|
