VASOVASOSTOMY EXPLANATION
INTRODUCTION
Microscopic vasovasostomy is a procedure performed to reconnect previously
severed ends of the vas deferens, or to reconstruct a vas deferens that is
partially blocked. The best candidates for
this procedure are men who have had a vasectomy within 5 years of the desired
reversal, or men whose blockage has been less than 5 years duration. Longer intervals are associated with
diminishing levels of success. Within
the 5-year time period success rates are in the range of 70%. Beyond 5 years the success rates average
50%.
Vasal reanastamosis has increased dramatically as a significant number of
men who have had a vasectomy want to regain their fertility. Additionally, one complication of vasectomy,
chronic testicular pain, may often be alleviated by reanastamosis.
The procedure may easily be performed in an office setting under local
anesthesia with sedation. In the
operating room the anesthetic may be spinal, general, or local with intravenous
sedation. Local anesthesia allows you
to express certain sensations as they occur and is our preferred choice.
Vasectomy reversal is NOT COVERED by many insurance carriers.
Any questions you or your wife have should be addressed and answered BEFORE
the procedure. It is suggested that you
come to the consultation / examination appointment and surgical appointment
together.
1. Purpose of the operation
The intent of the procedure is to allow you to regain fertility and the
ability to father children. Success is
dependent on the quality and character of sperm cells. It may take as long as one year after the
procedure to fully regain adequate sperm quality and quantity.
Other factors which prevent a successful result should be eliminated before
the procedure is attempted. These include primary testicular failure as
determined by an elevated FSH (follicle stimulating hormone) level, testicular
atrophy, a history of male infertility before the vasectomy, and infertility of
the female partner. The method of
previous vasectomy and its location along the length of the vas deferens may
help in planning the reversal.
2. Nature of the operation
The vas deferens is the tube that carries the sperm from the testicle. There is usually one tube from each
testicle. Bilateral vasovasostomy means
reconnecting or reconstructing these tubes.
This is done through bilateral, high scrotal incisions; the no-scalpel
technique might be used if the ends of the vas are easily located on
examination. An operating microscope is
necessary because the inside of the vas deferens is only 0.3mm in diameter, and
accurate anastamosis is the only way to assure a successful reconnection.
3. Other options
When there are no sperm cells in the testicular fluid from the lower end of
the vas, or if obstruction of the epididymis has been determined, a similar
procedure, the epididymovasostomy may be performed. Epididymovasostomy is a procedure in which the vas deferens is
anastamosed to a tubule of the epididymis that contains fluid with a likelihood
of containing sperm cells. The
epididymis is a worm-like structure, closely attached to the testis, made up of
tubules which carry sperm cells and testicular fluid from the testis to the vas
deferens.
This procedure is performed by exposing the epididymis, and opening the
covering over the epididymis to expose the underlying tubules. A tubule that appears to be distended with
fluid is cut and anastamosed to the vas deferens. This is one of the most demanding procedures in microsurgery and
may take as long as 5 hours to perform.
Patency rates range from 60-85%, and pregnancy rates are from
35-50%. It can be as long as one year
however, before sperm cells appear in the ejaculate.
The epididymis is subject to the formation of obstructing scar tissue
because of trauma and infection.
Obstruction may follow vasectomy.
If a vasectomy has been performed in a way that obstructs the vas,
pressure may build up in the epididymis causing rupture of the epididymal
tubules and obstruction of the site. Sperm
granuloma formation occurs because of
leakage of sperm cells and testicular fluid from the end of the severed vas,
and is named this because of its appearance under the microscope. The formation of a sperm granuloma relieves
the pressure in the vas and epididymis thus preventing epididymal rupture. This prevents the most important cause of
unsuccessful vas reversal. Obstruction
of the epididymis may also be congenital due to absence of the vas deferens.
SIDE BAR: EPIDIDYMAL SPERM
ASPIRATION
Aspiration of sperm from the epididymis is a procedure that is performed
with an operating microscope to locate any tubules distended with testicular
fluid and sperm cells. Following
injection of the local anesthetic into the scrotum, the larger of the two testes
and its epididymis are exposed through a high vertical scrotal incision. The larger testis will be the most likely to
contain quality sperm cells. The
covering over the epididymis is incised after microscopic examination reveals a
tubule or tubules that appear to contain testicular fluid and sperm cells. The tubular incision is closed
with 10-0 nylon suture. The
scrotum is closed with absorbable suture.
Exploration and aspiration of the other side may be performed if
adequate sperm cells have not been obtained from the first side.
Microscopic epididymal sperm aspiration (MESA) requires the availability of
an in-vitro fertilization team, so the aspirated sperm may be immediately
processed and used for the selected in-vitro technique, or frozen for later
use. After aspiration, the fluid is
given to the in-vitro team to process the sperm cells. Processing involves washing the cells,
retrieving the most active cells from the sample, and removing any red blood
cells, if possible. This is critical
since red cells significantly interfere with sperm cell function. If adequate numbers of sperm cells cannot be
obtained from one testis, the other side may be aspirated to add to the sperm
bank. It may be necessary to aspirate
sperm cells from the rete testis, tubules between the testicles and the
epididymal head that carry cells to the head of the epididymis, if sperm cells
are not found in tubules closer to the vas deferens.
The sperm calls retrieved may be used for intracytoplasmic injection into
the partner’s egg (ICSI), the most successful of the in-vitro techniques
available. This technique is not as
dependent on the quality of the sperm as earlier techniques of in-vitro
fertilization. The procedure must be
timed according to the partner’s cycle of ovulation. Ova are aspirated as an office procedure just before the MESA is
performed. Using sperm cells from the
epididymis and intracytoplasmic injection techniques, pregnancy rates may
approach 50%. It may be possible to
retrieve sperm cells by aspiration of the testis, but the numbers of sperm
cells retrieved by this technique are not as high as with MESA.
4. After the operation
Complications that can occur postoperatively include:
· Hemorrhage:
Uncontrolled bleeding that does not stop with pressure
and ice application may require opening the incision to find the bleeding
vessel and cauterize or tie it. This may cause tenderness in the groin or
scrotum and possibly discoloration of the skin.
· Hematoma: (hematocele-bruise)
A collection of blood in the scrotal sac may cause
the scrotum to become swollen and darkly discolored. This may require opening the incision to remove blood clots.
· Infection:
Pus may form within the scrotum and require
opening the incision in order to be drained.
This may be present if swelling persists after 2 weeks; the scrotum
becomes reddened, warm or hot to the touch; the scrotum becomes hard or feels
solid; pain develops in the groin; a fever that is not easily resolved with
Tylenol occurs.
· Postoperative
occlusion of the anastamosis:
This is suspected when no sperm cells are present
in ejaculate that has previously contained sperm cells.
· Granuloma
formation:
Persistent tender swelling beneath the skin
incision above the testicle is commonly due to leakage of spermatic fluid into
the scrotal sac. This should resolve in
a short time but can affect the success of the procedure. It may feel like a
small pea.
· Swelling:
Localized swelling of the scrotal tissues usually
occurs following any surgical procedure in this area. The process may be reduced with the use of a cloth-covered ice
bag applied to the area for 24-48 hours.
VASOVASOSTOMY DOES NOT CHANGE YOUR
ABILITY TO FUNCTION SEXUALLY.
5. Fees
Vasovasostomy and epididiymovasostomy are NOT COVERED by many insurance
carriers. You should investigate with
your own insurance company before deciding to proceed. There will be a surgeon’s fee and an
anesthetist’s fee. The fees are
requested in advance for those who are self-pay, in the form of cash or a bank
check .
LAST UPDATED: June 14, 2005