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Outpatient Procedures > Vasectomy Reversals

VASECTOMY REVERSALS

Following a vasectomy, there is no sperm in the ejaculate. However, sperm are produced continuously within the testicle. With meticulous microsurgery it is possible to restore the continuity of the vas deferens so that sperm may reappear within the ejaculate. These microsurgical procedures require a surgeon who is comfortable with the operating microscope and who performs these procedures on a regular basis. Dr. Marmar has performed over 1000 vasectomy reversals.

The surgery may be performed with local anesthesia or light general anesthesia depending upon the patient's preference. At the onset, the old vasectomy scar is identified and removed. The cut ends of the vas are relatively small structures. The outer diameter of each vas tube is about 2mm, but the inner lumen (channel for sperm) is only 0.5-1.0mm in diameter. When the old vasectomy scar is uncapped, there should be a gush of fluid from the testicular side. The appearance of this fluid is important because it may help to determine the specific technique used for repair.

A droplet of the fluid is examined on a sterile glass slide to assist in determining the type of surgical repair needed for success in each case. Dr. Marmar has reviewed this subject (Int J Fertil. 36:352,1991) and established generalizations, as summarized below:                               

Fluid Findings From the Testicular Vas Type of Repair Expected Patency Expected Pregnancy Rate
Clear or Opalescent Fluid with Sperm Two Layer Vasovasostomy 80-90% 50-55%
Thick or Pasty with No Sperm Vasoepididymostomy Bypass 65-72% 30-40%

The success of Vasectomy reversals can be linked to the length of time between the vasectomy and the reversal. Those men who seek reversals within 10 years of vasectomies typically undergo a direct vasovasostomy with consistently good results.

When the obstructed interval is greater than 10 years, there may be other adhesions in addition to the scar of the vasectomy. In some cases, the patients develop a "blow out" or leakage of sperm within the epididymis leading to additional scarring. These patients are still producing sperm from within the testicle but the urologist must perform a "microsurgical bypass" to connect the channel or lumen of the abdominal vas to the individual epididymal tubule, which is very thin and measures only 0.3-0.5mm.

Recently, Dr. Marmar described a new technique that includes invagination of the epididymal tubule within the channel of the vas (J. Urol. 163:483, 2000). With this technique, the smaller epididymal tubule is telescoped into the larger channel of the vas deferens. This technique produces a watertight closure with the relatively rapid return of sperm into the ejaculate compared to more conventional microsurgical anastamoses. This new method was recently featured in the AUA news that is the official newspaper of the American Urologic Association (July 2000, Vol. 5, Page 1).

Vasectomy Reversal Fig. 1 Vasectomy Reversal Fig. 2
Needle from double armed, 10-0 nylon sutures is placed parallel into styrofoam block. Distance between needles is about 0.4 mm. or sufficient for microblade tip. Both needles are grasped with single needle holder and carefully removed simultaneously to maintain parallel arrangement. Tips of needles are passed through disdended epididymal tubule with simultaneous placement. Although there is subsequent leakage of epididymal fluid, tips are already through tubule and remainder of needle is advanced completely with jeweler forceps.
Vasectomy Reversal Fig. 3 Vasectomy Reversal Fig. 4
Sutures are retracted laterally and tubulotomy is cut with tip of 1.5 mm. microblade. Adequacy of tubulotomy is confirmed with methylene blue staining of all tissue except interior of epididymal tubule.
Vasectomy Reversal Fig. 5 Vasectomy Reversal Fig. 6
Vas is secured to epididymal tunic with 3,9-zero nylon sutures and each needle from epididymal sutures is placed 1mm. into cas lumen and out through muscularis of vas cut edge. Needles are placed at 8 and 10 o'clock positions on the left side, and at 4 and 2 o'clock on right side. Sutures are retracted laterally to demonstrate invagination of epididymal tubule.
Vasectomy Reversal Fig. 7 Vasectomy Reversal Fig. 8
Vas is stabilized anteriorly by additional 9-zero nylon stitch but remains mobile from side to side, which enables surgeon to view snug tie of epididymal sutures to complete invagination. Anastomosis is completed with additional 9-zero nylon sutures.

During the course of these surgical procedures, sperm may be obtained from the epididymis or testicle for cryopreservation (sperm freezing). Dr. Marmar's group reported that these specimens may be used at a later date for IVF/ICSI, if desired by the couple (J. Urol. 161:463,1999). The intraoperative specimines may be stored in liquid nitrogen and shipped locally, nationally or internationally at a later date.


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