VR Info - General
A vasectomy reversal is a surgical procedure that is performed to restore fertility in a man who has previously undergone a vasectomy. The procedure can be done with varying levels of anesthesia including full, general anesthesia (breathing tube), moderate sedation (IV sedation), light sedation (oral medications), local numbing medicine alone, or a combination of the above.
On anesthesia has been achieved, a scrotal incision is made, approximately 1 to 1.5 inches in length. The prior site of vasectomy is dissected free, and the vas deferens is cut on the testicular side of the prior vasectomy. Fluid is then sampled from this cut end. If sperm are present, then a simple repair (vasovasostomy) can be performed. If sperm are not present, then a complex repair is appropriate (epididymovasostomy). In our experience, roughly 40% of men will require a complex repair on one or both sides. Unfortunately, it is not possible to determine whether or not a complex repair will be required until the time of surgery. As such, it is strongly recommended that a surgeon is selected that has the ability to perform the complex reversal procedure if needed.
Once the determination as to which procedure is required is made, the vasal side that is closer to the abdomen is cut, and fluid passed through this region. This will assure that the tube is fully open. The microsurgery portion of the case then occurs.
A vasovasostomy is performed by placing two layers of very small sutures to connect the two vas deferens back together. It is important that this is done using an operating microscope, as this has been shown to improve success rates by 30-40% or more. Typically, 5-6 sutures are placed in the inner lining, while another 6-8 sutures are placed to secure the outer lining. Additional sutures are then placed to provide additional vasal support (ReVas technique). The vas is then replaced into the scrotum.
When an epididymovasostomy (complex repair) is required, the testicle is delivered through the skin wound, and the epididymis is examined. Once an appropriate area to connect is identified, the vas deferens is brought to the area and secured to the testicle and epididymis. Fine sutures are then used to secure the vas deferens in two layers. Four sutures are used to secure the inner layer, followed by 6-8 sutures on the outer layer. Additional sutures are used to provide additional strength as well. The testicle is then returned into the scrotum.
Once the connections have been completed, the wound is closed in two layers, and a sterile bandage is applied.
The amount of pain following a vasectomy reversal depends on several factors:
- The type of procedure that was performed (vasovasostomy versus epididymovasostomy)
- Development of an infection
- The presence of a hematoma
- Prior scrotal pain
Typically, vasovasostomies (simple procedures) lead to slightly more pain than a vasectomy and usually require taking Tylenol or ibuprofen. In contrast epididymovasostomies (complex repairs) usually cause more pain and may require narcotic pain medications for a brief time. The pain usually significantly improves by 7-10 days after surgery.
Infections can lead to an increase in post-operative pain. Typically, infections will occur around 5-7 days after the reversal and may also cause redness, drainage, warmth, or fevers. Infections usually will require antibiotics to treat. In rare cases (1/200), it may require an additional surgery to drain the area of infection.
Hematomas can also cause pain following surgery. A hematoma is a blood collection which leads to pain and swelling in the scrotum. On occasion, this can cause the scrotum to swell to the size of an orange or more. The body will remove the hematoma without need for surgery, but it can take several weeks or months to fully resolve. Although these cannot be fully avoided, the risk of developing a hematoma can be decreased by limiting trauma and exposure of the scrotum to heat for approximately 2 weeks after surgery.
Men who have chronic scrotal pain (from any cause) are at a greater risk of having pain following a vasectomy reversal. Chronic pain can also result from any surgery, although the risk is generally low.
There are several important factors to consider in deciding whether or not to undergo a vasectomy reversal:
- Female partner age
- Financial considerations
- Number of children desired
- Strict timeline for having baby
- Success rates
- Time since vasectomy
In general, the younger the female partner age, the more strongly that reversal would be recommended. In-vitro fertilization (IVF) success rates begin to decline with a female age of 35 and above, with IVF success rates declining from ~45% successful live birth rate at 35 years to 5% at 40 years and 0% at 45 years. This should be factored in to the decision, as the window for IVF is limited. It is possible to undergo reversal and IVF, however, this is more expensive than either option alone and therefore not feasible for most families.
In general, vasectomy reversal is a one-time expense ranging from $2,000 in our clinic to $7,000 at the Male Fertility and Peyronie's Clinic. Other clinics can range from $1,500 to $35,000 or more.
Intrauterine insemination typically costs about $1,000 per attempt and has roughly an 18% success rate per attempt. You will need 10 million swimming (motile) sperm or more to attempt intrauterine insemination.
In-vitro fertilization typically costs about $15,000 for the first cycle (mostly due to the cost of medications), and approximately $5,000 for each additional cycle. The ability to do more cycles before needing to pay the additional $15,000 will depend on how many good eggs were retrieved with the prior attempt. A realistic expectation for in-vitro fertilization is $20,000 to $25,000. The success rates with in-vitro vary by maternal age and range from roughly 45% at age 35 (live birth) to 5% at age 40, and 0% at age 45.
For more information, see the Financial Info
Once consideration in choosing between vasectomy reversal and assisted reproductive techniques (in-vitro fertilization) is the number of children desired. For example, if you only want one child and then would want a repeat vasectomy, then this may provide a reason to consider in-vitro fertilization. In contrast, if you wanted more than one child, it may be much more cost effective to do a vasectomy reversal (since each cycle of in-vitro can cost between $5,000 and $15,000). However, both vasectomy reversal and in-vitro fertilization would provide the possibility of having more than one child.
The average time to achieve a pregnancy after vasectomy reversal is 12-17 months. This means that half of the couples who will go on to achieve a pregnancy will take longer than 12-17 months to achieve a pregnancy in this way.
In contrast, in-vitro fertilization is able to achieve a pregnancy much faster, when successful. Typically, the time from start to finish to achieve a pregnancy in this way is 2-3 months.
The chance of having 5 million or more sperm per ml at 1 year following a vasectomy reversal at the Male Fertility and Peyronie's Clinic is 95% at the Male Fertility and Peyronie's Clinic. This number is accurate as of June 2019.
For intrauterine insemination, the typical success rate is 18% per attempt, although exact numbers will vary by clinic and patient factors. The challenge with intrauterine insemination is that you need 10 million or more motile sperm to use this technique. In other words, this is typically not an option following a vasectomy.
In-vitro fertilization success rates will also vary depending on multiple factors, including female patient age and health, male patient fertility status (and possibly age), how the sperm were retrieved, and other factors. The typical live birth rates (not pregnancy) are 45% with a female partner age of 35, 5% by 40 years, and 0% by 45 years.
A vasectomy reversal can be performed at any time after the vasectomy. There is currently debate as to whether or not the time since vasectomy has an impact on outcomes.
Early publications suggested that the longer the time since the vasectomy, the more likely that the repair would be unsuccessful. An example of this is a manuscript by Mui and colleagues who reported an approximately 15% need for a complex repair on at least one side among those who were <3 years, which maxed out at around 70% by 22+ years. Complex repairs are still successful in many cases, however, the success rate is still lower compared to a simple repair (vasovasostomy).
More recent data suggests that this prior belief may not be accurate, with some publications suggesting that success rates are similar regardless of how long it has been since the vasectomy.
In our data, we have found that before we started doing the ReVas procedure, men who were further out from vasectomy were less likely to have a successful outcome. However, since we began implementing the ReVas procedure, success rates are now similar regardless of how long it has been since the vasectomy. This may help to understand why there are differences in the scientific publications. It is possible that those who were reporting worsening rates with time since vasectomy had slightly less robust repairs compared to those who were publishing no differences based on time.
- Mui P, et al: The need for epididymovasostomy at vasectomy reversal plateaus in older vasectomies: a study of 1229 cases. Andrology. 2014 Jan;2(1):25-9.
Absolutely. However, given the costs involved, this is often not a financially viable option for most families. It likely results in the highest overall chances of achieving a successful live birth, depending on the age of the female partner.