Frequently Asked Questions
About Vasectomy Reversal FAQs
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.
Vasovasostomy
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, 4-6 sutures are placed in the inner lining, while another 4-6 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.
Epididymovasostomy
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 FAQs
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.
For fully updated results and a customized assessment, see the Success Rates page. Also, see the Success Rates FAQ for additional details.
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.
REFERENCE:
- 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.
Success Rates FAQs
This is probably the most common misunderstanding among patients who are researching vasectomy reversals. When a person comes in for a vasectomy reversal, it is not known until surgery begins whether that person would need a vasovasostomy only or an epididymovasostomy. In looking through our data, 10% of men ended up needing an epididymovasostomy on both sides, while 20% needed an epididymovasostomy on one side only.
This is important because if a man needs an epididymovasostomy, and you only do a vasovasostomy, it will not work. That means that if you choose to do surgery with vasovasostomies only, 70% of the time, you will be just fine (good success rate). But in 30% of cases, you will have a lower rate than you would have, had you chosen an option where you can do epididymovasostomies and vasovasostomies.
It's notable that the majority of surgeons offering vasectomy reversals only perform vasovasostomies. There are relatively few who perform epididymovasostomies in the US, and even fewer who perform them in the office.
It's also notable that the far majority of online reported success rates are ONLY reporting men who had the simple repair on both sides. We feel that this is misleading. Since it is not possible to predict whether or not you will need an epididymovasostomy until the time of surgery, it is misleading to only report success rates of those who had vasovasostomies on both sides.
If you are looking to have a vasectomy reversal performed, and you wish to have the best outcomes possible, it is important to choose an option and surgeon that includes an epididymovasostomy if needed.
The ReVas (REinforcing VAsal Suture) technique was developed by Dr. Landon Trost in 2018 to improve vasectomy reversal outcomes. The technique and outcomes are described in greater detail on the ReVas page (details). In brief, the new technique resulted in a higher percentage of men achieving success, higher sperm counts, and higher pregnancy rates 8.1x more likely). Dr. Trost and Josh Savage were the first to perform the technique, were the only team performing the technique as of October 2019, and have the most experience with the technique.
The success rate for a vasectomy reversal depends on several factors:
- Definition of success
- Whether a simple (vasovasostomy) or complex (epididymovasostomy) is performed
- Time since vasectomy
- Partner's age and fertility status
Each of these is described in greater detail below.
Probably the most important factor in determining whether a reversal is successful is how you define success. By far, the most common definition that is used on websites and in scientific publications is "patency." This means that at least one sperm was seen at some point following the reversal. The issue with this definition is that it does not accurately capture what truly successful means. A recent scientific publication identified that the true number needed to optimize chances for pregnancy is 5 million sperm per milliliter or more.(1) In that particular publication, the authors indicated that those who had <5 million/ml had a roughly 15% chance of achieving a pregnancy compared to 63% in men with 5 million or more. Interestingly, those who had even higher counts did not have an increased change for pregnancy compared to the men who had 5 million or more.
Another issue with definitions for success is that they often indicate sperm "at any point" but do not necessarily mean sperm at the most recent time point. This can be a problem, as in some cases, the area that was sewn back together can sometimes close down 3-12 months after the original surgery. So, even if an individual had 10 million sperm at 3 months, if they have 0 sperm at 6 and 12 months, it would still be considered a success by most definitions.
Many providers will also define success based on certain patient factors. For example, some will only include results from men who ended up having simple repairs on both sides. The problem with quoting statistics in that way is that you will not know what repairs are needed until the time of surgery. In those cases, although the numbers are technically accurate, in reality they are misleading since most patients will assume that these are referring to all-comers and not only to specific cases.
One other pitfall which many patients will encounter is when providers quote "published" success rates rather than their own true rates. Unfortunately, simply asking providers if these numbers represent their own rates will not always elicit a fully honest response, and there are no guideline or accrediting bodies that verify quoted results. To avoid this pitfall, patients should be able to request the provider's most recent 30-50 cases at any time and review results themselves. If the provider is not able to provide these numbers, then any quoted success rates should be viewed with some skepticism.
With the above details in mind, it is not surprising that so many providers will quote 95+% success rates despite the fact that pregnancy rates are often far lower. For the above reasons, we have elected to define "success" as 5 million sperm per milliliter or more at 1-year post reversal. We feel that this most accurately captures what a true "success" would be.
Reference:
1 - Majzoub A, et al: Vasectomy reversal semen analysis: new reference ranges predict pregnancy. Fertility and Sterility. 2017 Apr;107(4):911-915.
In general, success rates with complex repairs (epididymovasostomy) are significantly lower than simple repairs (vasovasostomies). This is probably due to several factors including the risk of the area pulling apart post-operatively, lack of viable dilated epididymal tubules, smaller volume of fluid that passes through the anastomosis, or other factors. Because of this, men who are able to have a simple repair on both sides are much more likely to have a successful outcome than those who have a complex on both sides. However, as noted above, it is not possible to know if you will need a simple or complex repair until the time of surgery.
The time since vasectomy may or may not have a significant role in predicting success rates. For many years, it was believed that the time since vasectomy was a key factor in predicting whether or not a reversal would be successful, with decreasing success rates noted among men who were further out from the reversal.(1) However, other publications have disputed this finding. In reviewing our own data, we have found that prior to our implementation of the ReVas technique, the time since the vasectomy was a predictor of success rates. After we began performing the ReVas technique though, it was no longer an important predictor. Because of this finding, we believe that if the repair is sufficiently robust, the time since reversal is no longer a key predictor of success rates.
Reference:
1 - 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.
Partner age will not impact whether or not sperm may be present after a vasectomy reversal. However, it may impact the chance of achieving a pregnancy.
The true definition for success of a reversal is whether or not a couple was able to achieve a live birth. However, this definition is not perfect for determining whether or not a reversal was successful since it includes partner factors as well. For example, female fertility will generally decline beginning at age 35. Additionally, up to 15% of couples are unable to achieve a pregnancy, even when the male partner has not had a prior vasectomy. Even in couples where both the male and female have achieved pregnancies previously, in some cases, they will not be able to achieve a pregnancy together. So, for these reasons, pregnancy is not an ideal measure of success.
Vasectomies can fail for several reasons including:
- The two ends pulling apart
- Wrong surgery performed
- Poor surgical technique
- Post-operative scarring or complications
Each of these factors are described in more detail below.
The most common reason for failure is the two sewed ends pulling apart. There are many activities which put strain on the vas deferens. Although this list is not comprehensive, the following activities pull on the vas and can increase the risk of failure: arching your back, reaching up high, twisting, bending, performing lunges, coughing, sneezing, tightening your stomach muscles (such as is needed to lift something), penetrative intercourse, and jogging, among others. You will want to limit any of these activities for up to 8 weeks after surgery to avoid pulling the repair apart.
Another reason reversals fail is that the correct surgery was not performed. To give you the best chances for success, you will want to make sure that your surgeon regularly performs complex repairs (epididymovasostomies). Unfortunately, it is not possible to know if you need a simple (vasovasostomy) or complex (epididymovasostomy) repair until the surgery has started. So, if the surgeon is only able to perform simple repairs (common among surgeons performing the repair in the office), then the chance of failure increases.
Surgical technique is also very important to assure success. The surgeon should utilize an operating microscope (not surgical loupes along) to perform the surgery. Also, fluid should be sampled intra-operatively to determine if a simple (vasovasostomy) or complex (epididymovasostomy) repair is needed. Although there is some debate about this, most established vasectomy reversal specialists recommend the use of fine sutures (10-0) to help reconnect the tubes. And as has been recently reported, a new technique (ReVas) increases all measures of success (sperm counts and pregnancy rates).
In some cases, although the surgery was performed appropriately, the tubes that were connected later scar down. This can result from resuming strenuous activities too soon after surgery, the wrong surgical technique (ReVas reduces this), complications, or due to unknown causes.
If a reversal fails, the options for a biological child are:
- Repeat reversal (typical success rates ~60%)
- In-vitro fertilization
If the reversal is unsuccessful, couples have the option of redoing the reversal or undergoing assisted techniques such as in-vitro fertilization or intracytoplasmic sperm injection. The success rates for a repeat reversal will depend on the experience of the first surgeon and what surgery was performed (simple vs complex repair). Also, it is important to determine if sperm are present. If the couple hasn't achieved a pregnancy, but there are large numbers of sperm present in the ejaculate, then it is likely that the initial reversal was successful and that other factors are preventing the pregnancy.
In-vitro fertilization / intracytoplasmic sperm injection may also be performed depending on the female partner's age. Success rates with IVF/ICSI are typically 40-45% live birth rate at 35 years of age, 5% by 40 years, and 0% by 45 years per cycle. So, female age often plays a significant role in this decision.
It is also possible to undergo both a reversal and IVF/ICSI. This ultimately gives the highest chances for a successful live birth, however, this is also the most expensive option and is therefore often not pursued by couples.
Financial FAQs
The cost for a vasectomy reversal across the US ranges from under $2,000 to over $30,000. For the Male Fertility and Peyronie's Clinic price, click here. Typically, the cost depends on several factors:
- Whether the procedure is performed in the office (least expensive), in an ambulatory surgical center, or in a hospital (most expensive)
- Surgeon experience
- Surgeon subspecialty training in infertility and microsurgery
- Use of an operating microscope
- One-layer (including modified) vs two-layer anastomosis
- Use of the Reinforcing Vasal Suture (ReVas) technique
- The quality of the suture used (10-0 sutures are significantly more expensive than 7-0, 8-0, or 9-0 sutures)
- The ability to perform a complex reversal if needed (epididymovasostomy)
- The use of general anesthesia
Not necessarily. The following factors do not impact the overall success rate of the procedure:
- Location (office vs ambulatory surgical center vs hospital) - although the specific site of surgery is not critical, it may be important if the surgeon is not able to perform the more complex repair (epididymovasostomy) in that particular setting. For example, there are very few surgeons in the US who are able to do an epididymovasostomy in the clinic.
- Use of general anesthesia - the type of anesthesia does not impact success rates, unless it impacts the ability of the surgeon to perform the more complex (epididymovasostomy) repair.
In contrast, the following factors directly impact success rates:
- Greater surgeon experience leads to higher success rates
- Specialty training - surprisingly, most people who do vasectomy reversals are not fellowship (specialty) trained. The surgeons who are most specifically trained for vasectomy reversals are those who are board certified in Urology and have done a Fellowship in Male Infertility.
- The use of an operating microscope has been shown to improve outcomes compared to the use of surgical loupes or no magnification.(1)
- Use of the Reinforcing Vasal Suture (ReVas) Technique results in higher success rates and lower re-stenosis rates over time.(2)
- The ability to perform an epididymovasostomy is essential to achieving good outcomes in many cases. It is not possible to know if an epididymovasostomy is required until the time of surgery. If the surgeon is not able to perform the procedure (either because of lack of training or other reasons), and if the procedure is indicated, then the patient will not receive the correct surgery and will have a lower chance of success.
1 - Jee SH, Hong YK: One-layer vasovasostomy: microsurgical versus loupe-assisted. Fertil Steril. 2010 Nov;94(6):2308-11.
2 - Savage J, Manka M, Rindels T, Alom M, Sharma KL, Trost L: Reinforcing Vasal Suture (ReVas) technique improves sperm concentration and pregnancy rates in men undergoing vasovasostomy for vasectomy reversal. Translational Andrology and Urology 2019.
And some factors may or may not impact the success rate (debatable):
- Performance of a one-layer vs two-layer technique. Although the clinical studies have currently not shown a difference between the two techniques, these studies have not been powered sufficiently (not enough patients included) to detect smaller differences in outcomes. In general, the two-layer technique is the more traditional one with a longer track record of successful outcomes, however, it is more time consuming and challenging to perform compared to the one-layer techniques.
- Suture quality has not been investigated in any rigorous manner. It is hypothesized that one cause of vasectomy reversal failure is leakage of sperm outside of the area that was sewn back together. This may occur if too few sutures are placed to re-connect them. Typically, if you want to place more sutures to assure that the connection is water-tight, you need to use a finer suture, such as 10-0. However, these are often expensive (up to $500 per suture), which is why many practices use the less expensive (7-0, 8-0, or 9-0) options. It is also more technically challenging to use 10-0 sutures given their small size (10-0 is smaller than 9-0, which is smaller than 8-0, etc.)
The cost of in-vitro fertilization will vary across the US, but typically costs $15,000-20,000 for the first cycle and $5,000-7,000 for each additional cycle.
Vasectomy reversal is very rarely covered by insurance in the US. In most cases, this requires the patient to pay for the procedure out of pocket. In some cases, patients may have flexible spending accounts that can be used to pay for the procedure using pre-tax dollars, however, this still requires the patient to pay for the entirety of the procedure.