In addition to the skill of the surgeon, the character of the fluid at the time of the reversal, and years since the vasectomy…the age of the female is an important factor in achieving pregnancy.
What Affects Pregnancy, Patency Rates After Vasectomy Reversal?
Urology – October 30, 2015 – Vol. 33 – No. 4
The Silber grading scale appears to dictate pregnancy rates after vasectomy reversal with increasing female age being a negative predictive factor.
Article Reviewed: Impact on Pregnancy of Gross and Microscopic Vasal Fluid During Vasectomy Reversal. Ostrowski KA, Polackwich AS, et al: J Urol; 2015;194 (July): 156-159.
Background: The examination of the vasal fluid at the time of vasectomy reversal has implications for surgical decision making with effects on patency and pregnancy rates. The Silber grading system characterizes these findings and has been used to help surgeons with the decision to perform vasovasostomy (VV) or the more technically challenging vasoepididymostomy (VE).
Objective: To determine both intraoperative and patient factors that affect pregnancy rates after vasectomy reversal.
Design: Retrospective review of prospectively maintained database.
Methods: This paper reviewed the results of a single surgeon series that encompassed >30 years of vasectomy reversals. Vasal fluid was characterized as opalescent, creamy, pasty or clear and intraoperative light microscopy was used determined if sperm parts were present or motile. Univariate and multivariate analysis examined the data set for significant factors that affected pregnancy rates.
Results: 2947 vasectomy reversals were included in the analysis. Pregnancy status was only known for 31% of these cases. Bilateral VV was performed 83% of the time and most patients fell into a Silber 1 to 3 classification. No factors met statistical significance for increasing the pregnancy rate, although the presence of motile sperm was almost significant (P =0.075).
Negative predictive factors for pregnancy were identified on multivariate analysis with increasing female age and the findings of either no sperm (odds ratio [OR], 0.08) or sperm heads only (OR, 0.46) on microscopy decreasing pregnancy rates. Rarely were sperm parts identified when pasty fluid was encountered.
Conclusions: The findings from this paper echo the findings of the Vasovasostomy study group, with the Silber grading system essentially dictating pregnancy rates.
Reviewer’s Comments: The decision to perform VV or VE can be a difficult one and is based on many factors including findings from the vasal fluid, time since vasectomy, and surgeon skill level. Few papers have examined this decision-making algorithm since the landmark paper by the Vasovasostomy study group in 1991. While most microsurgeons prefer VV to VE due to increased patency and pregnancy rates, the need to perform a VE is generally encouraged when pasty fluid or no sperm parts are found in the vas at the time of reversal. These findings are interesting and are another important addition to the literature. Unfortunately, despite the authors’ efforts, relatively few predictive factors were found. Their findings do somewhat parallel those published by the Vasovasostomy study group, wherein the Silber grading system appears to correlate with pregnancy rates. The authors identified sperm heads only (Silber 4) or no sperm (Silber 5) as negative predictors with motile sperm (Silber 1) almost achieving statistical significance as a positive factor.(Reviewer–Charles Welliver, MD).
Because a vasectomy reversal is usually not covered by insurance, the patient usually pays an all inclusive fee to the surgeon. This fee covers all of the components of having a surgical procedure such as:
The fee of the surgeon to perform the reversal.
The facility fee which includes the cost of the nurses and staffing, the facility (operating room), suture materials and the operating microscope, the anesthesiologist and the anesthesia supplies necessary to put a patient to sleep.
The cost of overnight accommodations (if necessary).
At Northeast Georgia Urological Associates our facility is accredited and owned by our practice which in turn allows our all inclusive fee to be much less than if a hospital were used. Our anesthesiologists are board certified as well as Dr. McHugh.
The all inclusive cost for a microscopic vasectomy reversal at the Northeast Georgia Ambulatory Surgery Center is $6,500.00. After promotion- $6,000.00.
Kathy Burton 770.535.0001 ext 113 or firstname.lastname@example.org is available to help with all things vasectomy reversal. CareCredit is an option for couples preferring to pay over time.
The more invasive tubal ligation still outnumbers vasectomy among the options for permanent sterilization for couples. The rationale for this involves speculation, but male partner anxiety surrounding issues of sexual function have been proposed and are certainly evident when counseling males before vasectomy.
Urology – April 30, 2016 – Vol. 34 – No. 1
Vasectomy is not associated with decreased frequency of sexual intercourse.
Article Reviewed: Relationship Between Vasectomy and Sexual Frequency. Guo DP, Lamberts RW, Eisenberg ML: J Sex Med; 2015;12 (September): 1905-1910.
Background: Men often report the concern that having a vasectomy will impair their future sexual function.
Objective: To determine in an objective and quantifiable manner if vasectomy leads to a decrease in sexual frequency.
Design: The authors analyzed data from the National Survey of Family Growth (NSFG), which is a large survey of American households.
If nothing else…this article is interesting. Although the most common cause of desiring a vasectomy reversal is a male who has had children and a vasectomy has remarried someone with no children. This study showed that %17 of the time a reversal is desired by a couple who have had a vasectomy and now desire more children. Their success rate is higher than if the male remarries and has a reversal.
Vasectomy Reversal Better With Same Partner as Prior to Vasectomy
Urology – July 30, 2015 – Vol. 32 – No. 12
Vasectomy reversal success in regard to clinical pregnancy is improved if the patient has the same partner before and after vasectomy.
Article Reviewed: Higher Outcomes of Vasectomy Reversal in Men With the Same Female Partner as Before Vasectomy. Ostrowski KA, Polackwich AS, et al: J Urol; 2015;193 (January): 245-247.
Background: Vasectomy reversal is requested by around 6% of men who previously had undergone a vasectomy and desire subsequent fertility. Frequently, this is due to a new relationship; however, some couples desire another child or may have lost a child. Two small prior studies have suggested improved pregnancy rates following vasectomy reversal with the same partner as before vasectomy.
Objective: To determine if clinical pregnancy and birth rates are higher for men undergoing vasectomy reversal with the same female partner.
Design: Retrospective review of a prospectively collected database.
Methods: All patients from a single surgeon were reviewed from 1978 to 2011. Obstructive interval, surgery type, vasal fluid character, and sperm character were recorded. Men either self-reported pregnancy and birth rates or completed a survey response. All patients had at least 12 months of follow-up data.
Results: Over the time frame, 3135 men underwent vasectomy reversal; 17% (524 men) undergoing vasectomy reversal had the same female partner. A total of 258 (49%) responded to the survey, and 89% (229) underwent bilateral vasectomy reversal. The average patient and partner age was significantly higher in the same partner group compared to the new partner group, although the same partner group had a significantly shorter obstructive interval at 5.65 years versus 9.23 years. Overall, the clinical pregnancy rate for men with the same partner was 83% compared with 60% in men with a new partner. After regression, this maintained an odds ratio of 2 and was significant.
Conclusions: Men undergoing vasectomy reversal with the same partner experience a higher pregnancy rate compared men with a new partner.
Reviewer’s Comments: This article supports prior articles by Kolettis et al and Goldstein et al. The larger number of patients provides an excellent dataset even though it is a single surgeon. The success rates are substantially higher and maintain significance, even after controlling for ages and obstructive interval. It is also useful to have typical data of a 60% pregnancy rate for those with a new partner. Many patients are interested in “success” following surgery, and this is not solely a desire to have sperm return to the ejaculate. There are limitations, however, because the survey results were returned by only 49% of patients, leaving the potential for reporting bias. Overall, this information is useful when counseling patients with the same partner as prior to vasectomy.(Reviewer–Gregory Lowe, MD).
I saw a patient recently on whom I performed a reversal around a year ago. He and his wife have not achieved pregnancy. He showed me the report of a semen analysis which showed around 50 million sperm with a motility of over 50%. Although 60-150 million sperm is considered normal, most urologists feel that any count above 20 million is suitable to achieve pregnancy. Motility should be over 45% (i.e. 45% of the sperm under the microscope are observed to be moving forward). Other parameters such as morphology (how the sperm look) are less important.
From the perspective of the surgeon who performed the procedure, any sperm in the ejaculate indicates that the reversal was successful and now it is up the the male to begin to produce the quality of sperm necessary to achieve pregnancy. As well, there is the added dynamics of the female ability to have a child. As a rule, when there is no pregnancy between a couple without the history of a vasectomy, the problem is about 50/50 male to female. The point is that even if the post reversal male has adequate sperm, pregnancy still requires other factors to be in place as well.
In the above scenario, the good sperm count and motility is a very good start and indicates a good reversal. And it makes the point about couples understanding the difference between patency (presence of sperm after a reversal) and pregnancy. There is usually a 10-15% differential between the two.
Pregnancy is a many splendored thing-Pregnancy after a reversal is a multi-factorial thing.
I have done over a thousand vasectomies and to my knowledge have not seen this syndrome in my practice.
Having said that, I do believe this malady does exist. But here is the thing, when a patient has a vasectomy reversal to alleviate the pain, it may not be the reversal per se that makes the pain go away.
I recently did a vasectomy reversal on a patient that wanted the procedure to have another child. He did, however, mention that he was told that clips were used for his vasectomy and that he had had pain in the right testicle since the procedure. At the time of the reversal on the right side I found a sperm granuloma (an inflammatory mass in the area of the vasectomy as a result of the body’s attempt to correct the trauma of the surgery and response to sperm which the body views as a foreign body) and marked surrounding inflammatory changes. There were clips noted and dissecting the granuloma out, cleaning the two ends of the vas and removing the “inflammatory glob” was more difficult than the usual dissection. So at the end of the reversal on the right side the patient had the granuloma removed and pristine ends of the vas reconnected with microscopic suture.
It is too early to say if the reversal in terms of pregnancy and patency was successful. But what if his right testicular pain goes away? Maybe it is the removal of the sperm granuloma and not reconstituting the vas. In other words a vasectomy reversal done of post vasectomy pain syndrome that is successful, might have been because of removing the scar tissue and not the reversal.
I had a reversal patient several months ago tell me as he was leaving our surgery center that the primary reason for having the reversal was for pain and not children. He failed to tell me that preoperatively and if he had I would have discouraged having a reversal for that purpose alone. (Surgeon’s rule number one: Don’t operate on folks for pain.) As it turned out, he wrote me a note complimenting my staff at our surgery center and that he was very pleased with the results, i.e. no more pain not that there was a pregnancy.
In summary, there may be something to having a reversal to alleviate chronic post vasectomy pain but it may have more to do with removing the sperm granuloma and inflammatory tissue than restoring the flow of sperm.
Gainesville Urologist Provides Unique Niche for Microscopic Vasectomy Reversal Surgery in Northeast Georgia.
Northeast Georgia Urologist John McHugh M.D. is one of a small number of urologists in Georgia who performs the Microscopic Vasectomy Reversal routinely.
“Naomi Aria Polk was born 12 months after having my surgery, & we couldn’t be happier with our newest addition!” Reginald Polk
Only a small percentage of urologists both perform this procedure at an acceptable cost and have the experience to assure optimal results.
Gainesville, Georgia (PRWEB)
Community urologist John McHugh routinely performs a procedure that most urologists don’t do at all. Although the concept of a vasectomy reversal (removing the vasectomy site scar and reattaching the vas tubes) is simple, the actual performance of the procedure is not. Two issues make a vasectomy reversal unique compared to other procedures that the urologist performs: one the number of couples who desire a reversal is only six percent of those who have had a vasectomy and as a result the number of potential reversals for the average practicing urologist is small, two the procedure involves microscopic suture and use of the operating microscope and as a result there is a steep learning curve. These two factors contribute to the fact that very few urologists perform vasectomy reversals and fewer yet perform it frequently to do it well. Although pregnancy after a reversal is multifactorial it all begins with the quality of the joining of the two ends of the vas deferens in a tension free and watertight fashion and this in turn highlights the importance of an experienced surgeon.
“Although I have done reversals for over twenty-five years, the opening our Urological Ambulatory Surgery Center in 2009 has added the dimension of making the procedure more cost effective and efficient for the patient. We have the same suture, operating microscope, microscopic instrumentation and staff without the expense of the hospital,” says Dr. McHugh.
Dr. McHugh performs the procedure using a modified two layer anastomosis using microscopic suture, a Zeiss operating microscope with anesthesia provided by a Board Certified Anesthesiologist. His surgery center is accredited adding safety of the patient to the benefits the reversal he performs.
“Few urologists perform microscopic vasectomy reversals routinely because the number of patients who desire it is small. If you add to this the cost of having it performed in a hospital and the fact that the procedure is not covered by insurance, you can see how the patients become very selective. In addition, the patient must undergo the expense and inconvenience of this procedure and rightfully wants the best chance of pregnancy. Few urologists meet the criteria of providing both acceptable cost and the experience to assure optimal results,” adds Dr. McHugh.
Dr. McHugh uses a technique in which the tube inside each vas deferens is joined by using six 9-0 microscopic sutures, which are smaller than a hair in diameter, making the use of a microscope a necessity. The outer layer is then joined with additional sutures assuring a watertight connection.
The procedure involves two small upper scrotal incisions and takes between two and half and three hours to perform. Success of the procedure is affected by the length of time between the procedure and when the vasectomy was done. Historical data regarding success rates depending on when the vasectomy was performed is on the reversal page of his practice website-ngurology.com.
Dr. McHugh offers a free consultation to couples considering having a vasectomy reversal and complimentary hotel accommodations for out of town patients who desire it.
“The microscopic vasectomy reversal has become for me the most enjoyable and rewarding procedure I perform as a urologist.” – Dr. John McHugh
Dr. McHugh has written several books available on Amazon and has practiced urology in Gainesville, Georgia for twenty nine years. His interests include history, writing, dogs, water and fishing.
Answer: One month is the usual recommendation however, I have had couples tell me (I am not making this up) that they had sex the evening of the procedure and that the reversal resulted in a baby.
The microscopic reversal is watertight from the microscopic sutures (meaning conceivably that tube is patent from the get go and that sperm can traverse the reversal without leakage) however there are other areas of the procedure that need to heal as well. So the one month of waiting is for everything to heal properly- from the skin incision, to the vessels that surround the vas deferens and the repair itself.