Earlier this year Dr. McHugh performed his hundredth microscopic vasectomy reversal in the Northeast Georgia Urological Surgery Center. Thanks to all the patients and the dedicated staff that helped make this possible. Here’s to the next one hundred!
So why is an operating microscope necessary for reversing a vasectomy?
The thickness of a strand of hair is 100 microns.
The outside thickness of the vas deferens is about 2 mm and the lumen of the vas (the part of the vas that is connected with the reversal procedure and the tube that sperm travels) averages about .56 mm.
The suture used used for the procedure is 70 -100 microns, i.e. the suture is about the diameter of the human hair.
So…12 or so sutures the size of hair is used to join a tube that is that is less than a millimeter in diameter.
1000 microns equals a millimeter.
Of note: The suture that is usually be used to close an incision after an abdominal procedure would be bigger than the tube in which sperm travels in the vas deferens.
Very small sutures must be used to connect very small openings if there is going to be enough room after connecting the tubes for sperm to travel in their quest to achieve pregnancy.
And now…you know the rest of the story-and why…size does matter.
Yes a vasectomy can be reversed…but that really isn’t the issue. The real question is if a vasectomy is reversed what are the chances that it will be successful?
The answer is multifactorial and dependent on the age of the male and female, how long ago was the vasectomy done, the reproductive health of the female, the surgical reconnection of the vas deferens staying open after they are rejoined, and finally the quality of the semen produced after the reversal. All of these factors explain why the patency of the procedure (presence of sperm) and the pregnancy (it worked) of the procedure differ.
Yes you can send a boy to college but you can’t make him think
and yes you can lead a horse to water but you can’t make him drink.
Yes you can reverse a vasectomy but that don’t guarantee no baby
It’s about if it will result in success and that my friend is a big maybe!
Reversal Rates Based on the Time Since Vasectomy
Less than 3 years Patency 97% Pregnancy 76%
3-8 years Patency 88% Pregnancy 53%
9-14 years Patency 79% Pregancy 44%
Greater than 15 years Patency 71% Pregancy 30%
Belker AM, et al. Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. Journal of Urology 1991; 145(3):505-11.
The very first vasectomy ever performed probably isolated the vas deferens, cut out a section and then destroyed the cut ends. This has the effect of a double whammy to assure sterility. How the ends are destroyed or closed is myriad-clips, suture, fulguration, folding the vas on itself and tying- doesn’t really matter in terms of the long-term success rates.
When I learned to do a vasectomy as a resident in the 1980’s, we made a fourth of an inch midline scrotal incision and brought the vas to the surface with a instrument called a towel clip. It had two fine pointed ends and was used to hold towels in place to isolate the surgical field. This instrument was adapted to many functions in surgery and in urology was the device of choice for a vasectomy.
The China Method or the No scalpel method introduced two instruments. One is the fine pointed hemostat which is used to spread the skin for the vasectomy opening. (So there is still an opening but you did not use a scalpel to make it-whoopee do.)
The fine pointed hemostat is also used to open the vas sheathing without having to incise it with a knife once the vas has been isolated and brought to the skin.
This is where the grasper is used. The opening is smaller-a grain of rice in length- and the grasper allows for the urologist to easily grasp and bring the vas to the skin to perform the procedure.
The story line goes that the procedure has a smaller opening, that the opening heals better because the skin has been spread and not cut, the procedure can be done quicker because of these instruments, and that the patients do better with less heal time and fewer complications.
So is it a gimmick? Well it is a better procedure now because of these instruments, but we still identify, cut and destroy. You can decide if all this fuss in nomenclature warrants “spreading” is better than “cutting” an opening that is less than a centimeter in length.
No Scalpel does have a ring to it I must admit. The No Needle vasectomy is another story; I’ll do that at another time.
Of note, these same two instruments are also very useful in preparing the post vasectomy vas for the microscopic vasectomy reversal.
Cutting the vas deferens in two (a vasectomy) is easier than putting it back together (a vasectomy reversal) and is indeed a horse of a different color.
- Vasectomies are covered by insurance-vas reversals are not.
- Because the reversal is not covered by insurance the patient sees, feels, and pays the entire expense of the procedure, the surgeon, the supplies (microscopic suture) and the facility.
- The surgeon fees are relatively high because very few urologists do reversals often or often enough to do well.
- Few urologists are comfortable enough to feel they can do the procedure with a high likelihood of patency (presence of sperm after a vasectomy reversal) and this in turn also limits the number of urologists willing to perform the procedure.
- The identification of the vasectomy site and preparing it for the reversal is something that is comfortable to all urologists. Reanastamosing the inner tubule of the vas deferens by tying microscopic suture while looking through a microscope is not what most urologists are comfortable with and to do efficiently and effectively requires experience and a steep learning curve.
- Some urologists perform the procedure in an office setting with local anesthesia and because this excludes the hospital and an anesthesiologist, these physicians are able to perform a reversal at a lower price. In other words in this setting the hospital fees, which is usually the highest cost component of any surgery, does not exist.
- Some urologists work exclusively through a hospital and with general anesthesia and the fees of this physician and associated costs are the highest.
- Some urologists use general anesthesia and an independent ambulatory surgery center. In this scenario the urologist pays the center for the anesthesia, materials and staffing. The fee of the urologist then is added to this for the all inclusive cost of the procedure.
- Some urologists own their surgery center and use general anesthesia. In this scenario the surgeon has more options regarding costs. Owning the surgery center cuts out the middle man so to speak of a hospital or an independent surgery center and often results in a lower cumulative price but with the benefits of a hospital. The cost of a reversal in this scenario represents a blend of the most expensive hospital based procedure and the least expensive office based procedure.
- Just because a surgeon charges more for a reversal doesn’t mean he or she is better qualified to perform the reversal. There may be other costs involved that the surgeon must account for in his pricing that have nothing to do with his fee for the procedure, i.e the facility, the microscope, the suture, anesthesia, and the staffing.
- Because a reversal is not covered by insurance necessitates the surgeon handling all the fees associated with the procedure so that the patient only has one fee.
- The above makes the reversal procedure expense noticed more because the patient must pay out of pocket.
- This in turn highlights why urologists are hesitant to say they can do a reversal despite having little experience do the procedure because the patient and the doctor are both very disappointed when the procedure doesn’t work. It would be somewhat disingenuous for a doctor to charge a patient the fees, put him through a surgical procedure, knowing he has very little experience in the procedure. This thought process also limits urologists agreeing to do a reversal for concerns of doing the procedure poorly and with poor results. In other words, if you take out a ureteral stone, you have taken it out and it is gone. This is considered a good surgical result. When a reversal is done, the urologist has done the procedure then there is the hopeful expectation of a result, i.e. you just don’t remove something and you are done. With a reversal there is the procedure itself and then there are functional expectations, i.e. the presence of sperm and pregnancy.
- Just with anything the due diligence and decision making is the responsibility of the patient and his family and all of the factors noted above should be taken into consideration.
- Patients need to know from the start what they are getting into and that despite everything going just right there is a percentage of patients who don’t achieve pregnancy.
- And this is why there is variance in the cost of a reversal and why it is harder to perform and more expensive than a vasectomy.
After a microscopic vasectomy reversal, several factors come into play that determine pregnancy. The technical aspects of the procedure must succeed. The surgeon, by experience and care to assure a watertight and tension free anastamosis, hopefully will give the patient the best chance of “having an open vas tube.”
If the reversal is successful and the tube is open, then it is the patient’s testicles turn to “man up.” The longer interval between the vasectomy and the reversal the less likely the testicles have the ability to “pick up the ball” and begin to produce normal sperm that have the ability to be motile. (No pun intended.) The longer the interval, the longer it takes the testicles to produce sperm that can get the job done. This is an imponderable; as no one knows before the reversal the potential of the testicles ability to produce sperm suitable for pregnancy.
So let’s say the reversal is perfect and sperm produced by the testicles are getting through the old vasectomy site are viable, strong, and very motile. Well then, there are the normal things that hinder pregnancy that normal couples, neither of which have had any procedure, experience.
After all this and surmounting the odds of the procedure, the testicles producing good sperm, the length of time since the reversal and the things that are sometimes difficult in pregnancy in the normal situation, pregnancy occurring is much lower percentage than the presence of sperm in the post reversal ejaculate.
This is why the couple considering a vasectomy reversal, and the attendant inconvenience and expense,need to be aware of the difference between patency and getting pregnant.
Alexis was born July 11, 2015. The microscopic reversal was performed by Dr. McHugh approximately one year ago. Congratulations to the happy couple who were kind enough to drop by the office to show off their family’s new addition.