Tag Archives: vasectomy reversal cost

Predictive factors in sperm appearance after vasectomy reversal.

img_0332

Patient’s often ask, “What is your success rate?” The successful reversal is heavily influenced by the quality of the fluid at the testicular end at the time of the reversal and the time interval since the vasectomy. JM

Time to Sperm Appearance Can Be Predicted After Vasectomy Reversal

Urology – November 30, 2007 – Vol. 23 – No. 08

After vasectomy reversal, motile sperm observed intraoperatively at the testicular vas, undergoing vasovasostomy, and an obstructive interval of <=8 years predict shorter time to appearance of sperm in the ejaculate.

Article Reviewed: The Kinetics of the Return of Motile Sperm to the Ejaculate After Vasectomy Reversal. Yang G, Walsh TJ, et al: J Urol; 2007; 177 (June): 2272-2276.

The Kinetics of the Return of Motile Sperm to the Ejaculate After Vasectomy Reversal.

Yang G, Walsh TJ, et al:
J Urol; 2007; 177 (June): 2272-2276

Objective: To study the time to appearance of sperm in the ejaculate for men undergoing vasectomy reversal. Design: Retrospective chart review of men who had undergone bilateral vasovasostomy, bilateral epididymovasostomy, or a combination of vasovasostomy on 1 side and epididymovasostomy on the other. Participants/Methods: 150 men whose records included intraoperative findings with type of reversal performed, record of sperm presence or absence, and associated fluid findings from each testicular vas deferens.

Results: Presence of motile sperm in vasa was associated with a shorter time to postoperative presence of sperm observed in the ejaculate: 95% of men with motile sperm in the intraoperative vasal specimen were observed to have sperm in the ejaculate by 6 months after vasectomy reversal compared to 76% of men without motile sperm in the intraoperative specimen (P =0.04). Features correlated with a shorter onset to the observation of sperm in the ejaculate within the first 3 months after vasectomy reversal included an obstructive interval of <=8 years and vasovasostomy rather than epididymovasostomy. Patient age did not affect time to the observation of sperm in the ejaculate after vasectomy reversal.

Conclusions: Motile sperm observed intraoperatively at the testicular vas, undergoing vasovasostomy, and an obstructive interval of <=8 years predict shorter time to the appearance of sperm in the ejaculate after vasectomy reversal. Reviewer’s Comments: The similarity with previous studies by other investigators of time to sperm seen in the ejaculate, with an average of 3.2 months for vasovasostomy and 6.3 months for epididymovasostomy, provides excellent counseling information for couples considering vasectomy reversal. (Reviewer–Craig S. Niederberger, MD).

 

Can you achieve pregnancy after reversing only one testicle?

download (3)

The above logo is a microbrewery  company in our city and I thought the name lends itself to introduce this blog’s message. I should have been asked to be an investor!

Actually this question comes up often to the urologist. Patients lose a testicle for several reasons to include: chronic epididymitis, orchitis, undescended testicle, testicular cancer, trauma, and chronic pain. In the majority of cases having only one testicle does not affect fertility or male hormone production.

The reason we mention this here is that it does become an issue for the couple desiring a reversal in the male with one testicle. Can you reverse the vasectomy on one testicle and have success? Yes. Do you have a better chance of success after a reversal if you have two testicles? Yes.

Although the one testicle can produce the quality and quantity of sperm for pregnancy after a reversal, having two testicles results in a higher likelihood of success because there are two chances that the anastomosis (the repair of the vas deferens) remain open, two chances of having good fluid in the proximal (testicle side of the vas), and the benefit of two testicles contributing to the semen quality.

It is not unusual at the time of a reversal to have very good quality fluid on one side because of a sperm granuloma on that side, and on the other side the fluid is of poor quality i.e. cloudy with sperm parts and no whole sperm.

So…if we had our druthers, we’d want to begin with two testicles to work with, however it is reasonable to have a reversal if the patient only has one testicle. Of note we often times give a price discount because we only have to one side.

ICSI vs. Vasectomy Reversal in men with prolonged interval since vasectomy?

Even after prolonged obstructive intervals of 15 to 20 years, vasectomy reversal offers better or comparable success rates to intracytoplasmic sperm injection.

Article Reviewed: Outcomes for Vasectomy Reversal Performed After Obstructive Intervals of at Least 10 Years. Kolettis PN, Sabanegh ES, et al: Urology 2002; 60 (November): 885-888.

Outcomes for Vasectomy Reversal Performed After Obstructive Intervals of at Least 10 Years.

Kolettis PN, Sabanegh ES, et al:
Urology 2002; 60 (November): 885-888Objective: To determine the outcomes for vasectomy reversal performed after at least 10 years of obstruction. Methods: 74 vasectomy reversal procedures were performed in 70 patients after obstructive intervals of 10 to 24 years (mean, 14.5 years). These patients were retrospectively reviewed for patency and pregnancy rates. Results: The overall pregnancy rate was 37%. Patency rates for an obstructive interval of 10 to 15 years, 16 to 19 years, and >=20 years were 74%, 87%, and 75%, respectively. Pregnancy rates for these same periods were 40%, 36%, and 27%, respectively. Assuming a live delivery rate per cycle of 25% for intracytoplasmic sperm injection (ICSI), the delivery rate for vasectomy reversal would not be exceeded until an obstructive interval of at least 20 years.

Conclusions: The authors believe that even after prolonged obstructed intervals, vasectomy reversal offers better or comparable success rates to ICSI. Depending on their success rates at various medical centers, a threshold obstructive interval probably exists at which ICSI surpasses vasectomy reversal.

Reviewer’s Comments: This is, in my opinion, a clinically worthwhile paper. It clearly shows the pregnancy and delivery rates in patients who have undergone vasectomy reversal surpass the historical success rates of ICSI even after prolonged obstructive intervals. In addition, vasectomy reversal avoids the complication associated with multiple births, which is commonly seen after ICSI and is cheaper. In summary, even in patients with prolonged obstructive intervals after vasectomy, vasectomy reversal is probably more effective, cheaper, and less complicated than is ICSI. (Reviewer-George S. Benson, MD).

Additional Keywords: 10 infertility interval reversal vasectomy

Reprints: Division of Urology; University of Alabama at Birmingham; 1530 3rd Ave S, MEB 606; Birmingham, AL 35294-3296 (Peter N. Kolettis, MD).

 

Vasectomy Reversal success rates depend on several factors…and yes a little luck!

img_3278

From VasectomyMedical.com

Vasectomy Reversal Failure Rates and Success Rates Vary With:

  • The vasectomy reversal technique used.
  • The years between the vasectomy and the reversal attempt.
  • The experience and skill of the vasectomy reversal doctor.

Some of the best vasectomy reversal success rates reported in the literature for vasovasotomy are a patency rate of 99% with a pregnancy rate of 64%, not including couples where the woman was infertile. This means that in the hands of the surgeon who quoted these rates, he was able to restore sperm flow in the vas tube 99% of the time, and this allowed a pregnancy rate of 64%.

Not every time that sperm flow returns to the vas is pregnancy guaranteed. The expected vasectomy reversal success rates results for vasoepididymostomy in the hands of the same surgeon are lower, reportedly at 65% patency rate and a 41% pregnancy rate.

Factors influencing the success rate of reversal surgery include the following:

  • Time interval since vasectomy-The length of time passed since the vasectomy greatly impacts vasectomy reversal failure, as seen on this chart:
Years Between Vasectomy Sperm Return Pregnancy Rate
Under 3 years 97% 76%
3-8 years 88% 53%
9-14 years 79% 44%
Greater than 15 years 71% 30%

As previously noted, with longer intervals between vasectomy and reversal, there is an increased vasectomy reversal failure rate due to epididymal blockage as well as rupture and obstruction of the epididymal tubules.

  • Sperm granuloma-Sperm granulomas at the vasectomy site are a favorable prognostic sign and increase the likelihood of vasectomy reversal success.
  • Anti-sperm antibodies-Post-operative, sperm-bound antibodies result in a lower pregnancy rate or higher likelihood of vasectomy reversal failure.
  • Quality of vasal fluid-The vasal fluid quality is checked before a decision is made whether to proceed with a vasovasostomy versus vasoepididymostomy when reversing the vasectomy. If no sperm are present in the vasal fluid the gross appearance of the vasal fluid can help in determining between a vasovasostomy versus vasoepididymostomy. Cloudy, water soluble fluid indicates the best case for eventual return of sperm to the semen (higher vasectomy reversal success rate). Thick white greasy toothpaste-like material indicates the worst prognosis (a higher vasectomy reversal failure rate).
  • Microsurgical Vasectomy Reversal Technique-The vasectomy reversal technique and the doctor`s judgment and experience are important factors for success. Given that choosing the vasectomy reversal doctor is one of the few choices controlled by the patient, it may become an important factor in determining the vasectomy reversal success rate.
  • Associated conditions-Any condition that impairs sperm production for example a varicocele may lower postoperative pregnancy rates (increase vasectomy reversal failure rate).

A vasectomy reversal consult is free and easy to schedule 24/7. Leave your number below and we’ll call with an appointment.

Listen to Vasectomy Reversal 101 Podcast While You Walk!

animated-stick-figure-image-0011-1

The Nitty Gritty…

  • The cost is all-inclusive-$6,500.
  • The pre reversal consultation is free.
  • Performed in a practice owned and accredited surgery center.
  • General anesthesia performed by board certified anesthesiologist.
  • 200 reversals have been performed.
  • Overnight accommodations is free.
  • Usually takes two and half hours or less to perform.
  • Out patient.
  • Operating microscope and microscopic sutures and instruments utilized.
  • Success rates mirror national studies. (See success rates page.)

Vasectomy 101 Podcast by Dr. McHugh

Schedule consultation 24/7 by leaving your number and we’ll call you with appointment.

Thoughts of a vasectomy reversal couple…

This week I don’t have to go into work. We had Christmas Eve and Christmas Day with the munchkins and then they headed to their mom’s house for a week. We picked them up Monday morning and we have them until Wednesday morning when they get dropped off at school. Our break routines are always […]

via It’s Our Year — Not the Average Mama

What is the effect of a vasectomy on the male? All you’d ever want to know.

135449-004-F2AB0A3F

From: Spermatogenesis. 2012 Oct 1; 2(4): 273–278.

Effects of Vasectomy and Vasectomy Reversal in Humans

Vasectomy is performed by transection of the vas deferens with suture, clips, cautery or a combination of these in the scrotal portion of the vas. This transection disrupts the mucosal, muscular, and adventitial components of the vas deferens, including the autonomic nerves that mediate vasal secretory function and peristalsis. Vasal obstruction results in increased intraluminal pressures within the testicular remnant of the vas deferens. The increased pressure may have physiologic effects on epithelial cell morphology, cellular ultrastructure, and gene expression in the vas deferens and epididymis. Moreover, sperm cannot traverse the intentionally obstructed vasal lumen, and as such they accumulate and die within the testicular remnant of the vas deferens and the epididymis. A resultant local inflammatory response occurs in reaction to dying sperm, which has significant downstream sequelae, including a systemic cellular and humoral immunologic response that may impair testicular and sperm function.The clinical importance of this response is not clear in humans. Vasal transection and occlusion cause significant, independent pathophysiologic sequelae that may or may not be reversible by microsurgical bypass of vasal and/or epididymal obstruction during vasectomy reversal in humans.

Perhaps the most relevant study on the effects of vasal transection during vasectomy on vasal innervation was conducted by Dixon et al. in 1987.8 This group utilized immunohistochemical staining and electron microscopy to evaluate the intramural autonomic innervation of the human vas deferens after vasectomy. Vasal segments were harvested during vasectomy reversal and compared with nonobstructed vasal segments acquired at the time of initial vasectomy. They found that there were marked decreases in the noradrenergic innervation of the testicular vasal remnants in previously vasectomized men. These findings imply that vasal peristalsis, which is mediated by sympathetic autonomic activity, may be irreversibly impaired after vasectomy unless significant regeneration of autonomic nerve fibers occurs in the months and years following vasectomy reversal. Unfortunately, no studies have adequately assessed the regenerative capacity of vasal intramural nerves in humans after vasovasostomy or vasoepididymostomy.

Despite the paucity of anatomic and histologic data in the literature concerning vasal nerve recovery after vasectomy reversal, a study by Shafik et al. did provide further insight regarding vasal autonomic nerve function after vasectomy and vasectomy reversal.9 Shafik utilized transcutaneous electrovasography (EVG) to record the velocity, frequency and amplitude of nerve conduction in the vas deferens in 22 healthy men, 20 vasectomized men, and 18 men after vasectomy reversal. In normal, fertile men there was minimal temporal or individual variability in vasal conduction frequency, amplitude and velocity. In contrast, vasectomized patients exhibited lower conduction frequency and amplitude in the testicular vasal remnant and irregular, described as aberrant “vasoarrhythmic” conduction patterns. One to seven years after vasectomy reversal 7 of 22 patients had successfully conceived. Interestingly, 4 of these 7 patients had a normal electrovasographic evaluation during follow-up while 3 had decreased conduction frequencies and amplitudes but did not exhibit any vasoarrhythmia. This is in contrast to the 11 patients who failed to conceive, all of whom demonstrated electrovasographic evidence of vasoarrhythmia. Notably, the likelihood of abnormal vasal conduction studies was correlated with the interval of vasal obstruction prior to vasectomy reversal. This study suggests that nerve conduction recovery may be variable after vasectomy reversal, and seems to depend upon the interval of vasal obstruction.

Significant changes also occur in epithelial cell ultra-structure within the vas deferens after vasectomy, most of which are thought to result from changes in the intraluminal pressure after vasal ligation (increased pressure in the testicular vasal remnant and decreased pressure in the abdominal vasal remnant). Andonian et al. documented this phenomenon by comparing the ultra-structural features of the abdominal and testicular vasal remnants after vasectomy (harvested at the time of vasectomy reversal) to vasal segments harvested from fertile men undergoing vasectomy.10 Transmission electron microscopic analysis of vasal segments from healthy fertile men revealed the presence of many apical cytoplasmic protrusions from epithelial principle cells into the vasal lumen. Some of these protrusions remained attached to the principle cells by a stalk, whereas others were self-contained within the lumen of the vas deferens, suggesting a secretory process. The cytoplasmic protrusions, termed “apical blebs,” contain ribosomes and endoplasmic reticulum. Interestingly, these investigators observed a marked reduction in the number of apical blebs within the testicular remnants of the vas deferens in vasectomized patients undergoing vasectomy reversal. In addition, they observed dramatic luminal narrowing, epithelial cell flattening, reduction in organelle density, and absence of apical blebs on the abdominal vasal remnant. These findings are suggestive of de-differentiation of vasal epithelium within the abdominal vasal remnant in the absence of contact with seminal plasma. Whether or not these ultra-structural changes are clinically relevant and reversible with vasovasostomy or vasoepididymostomy remains to be determined.

Morphological changes are also apparent in the human epididymides after vasectomy. Older studies of cellular morphology and ultra-structure in the epididymides of vasectomized animals have demonstrated vacuolization and increases in the number and size of lysosomes within epididymal epithelial cells11,12 as well as segmental thinning of the epithelial lining of the vas deferens and epididymis near sites of luminal distension.13 In humans, dilatation of the entire epididymal tubule has been documented, with the most pronounced increase in luminal diameter noted in the cauda. Moreover, the height of the epididymal epithelium is altered by vasectomy. In normal men, maximal epididymal height occurs in the corpus of the epididymis. After vasectomy, however, the maximal height of the epididymal epithelium occurs in the caput.14 Alternations in the height of the epithelial cell layer in the epididymis after vasectomy suggest the presence of complex molecular biological effects of vasectomy on gene expression, as epithelial cellular volume and height are thought to be indicative of underlying RNA translational and protein secretory activities.

Indeed, recent analyses of the human epididymal transcriptome using microarrays have confirmed that vasectomy causes significant alterations in epididymal gene expression. Sullivan et al. characterized the epididymal transcriptomes within each region of the epididymis in both normal and vasectomized men.15Cluster analysis of nearly 3000 genes demonstrated that expression of 1363 genes did not differ based on vasectomy status, whereas 911 genes were expressed only in normal epididymides, and 660 genes were only expressed after vasectomy. Interestingly, three of the differentially expressed genes have well-established roles in sperm maturation during epididymal transit (NPC2, CRISP1, and DCXL).

Unfortunately, no studies have directly examined the impact of vasectomy reversal on gene expression in epididymal fluid or tissue, as the only candidates for such a study would be the rare patients who desire a vasectomy subsequent to successful vasectomy reversal. However, RNA and protein detection studies in semen after vasectomy reversals have suggested that some of the alterations in epididymal gene expression that result from vasectomy may not be reversible.15 The clinical significance of such studies remains to be determined.

Vasectomy with subsequent vasectomy reversal may also be associated with detectable alterations in sperm DNA integrity. Sperm DNA integrity testing has emerged as a valuable measure of sperm quality that is predictive of natural conception, pregnancy outcomes after intrauterine insemination, and pregnancy loss after in vitro fertilization cycles.16,17 The most commonly utilized assay is the sperm chromatin structure assay (SCSA), which is a flow cytometric method that sorts sperm according to their susceptibility to DNA strand breaks upon exposure to a denaturant.

A study by Smit et al. sperm looked at DNA fragmentation with the SCSA in ejaculated semen after vasectomy reversal in 70 men. They demonstrated that sperm DNA fragmentation was increased in the vasectomy reversal patients when compared with proven fertile controls (30% vs. 15%, p < 0.001). The increase in sperm DNA fragmentation was correlated with lower sperm concentrations, lower sperm motility, and a lower percentage of morphologically normal sperm.18 Interestingly, however, there was no relationship between sperm DNA fragmentation and the likelihood of pregnancy after vasectomy reversal. Though the clinical significance of sperm DNA integrity testing after vasectomy reversal remains unclear, this supports the notion that vasectomy likely causes a myriad of molecular biological sequelae, including sperm DNA damage, which may be irreversible in some cases.

Other factors have been isolated and suggested to be associated with infertility after vasectomy reversal, including antisperm antibodies,19,20 granuloma formation21and persistent mechanical partial obstruction,22which may occur despite partial patency and sperm in the ejaculate. Epididymal function, as discussed above, has been widely studied, as has epididymal dysfunction, which is believed by many to be one of the major factors contributing to infertility after vasectomy reversal when post-surgical patency has been established by demonstrating sperm in the ejaculate. Proteins isolated in epididymal fluid harvested at the time of vasectomy reversal, such as GTPase proteins in the Ras/RAB family and Syntenins, likely play a critical in sperm maturation23 and irreversible changes in protein synthesis despite microsurgical vasovasostomy or vasoepididymostomy may play a large role in infertility despite patency after vasectomy reversal.24,25

How long to pregnancy after vasectomy reversal?

From Vasectomy.com

a-reversal-success-twins

Although vasectomies should be viewed as a permanent form of birth control, there may be certain circumstances in which a man desires to have his vasectomy reversed. If this is the case, questions might arise about how long it takes for a vasectomy reversal to result in pregnancy.

There are no definitive answers. Research indicates that, if a reversal is successful, it can take anywhere from three months to several years for couples to get pregnant. Up to 75 percent of all vasectomy reversals ultimately lead to natural pregnancies, with over half occurring in the first two years.

However, there are several factors that impact whether conception will occur and how quickly:

  • Type of vasectomy reversal procedure: The type of vasectomy reversal procedure a man has will impact reversal success and pregnancy outcomes. Men who have a vasovasostomy — the shorter and simpler of the two types of reversal procedures — tend to have higher success rates than those who have undergone a vasoepididymostomy. The vasoepididymostomy is a more complicated procedure, and is performed when a surgeon believes that the vas deferens tube is blocked closer to the testicle, in a coiled part of the vas deferens known as the epididymis. Because patients who have had a vasoepididymostomy tend to have longer periods of impaired sperm motility, it tends to take longer for their partner to conceive.
  • Time since the vasectomy procedure: The amount of time between the original vasectomy procedure and the vasectomy reversal also affects the length of time it will take to conceive. In general, higher success rates have been reported when the reversal is performed closer to the original vasectomy procedure, especially if less than five years. After 10 years of a vasectomy, pressure within the vas deferens can cause a rupture or blockage in the epididymis. This blockage requires the micro-surgeon to perform a more difficult vas-to-epididymis reconstruction, which causes the success rate to decrease.
  • Maternal and Paternal Age: If a woman is over 35, her hormone levels and ovulation cycles may be harder to predict; if a man is over 50, the quality or concentration of his sperm may slightly decrease. Both of these can increase the amount of time to conception. Talk to your urologist about which alternative methods for conception, such as in vitro fertilization, might be an option.

What It Boils Down To

There is no perfect way to predict when, or if, a couple will be able to get pregnant after a vasectomy reversal. But talking to a doctor can help couples understand their own personal chances of success, which obstacles may stand in the way of conception, and whether a reversal is the right choice.

Reviewed December 4, 2012, by Larry Lipshultz, MD – Urologist

References:

Busato, W.F. (2009). Vasectomy reversal: A seven year experience. Urologia Internationalis, 82(2), 170-174.

Graham, S.D., & Keane, T.E. (2009). Glenn’s urologic surgery. Philadelphia, PA: Lippincott Williams and Wilkins.

Labrecque, M., Durfresne, C., Baone, M.A., & St-Hilaire, K. (2004). Vasectomy surgical techniques: A systematic review. BMC Medicine, 2, 21-32.

Palkhivala, A. (2006). Vasectomy reversal: Data point to choice of technique. Urology Times, 43(2), 23, 41.

Does it matter where the vasectomy site is if having a microscopic reversal?

001

The vas deferens closest to the testicle and just before the epididymis is the convoluted portion of the vas. As you see above the vas then “straightens out” the further you get away from the testicle.

Above you see the “old vasectomy” site marked and it is in the mid scrotal area and in the straight not convoluted portion of the vas. This is the ideal location for the reversal doctor because it is away from the inguinal area and up from the smaller and more difficult to isolated convoluted portion.

Although you can feel the vasectomy site through the scrotal skin preoperatively, you really cannot tell where in the course of the vas it actually is.

Recently I performed a reversal and both sides of the vasectomy site were in the convoluted portion of the vas and close to the epididymis. This required more dissection to reach and it is tricky to get a portion of the convoluted vas to reconnect that is straight (as opposed to curved away from the other side of the vas).

So yes if the person who did the vasectomy happened to do it in the middle, that is away from the inguinal area as well as away from the convoluted portion of the vas then the procedure is much easier to locate, to prepare for the reversal, and to perform the reversal.

You might ask, ” Why wouldn’t every urologist make a point to do the vasectomy in the best position in case a reversal has to be done years later.”

Well a reasonable enough question but there are two factors to consider as to why urologists don’t think this way.

  • Vasectomies are usually done in the office under local anesthesia and depending on the patient and the patient’s scrotal anatomy…he gets the vas where he can get it…i.e. sometimes you can’t pick and choose a site the patient’s anatomy dictates that.
  • Also, the vasectomy is supposed to be considered permanent and the primary goal is a good vasectomy and prevention of pregnancy. Vasectomies are not and probably should not be done with the idea in mind that the patient will reverse it.
  • In my practice if I were asked to do the vasectomy so it could be more easily reversed, I’d probably tell the couple to re consider a vasectomy until they felt it was permanent and they had no plans for further children.
  • Having said that, a urologist can try to make a point to be “in the middle” but as I mentioned sometimes you take the vasectomy site where the patient’s scrotum gives it to you.

FAQ-Vasectomy Reversal 101

39bb6928e1c930a935046397f62ef6f5

 

Articles addressing common questions regarding a vasectomy reversal.

A Microscopic Vasectomy Reversal Podcast by Dr. McHugh

If you prefer to read a PDF of Reversal 101

You can schedule your free reversal consultation 24/7 by giving us your phone number and our reversal coordinator will call you with an appointment.