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 […]
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
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:
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.
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.
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.
What is a “hat trick?” Click image above to find out!
What is a vas deferns “hat trick?” Well…
I am seeing patients one day and come to a room with a chart in the door which says “Post vasectomy.” I note that the patient had had a vasectomy by me about several years prior to this visit.
I enter the room and there I see a husband and wife and the husband is holding a newborn baby. Only a urologist can really know how it feels to be told of a possibility of a patient having a child after you did the vasectomy. It is not a good feeling…like all the blood goes to your feet feeling.
I ask, “I did your vasectomy?”
The husband says, “Yes”
I say, “Is that y’all’s baby.”
The couple smiles and beaming in unison say, “Yes”
There is a pause. I don’t know really what to say. I was about to say, “I’m sorry. You know there is a one in 2000 chance of these tubes growing back together.”
The wife says, “We are here for a vasectomy.”
Aside: I have had pregnancies after a vasectomy in career about 5 times. Usually it is because the male did not assure sterility by bringing a specimen to the office to be checked. More commonly the couple will have sex too soon after the vasectomy assuming that “If I had a vasectomy then there are no sperm.” They forget that it takes approximately thirty ejaculations to clear the sperm after a properly performed vasectomy. So sex before the sperms clears can cause pregnancy as the sperm is beyond the vasectomy site of occlusion. So even though the urologist never wants to hear about pregnancy after the vasectomy, most commonly it is not because the vasectomy was not performed properly.
Aside 2: It is also common that when a couple has a child after a vasectomy, for whatever the reason, they are happy or shall I say not disappointed about it. Some will say, “It’s God’s will.” By the tone of the conversation with the referenced couple, I felt that they were happy to have a had a child and that were not angry at me nor blaming me for anything.
Where was I? Anyway I say, “I am sorry about this. You came to me for the vasectomy because you did not want anymore children. Regardless of the cause I apologize and will happily do the vasectomy at no charge.”
The couple appears surprised and the wife says, “We wanted a baby.”
I am relieved and the blood in body is beginning to circulate to my upper extremities again.
Another pause and now the couple appears confused.
The wife says, “Doctor McHugh, there is no reason for an apology. We are very happy.”
The husband says, “Remember…you did my vasectomy reversal last year. We just had this beautiful baby and now I want a vasectomy.” The nurse had failed to put the most recent note in the chart of this patient which would have let me know this patient had had a reversal.
So…I do the vasectomy.
A lot of couples debate which of the two major methods of having a child after vasectomy they should pursue. Often times it is a decision based on cost. For that couple wanting to do IVF first, this study shows no significant scarring as a result of the aspiration and no significant negative effect to a successful vasectomy reversal.
Urology – July 30, 2008 – Vol. 24 – No. 07
Article Reviewed: Results of Vasovasostomy or Vasoepididymostomy After Failed Percutaneous Epididymal Sperm Aspirations. Marmar JL, Sharlip I, Goldstein M: J Urol; 2008; 179 (April): 1506-1509.
Vasectomy reversals are longer and more complicated than the original vasectomy procedure. Because of that, recovery takes more time, although it is still fairly quick. In general, side effects after a reversal tend to be mild and disappear within a short period of time.
During the first couple of days after surgery, you may experience slight swelling or bruising in the scrotum. In addition, the surgery and anesthesia could cause a headache, general pain, and nausea, among other short-lived side effects.
To soothe the scrotal area and help minimize swelling during the first few days, you’ll need to elevate your legs, stay off your feet, and use ice packs. You’ll need to avoid submerging the incision in water fort he first 48 hours after the procedure–showers after a day or so are just fine but avoid baths and swimming, both of which increase the risk of infection. Your surgeon will also give you a course of antibiotics to prevent infection.
Contact your doctor immediately if you have sudden chills or fever, swelling or pain that gets worse, or drainage from the site of surgery. These are all potential signs of infection.
After a vasectomy reversal, you will gradually be able to return to your previous physical activities, typically over the course of three to four weeks.
Within a week or so you should be able to return to work and handle most of your normal routine, but you’ll want to avoid major physical activity for two to three weeks. This includes heavy lifting, working out, and excessive walking or driving.
You should also be able to resume sexual activity within two to three weeks; the procedure should have no effect on your sex drive nor your ability to have an erection or orgasm.
Your doctor will begin checking for the presence of sperm in your semen after one or two months, and will continue testing periodically until sperm have reached acceptable levels. It’s normal for sperm to take several months to appear in ejaculate, and it can sometimes take up to 15 months for them to return.
One way in which the success of a vasectomy reversal is measured is sperm count and sperm motility. Both of these may not return to a normal range for three to six months. Overall, 92 percent of vasectomy reversals result in sperm returning to the semen.
The ultimate test for whether a reversal has been successful, however, is pregnancy, which can sometimes occur as quickly as a few months after the procedure or as long as several years later. Roughly 30 to 60 percent of vasectomy reversals ultimately lead to natural pregnancies, and over half result in pregnancy within two years.
Reviewed November 19, 2012 by Sarah K. Girardi, MD – Urologist
References
van Dongen J, Tekle FB, van Roijen JH. Pregnancy rate after vasectomy reversal in a contemporary series: influence of smoking, semen quality and post-surgical use of assisted reproductive techniques. BJU Int. 2012; 110(4):562-7.
Michielsen D, Beerthuizen R. State-of-the art of non-hormonal methods of contraception: VI. Male sterilisation. Eur J Contracept Reprod Health Care. 2010 Apr;15(2):136-49.
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.
Urology – October 30, 2015 – Vol. 33 – No. 4
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.
You can learn something from almost anything!
