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JOHN J. BASILE, MD, PC SUNIL V. PATEL, MD Adult and Pediatric Urology
Vasectomy Reversal Procedure
During a 9-year period, 1,469 men who underwent microsurgical vasectomy reversal procedures were studied at 5 institutions. Of 1,247 men who had first-time procedures sperm where present in the semen, in 865 of 1,012 men (86%) who had postoperative semen analyses, and pregnancy occurred in 421 of 810 couples (52%) for whom information regarding conception was available. Rates of patency (return of sperm to the semen) and pregnancy varied depending on the interval from the vasectomy until its reversal. If the interval had been less than 3 years patency was 97% and pregnancy 76% , 3 to 8 years 88% and 53%, 9 to 14 years 79% and 44% and 15 years or more 71% and 30%. The patency and pregnancy rates were no better after 2-layer microsurgical vasovasostomy than after modified 1-layer microsurgical procedures and they were statistically the same for all patients regardless of the surgeon. When sperm were absent from the intraoperative vas fluid bilaterally and the patient underwent bilateral vasovasostomy rather than vasoepididymostomy, patency occurred in 50 to 83 patients (60%) and pregnancy in 20 to 65 couples (31%) Neither presence nor absence of a sperm granuloma at the vasectomy site nor type of anesthesia affected results. Repeat microsurgical reversal procedures were less successful. A total of 222 repeat operations produced patency in 150 and 199 patients (75%) who had semen analyses and pregnancy was reported in 52 and 120 couples (43%).
Men who have no sperm in the semen and who have extremely small semen volumes may have either congenital absence of the vas and the seminal vesicles or may have obstruction of the ejaculatory duct on both sides (see Figure 6). A blockage of the ejaculatory duct often can be treated with a procedure performed through a cystoscope, which is inserted through the penis (no outside incision required). Men who have congenital absence of the vas and seminal vesicles may be candidates fro a special procedure of microsurgical operative retrieval of sperm from the epididymis combines with in-vitro fertilization of the wife's eggs. Before a man has surgery to correct his infertility, his wife should be examined by a gynecologist to be certain her fertility in normal. It seems pointless for the husband to have surgery if his wife has developed some serious fertility problem or has some finding on examination which prompts the gynecologist to advise that pregnancy would be dangerous to her. Even if the wife previously has become pregnant easily, a simple gynecological exam helps assure that her fertility has not changes. If the wife is near or beyond 35 years of age, she should ask the gynecologist about the slight increase in the percentage of abnormal children resulting from pregnancy beyond a maternal age of 35 years. This discussion has not contained certain specialized topics pertaining to a small percent of infertile patients who have no sperm in their semen. However, it should give all infertile patients who do not have sperm in the semen due to a blockage a better understanding of the possible causes and treatment of their infertility. Regarding the technical performance of these operations, microscope magnification from five to forty times actual size allows the surgeon to use stitches smaller in diameter than an eyelash. Microsurgical operations may require two and a half to five and a half hours to perform. Almost all patients undergoing microsurgical reversal procedures are managed as outpatients. Some urologists who use microsurgery perform vasovasostomy using one of the full-thickness "one-layer" stitching techniques shown in Figure II. With any of theses "one-layer" methods, only a single layer of stitches is placed. FigureIV:
Vasoepididymostomy (the bypass operation) may be required both in certain cases of vasectomy reversal and in cases of blockage of the epididymis due to congenital abnormalities or acquired diseases. Before the use of microsurgery, vasoepididymostomy was performed as shown in Figure IV, but successful results were infrequent. Using microsurgery, a "two-layer" connection of the vas to the epididymal tube may be performed as shown in Figure V. For those patients who have not had a vasectomy, but who have a congenital or acquired blockage in the epididymis, the vas is divided at its lowest end rather than at the old vasectomy site to accomplish bypass vasoepididymostomy. Fees My fees depend upon the exact procedure performed on each side. In some patients surgery can be performed only on one side, but it is performed on both sides whenever possible. Surgery performed on one side is termed "unilateral", while surgery performed on both sides is termed "bilateral". I perform surgery bilaterally (both sides) unless rare special circumstances indicated otherwise. My fees currently are:
These fees are for the microsurgical methods and are considerably higher than fees for non-microsurgical procedures. Some insurers cover most or all of these fees, but other insurers cover either none or only a small percentage of the fees. Anesthesia fees will general vary from $500.00 - $1,500.00, depending upon the length of the time required for the procedure. The pathologist performs microscopic examination of the vas fluid during your surgical procedure, and will also subsequently examine any tissues removed during the procedure. The pathologist's fees general range from $50.00 - $150.00. Surgery Center and Rates Hospital bills are quite variable. The amount billed by the hospital depends mainly on the length of the operation. Only a rare patient requires hospitalization, and thus most patients are managed on an outpatient basis (which will keep your charges down). The business office at Fairfax Surgery Center is usually quite helpful in answering any finance related questions. On occasion, a payment plan can be made if your financial situation warrants this. Any questions can be addressed to the business office at Fairfax Surgery Center at 703.698.2349. Instructions to be followed prior to surgery: It is asked that you DO NOT take aspirin or nonsteroidal anto-inflammatories (e.g., Motrin, Aleve, Advil, ibuprofen) for ten days prior to your surgical procedure. These substances may thin your blood and result in excessive bleeding. On the day of the procedure, you are instructed to arrive at the hospital one and a half hours prior to the time of the procedure. You should have NOTHING TO EAT OR DRINK AFTER MIDNIGHT OF THE NIGHT BEFORE YOUR PROCEDURE. Instructions to be followed after surgery:
Figure 5. Vasoepididymostomy performed by a microsurgical method. I (B), an incision is made into the epididymal tube above the level of obstruction. If sperm are present in the fluid at this level, a two-layer connection of the vas to the epididymis is performed. The outer muscular layer of the vas is connected to the vas to the epididymis is performed. The outer muscular layer of the vas is connected to the outer capsule of the epididymis as in (C) and (F), while the edges of the inner lining layer of the vas are connected to the edges of the tube in the epididymis as in (D) and (E). Microsurgery is required for performance of this method of vasoepididymostomy. Because of the extremely tiny size of the tube in the epididymis (0.2 to 0.3 millimeters, or about 2/25th to 3/25th of an inch in diameter), the details of the tube cannot be seen without considerable magnification. (reprinted with permission from Craig T. F., Jr.: Reproductive and urogenital microsurgery. Clinic In Plastic Surgery 10:1555,1983.) Most urologists performing "two-layer" microsurgical vasovasostomy report postoperative pregnancies in the wives of 55% to 65 % of patients. 
Commonwealth Urology
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