Vasectomy Reversal

Vasectomy is a common procedure for permanent birth control in the U.S., with over 520,000 performed a year. Of men who have undergone a vasectomy, 6% desire a reversal, with 12-times higher desire for reversal if the vasectomy was performed under the age of 30. Options for men who wish to have more children include vasectomy reversal, sperm aspiration (not undoing the vasectomy) with in vitro, donor sperm insemination or adoption.

The decision to follow a particular option is determined on a case-by-case basis and depends on important factors such as length of time from vasectomy, experience and training of the surgeon, and use of an operating microscope; age of the female partner; gynecologic history of the female partner and economic/financial issues, since post-vasectomy fertility management is most often not covered by insurance.

A common myth is that men who had a vasectomy more than 10 years ago should not have a vasectomy reversal. This is incorrect. The decision is based on the whole evaluation, including examination and the couple’s desires and timeline. Vasectomy reversal is performed in one of two ways. The first is an end-to-end connection – removing the area of vasectomy and reconnecting (vasovasostomy). The other type of reversal is a connection between the vas and the back of the testicle (epididymis) called a vasoepididymostomy. The decision to perform one of these operations depends on the fluid seen at the vasectomy site at the time of the vas reversal. The vasoepididymostomy is a highly specialized microsurgery operation that requires significant training. Ajay Nangia, MD is trained in this operation.

Vasectomy reversal is an outpatient surgery, with semen analysis checked 4 weeks after surgery and periodically thereafter until pregnancy occurs. Success rates range from approximately 75% pregnancy if the vasectomy was performed under 3-5 years prior, to approximately 30% if vasectomy was 15 or more years prior. 

Sperm aspiration/retrieval techniques are used with IVF-ICSI and can be performed in many ways (MESA, TESA, TESE, microTESE) depending on the situation for each patient/couple – ranging from men who have had a vasectomy to men who do not have sperm in the ejaculated semen, known as azoospermia.

The reason men have no sperm in the semen can be genetic, hormonal or unknown. In up to 10% of cases, the genetic reason is a missing piece of the male Y chromosome, known as the AZF region. Some men may also have pieces of one chromosome on another (translocation) or too many X chromosomes. These can be checked by performing blood work. Azoospermia is not the end of the road for having biological children.

Even though a man may not have sperm in the semen, there may still be pockets of sperm in the testicles that are not getting out and can be retrieved in up to 60% of cases. This does require a special type of sperm retrieval called microTESE, which is an extensive biopsy using an operating microscope. This does have to be performed in the operating room. The number of sperm can only be used with IVF-ICSI. Genetic counseling of a couple is sometimes needed especially if a known genetic problem is found.

Another group of patients may develop infertility – patients who receive chemotherapy or radiation for cancer. In these cases, men should try to freeze sperm prior to treatment for later use if their counts are too low or zero. Hope is not lost in those who did not freeze and may require microTESE or use of assisted reproductive techniques.

Spinal cord injury in a young man is another reason for fertility problems – mainly because of ejaculatory issues. In this situation, special methods are required to retrieve sperm for couples to have children.

Sometimes men have retrograde ejaculation – sperm going into the bladder, e.g., diabetics, spinal cord injuries, neurologic issues, urologic/prostate surgery and medications. Retrieval of the sperm from the bladder can be performed to use with assisted reproduction. Sometimes medications can reverse retrograde ejaculation.

We have a comprehensive male infertility center that includes an andrology laboratory capable of semen analysis, cryopreservation and other sophisticated sperm testing.