Vasectomy Reversals: Common Q & A

Q. Is it always necessary to use a surgical (operating) microscope to do a vasectomy reversal?

A. Yes. While the vas has the thickness of a very fine piece of spaghetti, we are really attaching the tiny opening in its center. This opening is about 1/100 of an inch in diameter, many times smaller than the vas itself. Its is impossible to properly align microscopic structures without a microscope. Optical loupes (also called jewelers loupes or magnifying glasses) can magnify only about 5 times. A surgical microscope can magnify 50 times. The result is that a surgeon using a microscope works with an image which is 10 times larger The difference is enormous.

Q. Is that the only reason to use a microscope?

A. No. The microscope is also necessary just in case the surgeon has to convert the surgery to a vaso-epididymostomy (VE). The epididymal tubule is much tinier than the vas deferens. It is impossible to attach the vas deferens to this structure without a microscope. About 7% of reversals need to be converted to a VE. If a microscope is not used, the operation must be terminated when such a conversion is necessary.

Q. What is VE?

A. The epididymis is a coiled, tubular structure between the testicle and the vas deferens. The actual length of the epididymal tubule is 12-20 feet. The epididymal tubule is much finer than the vas deferens and has very thin walls. When sperm leave the testicle, they spend a number of days maturing in the epididymis before reaching the vas deferens (vas). After vasectomy, pressure increases inside the vas, epididymis, and testicle. The pressure builds because sperm production continues in a closed space after the vas is cut and blocked.

Since the epididymis is the weakest link in the chain, it sometimes ruptures (blows out) from the pressure. A blockage occurs at the site of the blow-out.

The blockage is "upstream" of the vas so reattaching the vas will do no good. The surgeon must go back to the epididymis to perform the connection. This is a much more difficult and time consuming operation than regular vasectomy reversal. It is completely impossible to perform a VE without a good surgical microscope.

Q. Are all operating microscopes the same?

A. No. Older and less expensive models require manual focusing, have weak light sources, and less power. A simple operating microscope can cost less than $5,000. Technologically advanced microscopes are electronically powered with automatic zoom systems and auto-focus. Their light sources are usually xenon bulbs. Xenon light allows more detail and natural tissue color to be visualized by the surgeon. A xenon bulb lasts only 200 hours and costs about $800. Top of the line scopes also have photographic and video capability so spouses, doctors, or medical students can watch the surgery on TV monitors. These microscopes, such as our Zeiss scope, cost over $100,000.00, and require expensive maintenance.

Q. Can doctors do a good job on vasectomy reversals if they practice other aspects of urology or surgery as well?

A. It's impossible to stay sharp at microsurgery unless you do it regularly. A doctor who performs less than a hundred reversals a year cannot possibly maintain expert proficiency. Physicians who have the opportunity to do only an occasional vasectomy reversal would better serve their patient by sending him elsewhere.

Q. How long after my reversal until sperm returns to the semen?

A. The time from surgery to sperm appearance is quite variable. Some patients have sperm within a couple of months or less. Others don't have any sperm until 6 months or more. In patients who have a VE, sperm sometimes does not appear for a year. We generally recommend a sperm count at 8 weeks, 4 months, and 6 months following surgery, but this advice is flexible, as every patient's situation is unique.

Q. I have had an unsuccessful reversal. Is it worthwhile to try again?

A. Some, but not all, failures are due to technical mistakes by surgeons. Rough handling of the vas can lead to scarring and obliteration of the tubal openings. Leaking connections and improperly placed sutures can also cause failure. Many failures are unpreventable. Healing is a natural process which is slightly unpredictable. In most cases, it is worth while to try a second time. A second attempt is still the cheapest and most cost effective choice. Of course, each case must be evaluated separately.

Q. What will my recovery from reversal be like?

A. Most patients say the post-operative recovery from a vasectomy reversal is not any worse than what they experienced after their vasectomy. Some men find it to be somewhat more uncomfortable. In all cases, aching or discomfort can easily be controlled with medication. Many of my reversal patients require only Advil or Aleve. We give all patients a prescription for stronger medication which can be filled if necessary.

Q. Is vasectomy reversal the right decision?

A. In most circumstances, vasectomy reversal is the best option for the couple that wishes to have a child after vasectomy. It's the most natural, most effective, and cheapest way to achieve pregnancy, assuming the female is fertile. Alternatives, such as IVF and ICSI are far more expensive, less effective, and more invasive. Description of the other techniques is quite quite complex and beyond the scope of this brochure.

Q. I had an extremely difficult vasectomy and the doctor struggled for a long time to find my tubes. Would this make my reversal more difficult or impossible?

A. Absolutely not.

Q. What if the doctor who did the vasectomy took out a long length of vas, used metal clips, tied suture around the ends, and then cauterized the ends with electricity?

A. In every man I have seen, the reversal could still be done. If extremely large segments of vas deferens have been removed, this could add a bit of extra time to the procedure. However, the reversal will still be possible if done by an experienced microsurgeon.

Q. Why do you check the fluid for sperm during surgery?

A. During the reversal procedure, we check the fluid from the testicular side of each vas deferens. We look to see if it is very thick, white and creamy, cloudy, or clear and watery. The sample is then examined under the microscope for the presence of sperm or sperm fragments. Cloudy fluid with live sperm carries the best prognosis. Very thick secretions mean a blow-out in the epididymis and indicate the need for a vaso-epididymostomy (VE). The purpose of a VE is to do the reattachment upstream from the point of a blockage in the epididymis, the long coiled tube which connects the testicle to the vas deferens.

The absence of sperm at surgery does not necessarily indicate that a reversal will fail.

Postoperative Care - Vasectomy Reversals

It is always recommended spending the first 16-24 hours after the vasectomy reversal off your feet as much as possible.

Out of town patients may return home the day after vasectomy reversal. Use your judgment about this. Remember, you cannot lift any luggage and prolonged walking is not allowed. Very long rides in the car will not cause any damage but could be somewhat uncomfortable for you.

Remember, less time spent standing for the first few days makes for faster vasectomy reversal recovery. Most patients can return to work within 48 hours, but this depends on your occupation.

Bring supportive briefs on surgery day. This lifts the testicles a bit and prevents their weight from being carried by the healing tissues.

You may shower on the day after your vasectomy reversal procedure. Bathing or swimming may be resumed after 48 hours. Strenuous exercise, such as working out, can start in 14 days. Sexual activity is prohibited for 21 days after a vasectomy reversal.

Otherwise, the surge of fluid up the vas deferens could cause leakage, or even disrupt the new connections. The pressure inside the vas deferens during ejaculation is even higher than systolic blood pressure.

Vasectomy Reversal Recovery Timeline

Vasectomy Reversal Day (Day 0). . . Stay off feet as much as possible. Bring briefs with you. You may go out to dinner on surgery night.

Day 1. . . .You may shower.
Day 2. . . .Bathing allowed.
Day 14. . . Very light exercise allowed
Day 21. . . sex permitted!

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my testicle is displaced upwards into abdominal part after vasectomy reversal. What could cause that and is this normal?

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