Vasovasostomy

Definition

A vasovasostomy is a surgical procedure in which the effects of a vasectomy (male sterilization) are reversed. During a vasectomy, the vasa deferentia, which are ducts that carry sperm from the testicles to the seminal vesicles, are cut, tied, cauterized (burned or seared), or otherwise interrupted. A vasovasostomy creates an opening between the separated ends of each vas deferens so that the sperm may enter the semen before ejaculation.

Purpose

The purpose of a vasovasostomy is to restore a man's fertility, whereas a vasectomy, or male sterilization, is performed to provide reliable contraception (birth control). Research indicates that the level of effectiveness in preventing pregnancy is 99.6%. Vasectomy is the most reliable method of contraception and has less risk of complications and a faster recovery time than female sterilization methods.

In many cases, a vasectomy can be reversed. Vasectomy reversal does not, however, guarantee a successful pregnancy. The longer the time elapsed since a man has had a vasectomy, the more difficult the reversal and the lower the success rate. The rate of sperm return if a vasovasostomy is performed within three years of a vasectomy is 97%; this number decreases to 88% three to eight years after vasectomy, 79% by nine to 14 years, and 71% after 15 years. In addition, other factors affect the success rate of vasectomy reversal, including the age of the female partner, her fertility potential, the method of reversal used, and the experience of the surgeon performing the procedure.

Vasovasostomies are also performed in men who are sterile because of genital tract obstructions rather than

In a vasovasostomy, the surgeon makes an incision in scrotum at the site of the vasectomy scar (B). The spermatic cords are located, and the two vas deferens are reconnected with two layers of suture (C and D). (Illustration by GGS Inc.)

prior vasectomies. A vasovasostomy may also be performed on occasion to relieve pain associated with post-vasectomy pain syndrome.

Demographics

An estimated 5% of men who have had a vasectomy later decide that they would like to have children. Some reasons for wanting a vasectomy reversal include death of a child, death of a spouse, divorce, or experiencing a change in circumstances so that having more children is possible. One study found that divorce was the most commonly reported reason for a vasovasostomy and that the average age of men requesting a vasovasostomy is approximately 40 years.

About 7.4% of infertile men have primary genital tract obstructions caused by trauma, gonorrhea or other venereal infections, or congenital malformations of the vasa deferentia. Many of these men are good candidates for surgical treatment of their infertility.

Description

Most surgeons prefer to have the patient given either a continuous anesthetic block or general anesthesia because of the length of time required for the operation. A vasovasostomy generally takes two to three hours to perform, depending on the complexity of the surgery and the experience of the operating physician. More complex surgeries may take as long as five hours. The advantage of general anesthesia is that the patient remains unconscious for the duration of the surgery, which ensures that he remains comfortable. Regional anesthesia, such as a spinal block, allows the patient to remain awake during the procedure while blocking pain in the area of the surgery.

After an adequate level of anesthesia has been reached, the surgeon will make an incision from the top of one side of the scrotum, sometimes moving upward as far as several inches (centimeters) into the abdominal area. A similar incision will then be made on the other side of the scrotum. The vasa deferentia will be identified and isolated from surrounding tissue. Fluid will be removed from the testicular end of each vas deferens and analyzed for presence of sperm. If sperm are found, then a simpler procedure to connect the cut ends of the vasa deferentia will be performed. If no sperm are found, a more complex procedure called a vasoepididymostomy or epididymovasostomy (in which the vas deferens is attached to the epididymis, a structure in which the sperm mature and are stored) may be more successful in restoring sperm flow.

There are two techniques that may be used to reconnect the cut ends of the vasa deferentia. A single-layer closure involves stitching the outer layer of each cut end of the tube together with a very fine suture thread. This procedure takes less time but is often less successful in restoring sperm flow. A double-layer closure, however, involves stitching the inner layer of each cut end of the tube first, and then stitching the outer layer. After reconnection is established, the vasa deferentia are returned to their anatomical place and the scrotal incisions closed.

Diagnosis/Preparation

Before a vasovasostomy is performed, the patient will undergo a preoperative assessment, including a physical examination of the scrotum. This evaluation will allow the surgeon to determine what sort of vasectomy reversal should be performed and how extensive the surgery might be. A medical history will be taken. The physician will review the patient's medical records in order to determine how the patient's vasectomy was performed; if large portions of the vasa deferentia were removed during surgery, the vasectomy reversal will be more complicated and may have a lower chance of success. The patient's partner should also undergo a fertility assessment, including a gynecologic exam, to assess her reproductive health.

Some surgeons prefer to give the patient a broad-spectrum antibiotic about half an hour before surgery as well as a mild sedative.

Aftercare

After the procedure the patient will be transferred to a recovery room where he will remain for approximately three hours. The patient will be asked to void urine before discharge. Pain medication is prescribed and usually required for one to three days after the procedure. Antibiotics may be given after the procedure as well as beforehand to prevent infection. Ice packs applied to the scrotum will help to decrease swelling and discomfort. Heavy lifting, exercise, and sexual activity should be avoided for up to four weeks while the vasovasostomy heals.

Patients are usually allowed to return to work within three days. They may shower within two days after surgery, but should avoid soaking the incision (by taking a tub bath or going swimming) for about two weeks. The surgeon will schedule the patient for an incision check about a week after surgery and a semen analysis three months later.

Risks

The complications that most commonly occur after vasovasostomy include swelling, bruising, and symptoms associated with anesthesia (nausea, headache, etc.). There is a risk of low sperm count if the operation is done inadequately or if scarring partially blocks the channel inside the vasa deferentia. Less common complications are infection or severe hematoma (collection of blood under the skin). The most serious potential complication of a vasovasostomy is testicular atrophy (wasting away), which may result from damage to the spermatic artery during the procedure.

Normal Results

If a successful vasectomy reversal has been performed, the average time to achieving pregnancy after the procedure is one year, with most pregnancies occurring within the first two years. A good sperm count usually returns within three to six months.

Morbidity and Mortality Rates

The chance that the vasa deferentia will become obstructed after a successful reversal is approximately 10%. Some doctors recommend that patients bank their sperm as a precautionary measure. Scrotal hematoma occurs in 1–2% of patients after vasovasostomy, and infection in less than 1%.

Alternatives

A vasoepididymostomy may be performed if the physician determines that a vasovasostomy will be insufficient in restoring sperm flow. The determining factor is usually the absence of sperm or fluid in the testicular end of the cut vas deferens (which is found during surgery), although a swollen or blocked epididymis found during a preoperative scrotal examination may also indicate a vasoepididymostomy will be necessary.

There are some options available to men and their partners who are seeking to conceive after a vasectomy but wish to avoid vasectomy reversal. As sperm are no longer present in the man's ejaculate, they may be retrieved from the testicle or epididymis by extraction (removal of tissue) or aspiration (removed by a needle). The sperm may then be incubated with a female egg under carefully controlled conditions, then transferred to the female uterus once fertilization has occurred; this process is called in vitro fertilization (IVF). A process called intracytoplasmic sperm injection (ICSI) may be used to improve the success rate of IVF; in this procedure, a single sperm is injected into the female egg.

Resources

Books

"Family Planning: Sterilization." Section 18, Chapter 246 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

Periodicals

Sabanegh, Edmund, MD. "Vasovasostomy and Vasoepididymostomy." eMedicine, February 13, 2002 [June 5, 2003]. www.emedicine.com/med/topic3090.htm.

Schroeder-Printzen, I., T. Diemer, and W. Weidner. "Vasovasostomy." Urologia Internationalis 70, no. 2 (2003): 101-107.

Organizations

American Board of Urology (ABU). 2216 Ivy Road, Suite 210, Charlottesville, VA 22903. (434) 979-0059. www.abu.org.

Center for Male Reproductive Medicine. 2080 Century Park East, Suite 907, Los Angeles, CA 90067. (310) 277-2873. www.malereproduction.com.

Other

"Alternatives to Vasectomy Reversal." VasectomyMedical.com. December 3, 2002 [cited March 22, 2003]. www.vasectomymedical.com/vasectomy-reversal-alternatives.html.

Fisch, Harry. The Patient's Guide to Vasectomy Reversal. [cited March 22, 2003]. www.cpmcnet.columbia.edu/dept/urology/infertility.html.

Silber, Sherman J. Microscopic Vasectomy Reversal. 2002 [cited March 22, 2003]. www.infertile.com/treatmnt/treats/mvr/mvr.htm.

"Vasectomy Reversal." Center for Male Reproductive Medicine. [cited March 22, 2003]. www.malereproduction.com/08_vasectomyrev.html.

— Stephanie Dionne Sherk

Surgical creation of a passage connecting the ends of a severed vas deferens, usually to restore fertility in a vasectomized man.

Anastomosis of the ends of the severed vas (ductus) deferens.

The noun has one meaning:

Meaning #1: a surgical procedure that attempts to restore the function of the vas deferens after a vasectomy

It has been suggested that this article or section be merged with Reverse vasectomy. (Discuss)

This article needs additional citations for verification. Please help improve this article by adding reliable references. Unsourced material may be challenged and removed. (August 2007)

Intervention: Vasovasostomy
ICD-10 code:
ICD-9 code:	63.82
MeSH	D014669
Other codes:

Vasovasostomy (literally connection of the vas to the vas) is the surgery by which vasectomies are reversed in males.

It can be performed in the convoluted or straight portion of the vas deferens.^[1]

Contents 1 History 2 Limitations 3 What is required for a successful vasectomy reversal 4 Procedure 5 Prognosis 6 Rate of Pregnancy 7 Statistics 8 See also 9 References 10 External links

History

The medical term used to describe the reversal procedure is called vasovasostomy (a form of microsurgery first performed by Earl Owen in 1971).

The physician can reconnect the sperm canal by performing a vas-to-vas connection (vasovasostomy).

The term Vasectomy Reversal (vasovasostomy) is the process of reconnecting the tubes (vas deferens ) that were cut during a vasectomy Vasectomy reversal is usually an outpatient procedure without an overnight stay.

Limitations

In most cases the vas deferens can be reattached but, in many cases, fertility is not achieved. There are several reasons for this, including blockages in the vas deferens, and the presence of autoantibodies which disrupt normal sperm activity. If blockage at the level of the epididymis is suspected, a vaso-epidymostomy (connecting the vas to the epididymis) can be performed.

Return of sperm to the ejaculate ranges from roughly 30 to 90 percent, and may depend greatly on the length of time from the vasectomy. Generally, the shorter the interval, the higher the chance of success. The likelihood of pregnancy is somewhat lower (30 to 60 percent), and can depend on female partner factors.

Over half of men who have undergone a vasectomy develop anti-sperm antibodies. The effects of anti-sperm antibodies continue to be debated in the medical literature, but there is agreement that antibodies reduce sperm motility.

What is required for a successful vasectomy reversal

Only two conditions must be satisfied for sperm to be returned to a patient's semen with vasectomy reversal by vasovasostomy (VV). The first condition is rather obvious. The patient must have sperm available to pass through at least one reconnection. The second condition is that each reconnection must be as watertight as possible. The surgeon's goal is to achieve a very precise circumferential reconnection of the sperm canal edges by using meticulously placed microsurgical sutures.

Procedure

This article may require cleanup to meet Wikipedia's quality standards. Please improve this article if you can. (October 2009)

Vasovasostomy is typically an out-patient procedure (patient goes home the same day).

The medical term used to describe the reversal procedure is called vasovasostomy (a form of microsurgery first performed by Earl Owen in 1971). The physician can reconnect the sperm canal by performing a vas-to-vas connection (vasovasostomy). The term Vasectomy Reversal (vasovasostomy) is the process of reconnecting the tubes (vas deferens ) that were cut during a vasectomy Vasectomy reversal is usually an outpatient procedure without an overnight stay.

The procedure is typically performed by urologists. Most urologists specializing in the field of male infertility perform vasovasostomies using an operative microscope for magnification, under general or regional anesthesia.

Doctors can perform this surgery in one of two ways:

Vasovasostomy (VV) with this procedure, the surgeon sews the severed ends of the vas deferens back together. However, sometimes this isn't possible and a more complex surgery is needed to restore the flow of sperm.

Vasoepididymostomy (VE) is often considered one of the most technically challenging operations in the field of urology. The procedure requires anastomosis of a single epididymal tubule (luminal diameter .15-.25 mm) to the lumen of the vas deferens (diameter .3-.4 mm), and is reserved for patients with congenital or acquired epididymal obstruction, or patients who have failed previous attempts at surgical reconstruction of the vas deferens. This surgery attaches the vas deferens directly to the epididymis, the coiled tube on the back of each testicle where sperm matures. A vasectomy can cause blockages or a break in the vas deferens or the epididymis. This surgery is used when a vasovasostomy won't work because sperm flow is blocked. The vas deferens is connected to the epididymis above the point of blockage.

If sperm were seen in one or both vas contents at the time of surgery, or sperm reached the patient’s semen only transiently after the reversal, microsurgical vasovasostomy (VV) will very likely be successful. Unfortunately, surgeons performing only an occasional vasectomy reversal often neglect examining the vas contents for presence or absence of sperm. A surgeon absolutely cannot determine sperm presence or absence by the naked eye. The most common cause for failed vasectomy reversals is the inappropriate non-microsurgical technique using sutures that are too large to achieve watertight reconnections. The failure of a competently performed microsurgical “vasovasostomy” (VV) following the absence of any sperm in the contents of each vas usually is due to “blowouts” in each epididymis. Under these circumstances an operation should be performed only by a micro-surgeon with proven “vasoepididymostomy” (VE) expertise, bypassing the blowouts.

Prognosis

The prognosis for each patient should be determined by a pre-operative examination of the vasectomy sites besides consideration of the time interval between vasectomy and reversal.

Rate of Pregnancy

The rate of pregnancy depends on such factors as the method used for the vasectomy and the length of time that has passed since the vasectomy was performed. The reversal procedures are frequently impermanent, with occlusion of the vas recurring two or more years after the operation.

A local urologist can easily determine whether you have 0, 1, or 2 sperm granuloma by a painless examination of each vasectomy site. This exam can be fairly inexpensive, if you inform his office in advance that this is the only service you wish and you obtain the cost for only this specific examination. If the interval since your vasectomy is less than fifteen years, your prognosis will be 70% or better and this local examination is probably not needed. A sperm granuloma develops from post-vasectomy sperm leakage and somehow it behaves like a safety valve preventing internal pressure build up and ruptures of the delicate epididymis tubules with subsequent obstructive scarring.^[2]

Statistics

Between 4 and 6% of vasectomized men consider a vasectomy reversal. Approximately 60% of men who consider vasectomy reversal do so because of remarriage. There are many other reasons that include family planning and the desire to maintain fertility for the future.

Vasectomy reversal can be effective regardless of how long it's been since the original vasectomy. However, if more than 15 years have passed since the original vasectomy, you may have a lower chance of having enough healthy sperm in your semen to father a child.

See also

• Tubal reversal, the female version, reversal of a tubal ligation

References

1. ^ Patel SR, Sigman M (2008). "Comparison of outcomes of vasovasostomy performed in the convoluted and straight vas deferens". J. Urol. 179 (1): 256–9. doi:10.1016/j.juro.2007.08.169. PMID 18001786. http://linkinghub.elsevier.com/retrieve/pii/S0022-5347(07)02349-X. 
2. ^ "[[] []]". Dr Don R Pohl, M.D.. 2006-06-17. []. Retrieved 2008-08-19. 

External links

• Vasovasostomy Vasectomy Reversal
• All About Vasectomy Reversal, Vasectomy and Finding a Doctor
• Vasectomy Reversal American Urological Association sponsored site.
• Vasectomy.com Articles on Vasectomy Reversal.

v • d • e Genital surgical and other procedures (ICD-9-CM V3 60-71) Male reproductive system Prostate Prostatectomy (Transurethral resection of the prostate) Vas deferens Vasectomy · Vasovasostomy Penis Circumcision · Penectomy · Penile prosthesis · Preputioplasty Testes Castration (Inguinal orchiectomy) Female reproductive system (gynecological surgery) Ovary Oophorectomy Fallopian tubes Tubal ligation · Salpingectomy Uterus Hysterotomy · Hysteroscopy · Pelvic exenteration · Hysterectomy · Vacuum aspiration Vagina Colposcopy · Culdocentesis · Hymenotomy · Vaginectomy Vulva Female genital cutting · Vulvectomy reproductive system navs: anat female,male/physio/dev, noncongen/congen/neoplasia, symptoms+signs/eponymous, proc

This entry is from Wikipedia, the leading user-contributed encyclopedia. It may not have been reviewed by professional editors (see full disclaimer)