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Vasovasostomy (Vasectomy Reversal)

Vasovasostomy (vasectomy reversal) by micro-incision under a high resolution microscope

2 to 6% of vasectomized men later consider fertility, although a vasectomy is a permanent method of contraception. It has long been considered irreversible.

There are 2 options if you want to be pregnant after a vasectomy:

Vasovasostomy (reversal of vasectomy)
Testicular biopsy associated with intracytoplasmic sperm injection (ICSI).

Vasovasostomy is the method of choice for having children again after having a vasectomy. It is based on very high success rates. Another advantage is that the complication rate is very low compared to other known techniques of artificial fertilization.

For a vasectomy reversal procedure, it is necessary to have a first evaluation consultation ideally in a couple. The vasovasostomy is done in a second appointment.
The delay for a vasovasostomy in clinics is a few weeks depending on the day of the week you want.

Please note that vasovasostomies are performed exclusively in a non-participating private clinic to the RAMQ. They are not reimbursable by the RAMQ.

Is vasovasostomy still possible?
Vasectomy is an operation designed to block the spermatozoa from progressing in the duct (vas deferens of each testicle), which transports the spermatozoa to the ejaculatory ducts during ejaculation through the urethra. Each vas deferens is then sectioned and ligated. The ejaculate no longer contains spermatozoa. Unused spermatozoa degenerate and are gradually destroyed. This procedure is relatively simple, fast and with a low rate of complications.

During a reversal of vasectomy, the continuity of each end of the 2 deferential channels severed is restored. Sometimes vasovasostomy is not possible. The vas deferens should then be directly connected to the epididymis (the palpable structure below the testes where the spermatozoa produced in the testes are stored before engaging with the vas deferens). It is then a vasoepididymostomy. This procedure is technically more complex.
What are the success rates of a vasectomy reversal?
It must be clearly understood that vasovasostomy attempts to reverse a vasectomy that is in principle irreversible. There is no guarantee of success. It's a question of luck and probability.

The success rate of vasectomy reversal varies according to various factors, mainly the fertility of the partner who depends directly on his age. Women under 30 are generally much more fertile than older women. However, getting a pregnancy after a vasectomy reversal is influenced just as much by the partner's age and fertility potential. The pregnancy rate is lower (14%) for couples in which the woman is over 40 years old, 56% for the 25 to 39 age group and 67% between 20 and 24 years old. years.

Also, the determining factor in men is the time between vasectomy and reversal of vasectomy (the interval of obstruction after vasectomy).

The success rate is evaluated by the permeability rate. It is the presence of spermatozoa in the ejaculate. In the literature, the average rate of permeability after a vasectomy reversal is approximately 75-85%. This differs from the natural pregnancy rate by about 75%.

The presence of complications that occur after a vasectomy, which generates a significant amount of scar tissue, can reduce the chances of success when attempting a vasectomy reversal. Trauma or infection of the scrotal contents could have the same effect.

The patient may not produce sperm after surgery or produce anti-sperm antibodies following a vasectomy, which may affect the ability of sperm to travel through the woman's mucus.

The technique used has an influence on the success rates. Vasovasostomy has a better success rate than vasoepididymostomy. This procedure has a low success rate around the mark of 30 to 45%.

Aside from the method and length of time of the vasectomy, the surgeon's experience is essential to ensure success. They are often dependent on the number of reversals performed on average per year.
What are the chances of conceiving after a vasovasostomy?
According to a statistic of the American Society of Reproductive Medicine, the chances of conceiving after a vasovasostomy are statistically favourable when the reversal is done within 3 years after vasectomy. The permeability rate is 95% and the pregnancy rate is 75%.

Beyond 15 years, the permeability rate is 70%, the pregnancy rate 30%. This is due in particular to the fact that with the passage of time the narrow wound tube of the epididymis runs a greater risk of suffering pressure that can cause damage. The increase in pressure is mainly due to the influx and constant accumulation of fluids and spermatozoa produced in the testicles. Although this may not cause obvious damage, scar tissue may form at the site of rupture of the epididymis and may be a further impediment to sperm travel.

Another statistic from a study in the Canadian Journal of Urology, CUAJ, in November 2007, Volume 1; 4, page 388-393, predicting the success factors of a vasovasostomy, clearly demonstrated a progressive decline in permeability rates and pregnancy rates directly as a function of the interval of obstruction after vasectomy.
Does the age of the vasectomized man influence the success rate of the reversal?
The age of the vasectomized man generally has little influence on the success rate of vasectomy reversal. However, getting a pregnancy after a vasectomy reversal is influenced just as much by the partner's age and fertility potential.
How long does it take to get pregnant after a vasovasostomy?
It takes on average up to 12 months after the reversal before getting pregnant. Young partners in their twenties, however, may have a pregnancy in a few months. However, it may take up to 2 years in some cases to restore fertility after the procedure.

It should be remembered that successful procreation after vasovasostomy may be more difficult than before vasectomy because extensive fibrosis has developed in the vas deferens or in the epididymis. A change in the quality of spermatozoa and anti-sperm antibodies may also explain this difficulty. The fertility of a man before a vasectomy and after a vasectomy is not at all the same.
What are the possible complications after a vasovasostomy?
- Low risk of infection requiring antibiotic
- Edema (swelling)
- Bruising (blue scrotum)
- Low risk of hematoma (accumulation of blood in the scrotum)
- Scrotal pain
- No influence on sexuality
- Low risk of spermatocele (epidydymal cyst)
- Secondary obstruction (stenosis) may also occur, causing azoospermia.
What is the type of anesthesia for a vasectomy reversal?
In hospitals, surgery is often done under general anesthesia or under spinal anesthesia since you can not move during the procedure.

The procedure in the Marois clinics is done under local anesthesia, with a bilateral sperm block. It looks a bit like a vasectomy but is more effective. It is initially performed by an injector that sends anesthetic liquid under high pressure through the skin. You will feel rather a pinching sensation like the blow of an elastic band. Then, the small puncture of the skin and subcutaneous tissue at the scrotal site will not be felt.

Anesthesia is however limited to the proximity of the injection.

For a more effective anesthesia and a more comfortable vasovasostomy, a right and left spermatic block is realized. It is an infiltration of the spermatic cord that eliminates pain inside the scrotum. We wait about ten minutes before starting the procedure for optimal anesthesia.
How is a vasovasostomy performed?
The patient is lying on his back on an extra gel mattress for better comfort. A protective screen is put to the head for infertility and decrease the stress of the procedure. Sterile fields are set up on the patient and on the microscope.

Two incisions will be made in the scrotum, one side at a time. The vas deferens is first cleared by a skin incision of less than a few millimetres, such as a Chinese technique of a vasectomy, to expose the two ends of the vas deferens and attach them adequately. The scar tissue of the vas deferens that had been ligated is resected in order to obtain a net slice. During the operation, if the vas deferens is in good enough condition to allow a satisfactory flow of sperm, a vasovasostomy is performed.

Then, one verifies the reperminalization of the side of the epididymis, by examining under the microscope the liquid which leaves at the level of this slice.

Occasionally, vas deferens are too scarred to allow adequate sperm flow. It is then necessary to proceed to vasoepididymostomy.

A reversal of vasovostomy occurs with a surgical microscope under high resolution.

The two vas deferens are then sewn by means of very fine threads, barely visible to the naked eye. The procedure may take one hour per side (2 to 2.5 hours in total) given its complexity.

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