Vasectomy is a minor surgical procedure to cut and close off the tubes (vas deferens) that deliver sperm from the testes; it is usually performed as a means of contraception. The procedure typically takes about 30 minutes and usually causes few complications and no change in sexual function. About 500,000 vasectomies are performed annually in the United States. A vasectomy is less invasive than a tubal ligation (i.e., the procedure used to prevent a woman's eggs from reaching the uterus) and more easily reversed. An increasing number of couples choose it as a means of permanent birth control.
MALE REPRODUCTIVE SYSTEM
To understand a vasectomy, it is helpful to understand the male reproductive system and how it functions. The testicles, or testes, are the sperm- and testosterone-producing organs. They are located in a sac at the base of the penis called the scrotum. Each testicle is connected to a small, coiled tube called the epididymis, where sperm are stored for as long as 6 weeks while they mature. The epididymes are connected to the prostate gland by a pair of tubes called the vas deferens. The vas deferens are part of a larger bundle of tissue, blood vessels, nerves, and lymphatic channels called the spermatic cord. During ejaculation, seminal fluid produced by the prostate gland mixes with sperm from the testes to form semen, which is ejaculated from the penis.
PREPARATION FOR A VASECTOMY
Surgeons typically require men to do 4 things before vasectomy. They are:
1. Shave and wash the scrotum (to prevent infection and to allow easier access)
2. Bring a pair of tight-fitting underwear or athletic supporter (to support the scrotum and minimize swelling)
3. Arrange for a ride home (to minimize exertion and movement that exacerbates swelling)
4. Avoid anti-inflammatory drugs, such as ibuprofen and aspirin, before surgery (they thin the blood and can cause excessive bleeding)
A urologist performs a vasectomy on an outpatient basis, frequently in the office. The procedure takes about 30 minutes. The patient typically remains clothed from the waist up and lies on his back. The scrotum is numbed with one or more injections of local anesthetic (lidocaine), the vas deferens is gathered under the skin of the scrotum, and a small incision (usually 1 centimeter or less) is made. The vas deferens is then pulled through the incision, cut in two places, and a 1-centimeter segment is removed. Each end of the vas deferens is surgically tied off or clipped, and placed back in the scrotum. The incision is sutured and the procedure is repeated on the other side of the scrotum. Some urologists cauterize the ends of the vas deferens, but others find that cauterization complicates reversal and is unnecessary. The incisions are dressed and most men go home immediately after the procedure.
In the no-scalpel vasectomy, a surgical clamp is used to hold the vas deferens while a puncture incision (instead of a cut) is made with special forceps. The forceps are opened to stretch the skin, making a small hole through which the vas deferens is lifted out, cut, sutured or cauterized, and put back in place. The puncture incision does not require suturing. Some urologists recommend the no-scalpel method because they find it is quicker and minimizes postoperative discomfort and the risk for bleeding and infection. Recently, as encouraging studies are reported, more vasectomies are being performed using this approach.
VASOVASOSTOMY (VV) OVERVIEW
The vas deferens is the tube that carries sperm from the testicles to the ejaculatory duct. Vasectomy is the leading cause of obstruction of the vas deferens, but some men are born with or acquire obstruction later in life from trauma or infection.
The ultimate success of a reconstructive procedure is an unassisted pregnancy. This is dependent on several factors: the age and fertility of the female partner, surgeon's experience, the technique of vasectomy reversal and the length of time since the vasectomy was performed, so-called obstructive interval. In large study with 1,469 patients from multiple institutions, the success rate was inversely proportional to the obstructive interval. The shorter the interval, the higher the success. In men with obstructed intervals of less than 3 years, the likelihood of sperm in the semen after reversal (patency rate) was 96% and the pregnancy rate was 75%. On the other hand, when the obstructed interval was greater than 15 years, the patency rate was 70% with a pregnancy rate of 30%. Most men seeking reversal had obstructed intervals between 3 and 14 years, the patency rate was 87% and the pregnancy rate was 44% to 53%. In interpreting this data, one must keep in mind that the age of the female partner plays a very important role in pregnancy and delivery rate.
It is important to point out that, with a longer obstructed interval, the higher the chance that a more complex reconstruction may be required. The operation is called an epididymovasostomy (EV). At the time of the surgery, it will be determined if an EV will be necessary. The success for epididymovasostomy is lower than standard vasectomy reversal.
Vasectomy reversal is done as an outpatient. Anesthesia will be general. Oral pain medication will be prescribed and is generally required for 24 to 48 hours. Tylenol may also be used. No heavy lifting, sports or sexual activity may be undertaken for 4 to 6 weeks. You may return to work in 7 days unless you have a physically demanding job, then a 10 to 14 day wait is recommended. Semen analysis will be obtained at 3 months postop. Sperm may not return for 6 months or more with VV and for up to 12 months following EV. You should not drive for 7 to 14 days. It is preferable in the first 4 weeks that you be the rider rather than the driver in a car.
The average length of time to achieve pregnancy is about one year. 3% to 5% of initially successful VV may develop recurrent obstruction after sperm were initially present recommended that you consider sperm banking once sperm count has peaked to safeguard against this problem. Bleeding and infection are uncommon. Scarring and persistent pain at the operative site occur rarely.
The epididymis is the structure behind the testicle. It is made of coils of tubules through which the sperm migrate and mature. The procedure to correct epididymal obstruction is epididymovasostomy during which the vas deferens is attached to an epididymal tubule in order to bypass the obstruction in between.
The patency rate for epididymovasostomy is about 50% to 60 % with a pregnancy rate of 30% to 40%. Some men may not have sperm present for up to 12 months afterwards. Pregnancy may take one to two years to achieve. Up to 10% of initially successful EV patients may develop recurrent obstruction after sperm were initially present. I recommend sperm banking as a safeguard against this problem.
FAQ'S ABOUT THE VASOVASOSTOMY (VV) SURGICAL PROCEDURE
Q: Exactly what happens during vasectomy reversal?
A: Simply stated, we undo the vasectomy in vasovasostomy and bypass the blockage. In VV, a small incision is made on either side of the scrotum and the vas deferens is examined. The vasectomy site and the vas deferens are identified and excised back to healthy tissue. The side of the vas is now unblocked and typically oozes fluid of various consistencies, depending on the obstructive interval. For VV, the ends are then brought together and reconnected, using surgical sutures with the aid of an operative micro-scope. A modified one-layer technique may be used, depending on the surgeon's preference and the degree of vas lumen disparity. In EV, a larger incision will be needed to gain access to the epididymis. The vasectomy site is similarly approached and excised. The thick fluid consistency and the lack of sperm will mandate the performance of EV. The epididymis is examined and a single tubule is selected for the bypass. Various techniques have been used to connect the vas to the epididymis. The current approach relies on invaginating the epididymal tubule to the lumen of the vas. The approach or its variations has the distinct advantage of being easier to perform and has a higher success rate when compared with the traditional "end-to-side" technique.
Q: Will local anesthesia with sedation suffice?
A: In my experience, local anesthesia is inadequate and is not used in my vasectomy reversal. The problem with local anesthesia is that the patient will have to remain still for an extended period of time despite sedation. The delicate nature of the procedure and the greatly magnified operative field do not allow for any patient movement. Despite being touted by some as a money-saving alternative, local anesthesia has not gained popularity among the majority of surgeons for vasectomy reversal.
Q: What about two-layer vs. modified one-layer vasectomy reversal?
A: Depending on the surgeon's preference and the size difference between the ends of the vas, one may choose either one of above. In two-layer reversal, the lining of the vas lumen and the inner thickness are incorporated in the first layer of suture closure. The outer aspect is then approximated with the second layer of suture. In modified one-layer reversal, the initial layer incorporates the full thickness of the vas, including the lining. This is the approach I prefer. With either technique, one may then choose to further reinforce using the surrounding soft tissue coating. Success rate with either approach is the same (VVSG, 1991).
Q: What is micro-dot vasectomy reversal?
A: Micro-dot is the dotting the vas with a miniature marking pen to pre-select suture entry and exit points. In theory, it adds another degree of precision in suture placement and vas alignment. I personally have not found this extra step helpful in suture placement, and I do not utilize this technique