Vasectomy Reversal

Whilst vasectomy is regarded as permanent contraception, some 5 percent of men later desire further fertility and request vasectomy reversal. This is the most logical management to restore fertility after previous vasectomy. It is a safe, relatively straightforward surgical procedure, performed on a day-stay basis under general anaesthetic. The procedure takes up to 2 hours and is performed through a midline scrotal incision which is well tolerated and generally heals without complication. Most patients return to work and normal activities within a few days. I use an operating microscope to rejoin the vas where it has previously been divided (vasovasostomy).

There are however a number of considerations before proceeding with vasectomy reversal:

• Some 20 percent of normal couples experience some degree of infertility, relating to male factors, female factors or both. This rate of infertility applies to couples presenting for vasectomy reversal and therefore problems other than the previous vasectomy should be considered, investigated for and appropriately treated.
• Whilst return of sperm to the semen is a technical success, the ultimate objective is pregnancy with a well, live baby. Vasectomy reversal is technically successful in approximately 80% of patients and roughly half of these couples achieve spontaneous pregnancy and delivery.

Male Factors:

• Normal, ready fertility prior to vasectomy favours a good outcome from vasectomy reversal.
• An interval between vasectomy and vasectomy reversal of 5 years or less favours subsequent spontaneous pregnancy whereas intervals of greater that 15 years are less likely to achieve pregnancy.
• Recurrent epididymitis and scarring will compromise the likely success of vasectomy reversal. This affects both the technical success of vasectomy reversal and the likelihood of anti-sperm antibodies which interfere with fertilization.
• Male age appears to have a minor effect on the sperm motility and morphology.

Female Factors:

• Age impacts significantly on a woman's fertility. Spontaneous pregnancy declines progressively after 35 years and is only 15% in women older than 40 years.
• Previously-proven normal, ready fertility is a favourable factor.
• Coexisting gynaecological problems and previous pelvic infections compromise spontaneous fertility.

Assisted fertility treatment (IVF) is an alternative to vasectomy reversal to achieve pregnancy. Sperm can be extracted from the testicle, eggs removed laparoscopically from the ovary, the sperm injected into the eggs and the embryos transferred back into the woman for normal pregnancy (ICSI). The success rate is 10% per cycle and ICSI costs approximately NZ$10,000 per cycle. The likelihood of twins is 20 fold that of natural conception, with associated increased problems for both mother and infants, and greater health care costs.

IVF bypasses normal sperm and egg selective processes. Embryos created in this manner contain a significantly higher percentage of genetic abnormalities than is normally expected, and this genetic damage probably accounts for the higher rates of miscarriage that are seen in IVF. It may also allow genetic abnormalities to be carried through into the foetus and child. Some 4% of children from ICSI have major congenital abnormalities, higher than with natural conceptions.

Vasectomy reversal is therefore recommended in couples without significant other adverse factors. Cost-effectiveness analyses from the United States comparing vasectomy reversal with ICSI significantly favour vasectomy reversal (and even repeat vasectomy reversal) per live birth where the interval between vasectomy and reversal is 15 years or less.

Pure assisted fertility should be considered in preference to vasectomy reversal where there are a number of unfavourable factors, both male and female and where the couple desire only one pregnancy.

Many couples are somewhere in the middle of the spectrum and may use a combination of treatments. Vasectomy reversal is appropriate but consideration should be given to some additional assisted fertility, such as ovarian stimulation. In this situation, vasectomy reversal achieves large numbers of good quality sperm that can be readily provided by ejaculation rather than surgical extraction, which in turn allows for safer, cheaper, assisted fertility techniques using simpler technology to achieve pregnancy and a healthy baby.

This fact sheet complements the discussion during your consultation, which will apply your individual circumstances to the above facts.