Microsurgical vasectomy reversal

What the operation does

A vasectomy divides the vas deferens, the tube carrying sperm from the testicle. A reversal rejoins it. The testicle continues producing sperm normally after a vasectomy — they simply have nowhere to go — so reconnecting the tube can allow sperm to return to the ejaculate and natural conception to occur.

There are two operations, and which one you need is decided during surgery, not before it:

• Vasovasostomy — the two cut ends of the vas are rejoined directly. This is possible when fluid from the testicular end still contains sperm or is clear and copious.
• Vasoepididymostomy — the vas is joined directly to the epididymis, bypassing a secondary blockage that has developed there because of back-pressure over the years. This is a considerably more demanding operation requiring true microsurgical technique.

The need for the more complex operation becomes more likely the longer it is since your vasectomy. Any surgeon offering reversal should be able to perform both, and should tell you in advance that the decision is made at the operating table after examining the fluid under the microscope.

Who it suits

Reversal is appropriate for men who want to father children naturally after a vasectomy — typically after a new relationship, a change of mind, or bereavement. It is worth considering alongside the alternative, which is surgical sperm retrieval combined with ICSI.

Reversal has real advantages: it can allow more than one pregnancy without further intervention, it avoids your partner undergoing IVF, and conception happens naturally at home. Retrieval with ICSI may be preferable where your partner has her own fertility factors, where her age makes time critical, or where the interval since vasectomy is very long. I will set out both options honestly rather than steering you towards the operation I perform.

What happens before surgery

Consultation covers the date and type of your vasectomy, any previous reversal, your general health, your partner's age and fertility history, and your expectations. I examine you to identify the vas on both sides, check for a sperm granuloma, and assess the testicles and epididymis. Blood tests and further investigation are arranged only where indicated. Obtaining your original vasectomy operation note is helpful where possible.

The operation

Reversal is performed under general anaesthetic, usually as a day case, and takes between two and four hours depending on whether one or both sides need the more complex repair. Small incisions are made in the scrotum, the ends of the vas are identified and freshened, and fluid from the testicular end is examined under the microscope for sperm. The join is then made with sutures finer than a human hair, using a two-layer technique under the operating microscope.

Recovery

Expect scrotal swelling, bruising and discomfort for one to two weeks. Supportive underwear is worn day and night initially. Most men return to desk work within a week and to physical work, sport, cycling and heavy lifting at around four weeks. Sexual activity is usually resumed after two to three weeks.

A semen analysis is arranged around three months after surgery, and repeated periodically. Sperm can take several months to reappear after vasovasostomy, and longer — sometimes twelve months or more — after vasoepididymostomy. A single early negative result does not mean the operation has failed.

Risks

Risks include bleeding and scrotal haematoma, infection, chronic scrotal pain, sperm granuloma, and late failure where the join scars and closes months or years after initially working. Sperm freezing at the time of surgery is often offered as insurance against late failure, so that ICSI remains available without further surgery.

My experience

Microsurgical vasectomy reversal is a core part of my male infertility practice at Guy's Hospital, where I established the region's largest male infertility service and run a national training fellowship in male infertility surgery. I perform both vasovasostomy and vasoepididymostomy, and I am well known for offering only evidence-based treatments.