The Anatomy of the Vas Deferens.

The vas deferens is a long tubular structure that carries sperm from the testicle up through the scrotum and into the deep pelvis.  From there, the vas deferens wraps around behind the bladder and then through the prostate gland where it enters into the urethra.

During a vasectomy, this tube is divided and sometimes a piece is removed.  The ends are then sealed off using some combination of either clipping or tying the ends, cauterizing (burning) them, and sometimes also burying an end under another layer of surrounding tissue.  These maneuvers are used to prevent the ends from growing back together again during the healing process. 

The goal of a vasectomy reversal is to surgically re-establish the flow of sperm from the testicle through the vas deferens.  Precise surgical technique is essential in order to prevent scar tissue from re-blocking the channel after a reversal, since the vas deferens is quite small, with an outer diameter of only 2-4 mm (in comparison, a standard #2 pencil has an outer diameter of 6-7 mm).  The walls of the vas deferens are thick and muscular so the lumen (the inside channel where the sperm travel) is significantly smaller, with a diameter of only 0.3-0.5 mm (in comparison, the thickness of a standard sheet of copy paper is 0.1mm).


Vas-to-Vas or Vas-to-Epididymis

There are two ways in which a vasectomy reversal can be performed.  One option is to attach one end of the vas deferens to the other, which is called a vasovasostomy (or “vas-to-vas” connection).  The scarred, blocked areas(where the vas deferens had been cut, tied, burned, etc. during the original vasectomy procedure) are removed during the reversal procedure so that fresh healthy tissue is brought together for optimal healing.
The other option is to connect the vas deferens to the epididymis, a procedure which is called a vasoepididymostomy (or “vas-to-epididymis” connection).  The epididymis is the structure that wraps around the side of the testicle, and is where sperm maturation takes place.  The epididymal tubules are smaller than the vas deferens, and therefore it takes less scar tissue to block them off.  A vas-to-vas connection has a higher chance of success, and is always performed if possible.

Choosing Vas-to-Vas or Vas-to-Epididymis

Until the time of the reversal, it is not known whether a vas-to-vas or vas-to-epididymis connection will be needed.  The decision is made by examining the fluid that comes from the end of the vas deferens going towards the testicle when it is opened during the reversal procedure.  A drop of this fluid is placed on a glass slide and examined under a tabletop microscope in the operating room.  Vasal fluid is checked individually on each side.  Favorable fluid (clear or thin and milky in appearance, sperm/sperm parts present) indicates that the connection flowing from the testicle to the site of the prior vasectomy is not blocked and a vas-to-vas connection can be performed.  However, if thick creamy fluid without sperm is found, then one of the delicate epididymal tubules has ruptured under the back-pressure.  An epididymal rupture typically does not cause any symptoms (such as pain) but does block the transport of sperm beyond the rupture site.  When this occurs, a vas-to-epididymis connection is needed, and the vas is attached onto the epididymis where sperm are again found in the epididymal tubules above the rupture site.  If the surgeon does not know how to perform a vas-to-epididymis connection in this scenario, then the procedure almost certainly will not be successful on this side.

The chance of needing a vas-to-epidiymis connection increases with the amount of time that has passed since the vasectomy was performed.   

Keys to Microsurgical Reversal Success

When working with such tiny structures as the vas deferens, meticulous surgical technique is absolutely essential so that the two ends line up perfectly.  This is to prevent excess scar tissue formation.  Using the latest microsurgical techniques, 24 micro-sutures are carefully placed on each side to precisely line up the two ends of the vas deferens.  The smallest micro-sutures used (in the inner layer of the repair) are 10-0 in size with a diameter of 0.02 mm (to compare, the diameter of a human hair is on average 0.04-0.12 mm). Obviously, an operating microscope is necessary to adequately visualize and work with these incredibly small sutures.  When working under an operating microscope, any movement by the patient looks like an earthquake, so to perform the precision surgery needed for optimal outcomes, the patient must remain absolutely motionless for the entire procedure.  The latest microsurgical techniques typically take an experienced microsurgeon about 2.5-3 hours to perform, a period of time for which it is not reasonable to expect someone to remain completely motionless if they are awake or under “twilight” sedation.  Because of this, outpatient general anesthesia is almost always used.

It is very common for men to have some reservations and nervousness about going under general anesthesia.  However, modern anesthesia techniques are very safe when performed under the careful monitoring of highly trained anesthesia providers, especially in otherwise healthy men.  The benefits of using anesthesia during a reversal procedure are very important in that patient comfort during the procedure is not an issue (you wake up and it is done) and the performance of precision surgery is optimized, as the man remains completely motionless during his surgery.

If the surgeon is doing a careful, two-layered microsurgical re-anastomosis, the reversal procedure takes approximately 2.5-3 hours of actual operating time. This is an outpatient procedure so there is no hospital admission involved.  After the procedure, men are sore for a few days but can typically stay comfortable with several days of light activity, oral pain medications, and icing the area for 48 hours.  People with desk-type work can typically return to work in 3-4 days.  Men with jobs in which they are on their feet most of time (but do not perform heavy lifting or strenuous activity) can usually return to work in 5-7 days.  Returning to exercise and jobs which require more strenuous activity usually requires 2 weeks before returning to work.  The most strenuous jobs (e.g. firefighters returning to full duty) is about 3 weeks.

What is Involved in a Reversal Procedure?

 

Follow up testing

Semen testing is performed 6 weeks following the procedure at your nearest local fertility lab, and then repeated every 10 weeks until pregnancy (which on average takes about 7 to 8 months for most couples). 

Semen analysis test results are faxed to Dr. Russell's office, and he will call you to review the results in detail. 

Dr. Russell feels strongly that close follow-up with regular phone calls (usually after getting semen analysis results) is very important to optimizing fertility outcomes after a reversal, and there is no charge for this.  The job of a reversal surgeon should not end when the reversal procedure is complete, but should last until the couple has successfully delivered a healthy baby. 

Dr. Russell’s fellowship training involved not just microsurgery, but also the broader field of male infertility, and he uses this knowledge to help couples develop ongoing strategies to maximize their chances of fertility success.