The technical success rates and fertility rates for vasectomy reversal listed her are actual statistics from Dr. Finnerty’s nearly 30 years of experience in microsurgical vasectomy reversal. It is increasingly evident, however, that they are no longer an accurate indicator of success or fertility rates using current knowledge about the role of the epididymis in infertility, and in light of current techniques of epididymal reconstruction and understanding of the physiology of the epididymis after vasectomy.
Despite using microsurgical technique, epididymal repairs as recent as 5-10 years ago produced only fair success rates — often 50% or less — even in experienced hands. As a result, there developed a philosophy of reconnecting the vas even in cases where epididymal obstruction might be present, as the technical success rates for uncomplicated vas-to-vas repairs was far better than those of epididymal repair.
The decision-making process for determining whether an epididymal repair was necessary was as follows: when the vasectomy site was removed, the sperm fluid was then examined, both on visual appearance and the presence of sperm on microscopic exam. If any sperm was present — even degenerating sperm heads or sperm parts — a vas-to-vas repair was performed, on the assumption that the epididymis was not obstructed. Even if sperm was not found, but the sperm fluid appearance was clear or milky, there was assumed to be no obstruction and vas-to-vas repair was performed.
The length of time after vasectomy also played a major role in the decision about which type of repair to perform: epididymal obstruction was thought to be virtually unheard of in men who were 5 years or less from vasectomy, and was thought to be very rare in men less than 10 years from vasectomy.
Sperm passage through most of the epididymis has also been thought necessary for full sperm fertility to be achieved. Therefore, when an epididymal repair was performed, it was always done as far away from the top of the epididymis, where the sperm enter, as possible.
Virtually all of these assumptions have proven false.
The development of a highly reliable technique for epididymal repair — the intussusception technique — has encouraged a more thorough evaluation of epididymal obstruction. In Dr. Finnerty’s experience, he has found the following facts:
♦ Epididymal obstruction is far more common, and occurs much earlier, than originally thought.
A significant percentage of men who were originally thought to be unobstructed have partial or total epididymal obstruction. This often occurs only on one side, resulting in acceptable technical success rates when vas-to-vas repair is performed, but often resulting in lower counts and poor fertility.
♦ Epididymal obstruction is common even in men only a few years after vasectomy.
Dr. Finnerty has found this problem in many men less than five years from vasectomy — some only a year or two later. Many of these men still have sperm present at the vas site, and therefore appear to be unobstructed unless the epididymis is directly examined. Dr Finnerty also believes the growing popularity of cautery vasectomy (also known as the “no-scalpel vasectomy“) has led to an much higher incidence of early epididymal obstruction.
♦ The presence of sperm at the vasectomy site does not prove that the epididymis in not obstructed.
Dr. Finnerty has seen many cases where sperm was present in the fluid at the vasectomy site, but epididymal obstruction was present. Intact sperm can be found for many months — perhaps even several years — after an obstruction occurs, trapped between the vasectomy and the blockage in the epididymis. The sperm found in such a situation will never be motile, however — and often there are degenerating sperm, and many inflammatory cells. When the epididymis is inspected in such cases, active, motile sperm will be present above the obstruction, and far fewer, degenerating sperm present below that point.
Intact, non-motile sperm is often present in the vas fluid when partial obstruction of the epididymis is present. In such cases, repairing the vas may lead to success — as decompressing the epididymis by reversing the vasectomy my resolve some partial obstructions. In many such cases, however, postoperative sperm counts and motility are poor, and even when they recover often take many months or years before pregnancy can be achieved — if ever.
The presence of motile sperm at the vasectomy site is a good indicator that no obstruction is present, however.
♦ Motility and fertility of the sperm in the proximal epididymis after vasectomy is excellent.
In the normal, non-obstructed epididymis, sperm does not achieve motility and fertility until it has passed through most of the epididymis; sperm in the proximal epididymis (near where it leaves the testes) is poor. After vasectomy, however, changes occur in the epididymis which result in fertility development in the very first portion of the epididymis. Vasoepididymostomy (vas-to-epididymis bypass) performed in the proximal epididymis will result in sperm counts after surgery with much better motility than repairs in the distal epididymis — or even vas-to-vas repairs where no obstruction is present. Not all epididymal repairs need to be done in the proximal epididymis, of course — but motility results are significantly better when the repair is done at a level where motile sperm are present.
It is important when choosing a reversal surgeon, therefore, that you choose someone with extensive experience and expertise in microsurgical epididymal repair.
- Dr. Silber on vasectomy reversal and epididymal obstruction.
- Effects of obstruction on epididymal sperm and function
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