A vasectomy reversal which fails is an extremely disappointing — not to mention very expensive — experience. Patients are of course anxious to know why the surgery didn’t work — and what to do to prevent such failures, either on their first reversal, or especially when considering a redo after failed reversal.
Microsurgical vasectomy reversal is one of the most challenging operations in all of surgery, because of the extremely small size and delicacy of the structures being reconstructed. This is particularly true when the epididymis needs repair, where the wall of the epididymal tubule is only about 1/4 the diameter of a human hair.
Every surgeon who performs vasectomy reversal has some failures — if you find a surgeon who “guarantees” success, it is best to look elsewhere, as he or she is not being honest. Highly experienced reversal surgeons will, as expected, have the lowest failure rates — but its is important to determine the nature of even a good surgeon’s skills — in particular, their experience and success with epididymal reconstruction, which is far more challenging than uncomplicated vas-to-vas repairs.
Most well-trained and reasonably experienced reversal surgeons should achieve 90% or better success rates (that is, postop sperm counts in the normal range) in uncomplicated vas repairs. With current techniques, the success rate of epididymal reconstructions should approach 80-85% — but success rates like these require a great deal of experience with this very difficult repair. Less experienced microsurgical surgeons are generally more likely to achieve only 30-40% success on such repairs.
Some surgeons seem to blame the patient when the reversal fails, telling them that they formed “scar tissue” which blocked the reconnection. While this is occasionally true, it is far more likely that surgical technique, or failure to perform the correct surgery, are the cause of most reversal failures. Some surgeons promote the heavy use of anti-inflammatory medications and even steroids (such as Prednisone) after surgery, to prevent such “scarring” — despite the fact that there is no medical evidence for their benefit in reducing the failure rate of reversal surgery, and drugs such as Prednisone impair healing and increase the risk of infection, among other complications.
So why do reversal surgeries fail? In Dr. Finnerty’s experience of over 30 years of performing microsurgical reversal, they fail because of one of the following reasons:
♦ Technically poor repair: All non-microsurgical, and many microsurgical, vas-to-vas repairs fail because there is not a precise alignment of the vas, which results in leakage of sperm fluid, inflammation, and scarring. While technical failures can occur even with a very experienced microsurgeon, they are far more likely in less experienced surgeons. Repairs done with non-microsurgical techniques (loops) cannot be performed with sufficient accuracy to prevent this problem.
Epididymal repairs, because of the extremely small size and delicacy of the epididymal tubule, often result in technical failure by less experienced surgeons not comfortable with this demanding procedure.
♦ Inadequate blood supply to the vas: Many vasectomy techniques use cautery (using an electric current to coagulate the ends of the cut vas by heat). While small amounts of cautery pose no problem, extensive cauterization damages the blood supply to a long length of the vas. This damaged tissue may be subtle to detect at surgery and must be removed if proper healing is to occur. This type of failure usually results in some sperm being present early after surgery, with failure 3-12 months later.
♦ Failure to recognize and repair epididymal obstruction: This is very common in less experienced microsurgeons who are not comfortable with this very difficult procedure. Many surgeons skilled at repairing the vas with microsurgery are much less comfortable performing epididymal repairs for this reason, and often therefore perform vas-to-vas repairs when epididymal repair is a much better option. Note that the presence of a few sperm or sperm parts in the fluid found at surgery does not guarantee that there is no obstruction in the epididymis — a fact which many reversal surgeons do not consider.
♦ Extremely high epididymal obstruction: In some instances, obstruction after vasectomy occurs in the efferent ductules, which are delicate tubes which join the testes to the epididymis. In such cases, even epididymal repair may fail. Connecting the vas to the efferent ducts can be performed by an experienced surgeon, but is extremely challenging from a technical standpoint, and has a substantially higher failure rate even than epididymal reconstruction.
♦ Other infertility problems: In rare cases, failure is caused by other fertility issues. For example, I have seen a number of men fail who have been placed on testosterone replacement after surgery — which is a very effective form of male birth control, effectively stopping sperm production.
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