Second Attempt After Unsuccessful Vasectomy Reversal

Success rate for vasectomy reversal is generally reported in two ways: sperm recovery rate (patency success rate) and pregnancy rate. Patency rate refers to the likelihood of the vas deferens remaining open and providing unobstructed flow of sperm cells. High patency rate means that flow is unobstructed and sperm has a high likelihood of returning to the seminal fluid. Pregnancy rates are always lower than patency rates, as there are multiple factors that affect pregnancy.

The single most important factor in whether a vasectomy reversal procedure will be successful is the interval in time (years) between vasectomy and vasectomy reversal. Primary failure after a vasectomy reversal means no sperm is seen in the post semen analysis tests. If the sperms showed up in the initial semen analysis after the procedure, but is not seen in the follow up semen analysis, it is called secondary vasovasostomy failure.

If you have been frustrated and disappointed with an unsuccessful vasectomy reversal, you may want to ask a microsurgeon whether another attempt might be worth it.

In general, first-time vasovasostomy failures often occur in patients that are more prone to develop heavier scars, which can narrow at the location of the reversal. In some cases, the tissue in the ends of vas deferens could be dead due to ischemia. Other reasons include an undetected epididymal blockage and epididymal dysfunction. Of course, the surgeon’s experience and techniques matters. This is why it is particularly important to choose your surgeon carefully. The success rates for a second reversal are slightly lower than for first-time procedures.
Second-attempt Vasectomy Reversal Techniques

If the patients showed evidence of healthy sperm in their seminal fluid during the first reversal procedure, or had the positive result in the initial semen analysis, they are probably the good candidates for a repeat vasectomy reversal When the vas deferens appears healthy and doesn’t have a lot of scar tissue from the previous procedure, a surgeon will usually do another vasovasostomy, and the chances of a successful second attempt are fairly good.

If the vas fluid is not favorable and no sperm was seen, if the first reversal left the vas deferens too short, if injury to the vas deferens is more extensive, or if a surgeon believes that the epididymis is scarred or blocked, a vasectomy reversal re-do becomes more complicated. In some cases, the more effective approach is a vasoepididymostomy, which is a more complex procedure than a vasovasostomy. Dr.Shu doesn’t perform vasoepididymostomy, but he will refer you to see a urologist who performs vasoepididymostomy. In other cases, however, there are a number of effective alternatives to vasectomy reversal that are worth investigating, such as In vitro Fertilization (IVF), donor sperms, and adoption.

Still not Pregnant after Vasectomy Reversal? | Minnesota

Few things are more disheartening than months and months of negative pregnancy tests. You talked with your husband, and you both agreed that you wanted children. He got vasectomy reversal for you, but a year later you still aren’t pregnant. It may seem frustrating, but you shouldn’t lose hope without knowing all the facts.

You won’t get pregnant immediately

This cannot be said enough. If there is no sperm in the ejaculate six months following a vasovasostomy, the reversal is said to have failed. Even if there is sperm, that doesn’t guarantee pregnancy. It can take months for a man to return to a normal sperm count. Once sperm has been detected it still takes time for sperm number and motility to reach normal levels, and this time can vary from person to person.

Conception

Getting pregnant takes patience. It is generally known that most men produce millions of new sperm every day. However, you might not know that these new sperm take about 2 ½ – 3 months to fully mature or that when sperm are initially formed they lack the ability to swim forward or fertilize an egg. It can take a couple of these cycles for sperm to regenerate. Even at this point it can take another 6 months for conception to occur. It’s important to remember that getting pregnant within months of a vasectomy reversal is not the norm. We do have a few patients who got pregnant in 2 months after vasovasostomy in the past few years.

To monitor progress, a sperm sample will be taken 6 weeks after the procedure. Follow up tests will occur every two months after the initial test. This way we can see whether sperm has returned and at what level. Once sperm count has reached reasonable or normal levels, pregnancy usually occurs within 6 months of having timed intercourse- that is, having intercourse every other day from four to five days before and after ovulation. If this does not occur, it’s possible the issue may be due to fertility in the other partner.

How is Easy Vasectomy Reversal® (Vasovasostomy) Done without a Needle? | Minnesota

General anesthesia or intravenous sedation is needed in the traditional vasectomy reversal since a traditional approach to vasectomy reversal is to make two big incisions in each side of scrotum. Easy Vasectomy Reversal® with modern no scalpel technique and single mini incision reduces the trauma and pain, therefore, general anesthesia or intravenous sedation is no longer needed in the vasectomy reversal procedure (vasovasostomy).

Conventional needle anesthesia in vasectomy Reversal involves the use of a 27 gauge needle to raise a wheal at the skin of scrotum; it is then advanced to both ends of the vas on each side where further anesthetic solution is deposited. Since the opening is so small in the no-scalpel Easy Vasectomy Reversal®, it is easy to apply anesthesia without the use of needles. A spray applicator (MadaJet®) delivers a stream of anesthetic so fine that it penetrates the skin and diffuses to a depth of about 3/16 of an inch, enough to surround and anesthetize each end of vas tube in turn as it is lifted into position beneath the skin, attaining a close to 100% efficacy rate with no need for supplemental anesthetic in the initial vas grabbing.

The tiny opening in the dime-sized area of numb skin is made with a pointy hemostat: one tip makes a pinpoint opening, then the two tips are used to spread and enlarge the opening to about 1/3 of an inch. Since blood vessels in the skin are spread apart rather than cut, bleeding is less than when a scalpel is used.

MadaJet_2

MadaJetSprayApplicatorMadaJet

Once the vas ends are grabbed and lifted up, the complete local anesthesia is achieved by giving additional anesthetic with a fine needle, usually with no pain at all because of the partial anesthesia achieved with the MadaJet.

How is the Easy Vasectomy ReversalⓇ Done without a Scalpel? | Minnesota

The patients always wonder how the Easy Vasectomy Reversal is performed without a scalpel. This blog explains it.

No-scalpel vasectomy instruments were originally developed by Dr. Shungiang Li, in China in the mid-70’s and introduced into the United States in 1989. Many years ago, Dr. Steven Shu innovatively improved his surgical techniques on vasectomy reversal procedure (vasovasostomy) by using the same principles and no-scalpel instruments.

A vasectomy reversal (vasovasostomy) is a microsurgical procedure that reconnects the vas deferens where it was interrupted by a vasectomy. A traditional approach to vasectomy reversal is to make two big incisions in each side of scrotum. Over the past decade, more surgeons adopted a single incision in the middle of the scrotum. In order to further reduce the trauma, the recovery time, the operative time, and the postoperative complications, the mini incision vasectomy reversal approach was proposed. Similar to no-scalpel vasectomy, the initial mini-incision is created using a sharp penetrating forceps that spreads the tissue apart instead of cutting it with a sharp scalpel.

hemostat_2

ring clamp_2

Dr. Shu uses two important no-scalpel instruments to perform the vasectomy reversal procedure. They are simply a very pointy hemostat, used initially to make a tiny opening into anesthetized skin of the scrotal wall, and a ring clamp, used initially to secure each vas tube in turn beneath this opening.

The refined techniques of no-scalpel Easy vasectomy reversalⓇ minimize trauma, pain and complications. The introduction of no-scalpel Easy vasectomy reversalⓇ has successfully allayed many men’s fears with regard to the scalpel.

Understanding Male Infertility

Infertility, simply put, is the inability to conceive children. There are several causes for male infertility: low sperm count, low sperm motility, and poor sperm morphology. Each of these can make conception difficult. Each of these can be a result of genetics or environment. These days, it seems like the list of things that’ll give you cancer or a disease is increasingly long and confusing, so I’ll try to make it simple.

Low sperm count is simply the lack of sperm of in semen. A lot of this is caused by environmental factors such as excessive alcohol and drug abuse, sexually transmitted disease and infections, exposure to toxins, hazardous chemicals, and radiation. These can be usually be avoided by taking the proper precautions. Not to mention the many other negative side effects that accompanies them. Low sperm count can also be influenced by exposing the testicles to high heat (from a fever), and genetic causes such as Klinefelter’s syndrome, or cystic fibrosis.

Abnormal sperm refers to sperm that is not a normal shape and is thus unable to swim or function normally, preventing conception. This can be caused by testicular inflammation, twisted or swollen veins in the scrotum, exposure to heat, as well as environmental influences such as exposure to toxic chemicals.

Infertility can also be caused by other issues such as premature ejaculation, retrograde ejeculations, erectile dysfunction, and other structural problems related to the male reproductive organs. Although men do not suffer the same loss of fertility that women do with age, men past the age of 70 may exhibit decreasing sperm quality. Many medical conditions such as diabetes, HIV, thyroid diseases, organ failure, heart attack, and anemia can cause infertility as well.

Various drugs can also cause infertility, including: steroids, cimetidine (Tagamet), sulfasalazine (Azulfidine), salazopyrine, colchicine, methadone, methotrexate (Folex), phenytoin (Dilantin), among many others.

Vasectomy is obviously a common reason for male infertility.

The best way to treat male infertility will be different for everyone. Obviously, preventative measures such as moderating drug, tobacco, and alcohol abuse, avoiding working with toxic or radioactive materials, using protection, and limiting sexual partners. Other solutions will depend mostly on the cause- like treating ejaculation issues or a disease that is causing infertility. The vasectomized patients may consider the vasectomy reversal procedures to restore their fertility.

Robotic Vasectomy Reversal- The future of vasectomy reversal? | Minnesota

Vasectomy is the most effective method of male contraception, with an estimated 500,000 vasectomies per year and rising. Naturally, as divorce rates have been steadily increasing, there has been a corresponding increase demand for vasectomy reversals. This poses some challenges- while vasectomies have become increasingly simple, quick, cheap, and noninvasive with techniques such as no-scalpel vasectomy, vasectomy reversal is still a relatively complicated microsurgical procedure that requires time, skill, concentration, and money. To give you an idea, the opening of the vas deferens (the tube which carries sperm to the semen) is 0.1mm wide, about as wide as a human hair. Knowing that, it makes sense why vasectomy reversals are harder than vasectomies; it’s a lot easier to cut it in half than stitch it back together. That’s not to say vasectomy reversal isn’t effective as it is now. Patency rates (moving sperm) have risen from 5-30% to 85-90% today with the advent of microsurgical techniques.

How can it get better?

Of course, vasectomy reversals aren’t always perfect. As time goes on, the chance of pregnancy goes down considerably. Also, the procedure is time-consuming and highly dependant on a physician’s skill. Robotic surgery is an exciting alternative that could theoretically mean a higher patency rate if there are no other complicating factors. Robotic surgery also theoretically has several potential advantages:

Smaller incisions- Little robot arms are a lot smaller than a doctor’s hands. Also means less scarring.
Visualization- Robots mounted with cameras can give detailed magnified images that the eye could not resolve
Pain- Robotic surgery is usually less painful and likely to develop complications
Time- Robotic surgery has the potential to be much faster than hands.

What does the research say though?

There have been vasectomy reversals that have been performed using robotic-assisted vasectomy reversal, but so far it does not offer a lot of advantages. Studies have given different results, but on average, robotic-assisted vasectomy reversals take just as long and are equal in patency rates. With no significant advantages over a regular vasectomy reversal, it’s not worth it for most hospitals and doctors to spend a lot of money on expensive robotic-assisted surgery equipment. However, that doesn’t mean robotic-assisted vasectomy reversals should be discounted. The technology is still in its infancy; who knows where it might be in 20 years down the road. As robots and AI get more advanced, operating time, precision, and effectiveness should increase, and the physical role of the surgeon will go down- not just for vasectomy, but all surgical procedures. It’ll be a while before that happens though. Your best bet right now is the tried-and-true vasectomy reversal, done by your local human doctor.

Effects of Anti-sperm Antibodies in Patients with Vasectomy Reversal | Minnesota

What are Anti–sperm Antibodies?

An antibody is a blood protein produced by your body’s immune system in response to the stimulation of a specific antigen. Common antigens include multiple antigens in bacteria, viruses, cancer cells and foreign substances in the blood. The antibodies combine chemically with antigens and serve to help the body target and fight-off theses “dangerous” or “unwanted” cells or substances. However, it is possible for antibodies to work against the body’s own cells; such is the case in many autoimmune diseases. In cases of vasectomy, especially after long periods of time after the surgery, it is possible for the body to form antisperm antibodies. This is a concern for many patients seeking vasectomy reversal.

This is normally not a problem with sperm cells as they technically not in the body, in the same sense that the inside of our digestive tracts are not considered to be inside the body. Sperm is created in the testes, transported by the vas deferens, mixed with seminal fluid, and exits the body during ejaculation- at no point does sperm ever contact blood, as direct contact is prevented by the testes/blood barrier.

When the blood-testis barrier is compromised under certain circumstances, such as trauma/surgery, infection, cancer and congenital defect, sperm could be exposed to blood and trigger the immune responses, which leads to antibody development. Development of anti-sperm antibodies after vasectomy is thought to be related to the breakdown of the blood-testis barrier and leakage of sperm antigens from the epididymis. For this reason, the body may treat sperm as a foreign pathogen, creating antibodies that correspond to the antigens on the surface of the sperm cell. A vasectomy, especially if a long period of time has passed since the procedure, can result in higher concentrations of anti-sperm antibodies.

Antisperm antibodies are found in between 8% and 21% of men in the general population, 9% and 36% of infertile patients, and 70-100% of men after vasectomy. Studies have provided convincing evidence that a vasectomy does not lead to development of autoantibodies in men other than anti-sperm antibodies, and there is no evidence of any immunologic or other diseases related to development of anti-sperm antibodies following vasectomy.

What is the Relationship of Anti-sperm Antibodies with Vasectomy Reversal Procedures?

Antisperm antibodies can affect fertility in the male if they are in high concentrations. Fertility loss can come at varying degrees; the more antibodies one has, the lower fertility will be. B- immune cells create multiple types of sperm antibodies. Some antibodies will cause sperm to stick together, forming large clumps that hinder mobility of the sperm. Other antibodies act as a “flag” for natural killer cells, and others can even bind with the antigens on the surface of the egg in the womb, causing its destruction.

How Anti-sperm antibodies affect fertility following vasectomy reversal is not clear. While 79% of men that are tested after a vasectomy have elevated antisperm antibodies, the levels at which they are present are not significant enough in most men to cause a significant drop in fertility. Most experts, including those from the American Urological Association, agree that there are rarely significant long-term side effects that arise from vasectomy.

The practice guidelines of the American Society for Reproductive Medicine and the Society for Male Reproduction and Urology stated:

“Overall postoperative conception rate (following vasectomy reversal) is relatively high (50% to 70%) and the presence of antisperm antibodies does not correlate closely with postoperative fecundability. Consequently, the value of preoperative antisperm antibody testing remains controversial and unproven.”

Here is a summary of research evidence:

1) Despite almost all men having detectable antibodies following a vasectomy, two thirds of vasectomy reversals are successful in achieving a pregnancy.
2) The presence and levels of antibodies following vasectomy reversal inconsistently predicts what couples will be successful in achieving a pregnancy.
3) The subjects of most research were infertile men. Research data from fertile men is lacking.
4) Testing for sperm antibodies is not well standardized. There are different types of antibodies and different locations in the sperm. The influences from each antibody are unclear.

Why do Vasectomy Reversals Fail? | Minnesota

First, it’s important to distinguish patency rate and pregnancy rate. Patency rate refers to the likelihood of the vas deferens remaining open and providing unobstructed flow of sperm cells. High patency rate means that flow is unobstructed and sperm has a high likelihood returning to fluid. Pregnancy rate refers to likelihood of pregnancy. Pregnancy rates are lower than patency rates, as there are multiple factors that affect pregnancy.

One reason is abnormal sperm quality. Some men might just have low sperm quality to begin with, which a vasectomy reversal alone would not be able to fix, no matter how unobstructed the vas deferens is. Options for those wanting to have children with this condition include IVF or a trial of steroids and lycopene supplement.

Another common reason for failure is anti-sperm antibodies, which immobilize sperm. These antibodies are typically found in the blood, so it is not common to find it in seminal fluid. Studies suggest 8-21% of men that have not had a vasectomy have anti-sperm antibodies in their fluid. By contrast, studies on vasectomized men show that 50-80% of men develop concentrations of these antibodies after the first year post-vasectomy. It is unclear how much this affects fertility after a reversal, as there have not been many studies done that confirm it, and there is not a surefire method of testing for antibodies in the semen either.

Another possibility is simply scarring, which is not uncommon but possible as a result of vasectomy reversal. It can be treated with anti-inflammatory medication and/or repeat of the procedure. Even if none of these affect you, those who have had vasectomies for a very long time may experience epididymal dysfunction (e.g. the ability for sperm to move through the epididymis), which will either clear up on its own, or may require that you use IVF.

Finally, many times it is the female partner that results in low pregnancy rates. Women over 35 experience a drop in fertility, which may be one reason why there is a discrepancy between patency and pregnancy rates.

Microsurgical Vasovasostomy | Minnesota

Microsurgery involves the use of an operating room microscope or surgical loupes (magnifying glasses) to conduct very small scale operations on the body. Microsurgical reconstruction of tissue is often a complex and very technical procedure. In the early 1900s, Carrel and Guthrie pioneered microsurgery techniques through experimental procedures on animals, replanting and transplanting tissues and organs such as amputated limbs, and kidneys. The first use of optical magnification was recorded in 1921, where a monocular microscope was used for ear surgery by Nylen. It was during this time period microsurgical instruments, operating microscopes, and other advancements in medical technologies paved the way for microsurgery.

Advancements in vasectomy reversal closely mirror those in other procedures in well. The first successful vasovasostomy was in 1919, although its efficacy was questionably. By 1948, 18% of urologists had tried it, and the success rate was only 40%. The first microsurgical vasectomy reversal took place in 1971, by Owen. The next big advancements came in 1977, with the development of 2-layer and modified microsurgical suture techniques. The patency rate has rose to more than 90% with these advancements if vasectomies are done with nine years. Microsurgery continues to see advancements every year. Robots with hands far steadier than any human now have the capacity to perform operations as small as vasectomy reversal.

Ultimately, microsurgery is a powerful contemporary surgical technique with many different applications, not least of which is vasectomy reversal. It is because of microsurgery and its advancements that effective vasectomy reversals are possible, now with minimal pain or downtime at Procedure Clinic. It will be fascinating to see what this procedure could look like many years into the future!

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