Reversing Vasectomy Reversal Thinking

You had your wings clipped and now you want more children. What’s a guy to do? Well that depends on who you ask.  Your choices include vasectomy reversal or sperm retrieval and assisted reproduction (IVF – ICSI).
Doctors who perform IVF – ICSI might say that vasectomy reversals don’t work. Doctors who do vasectomy reversals say that they do. Other doctors fall in somewhere in the middle and say that “younger” vasectomies are reversible but “older” ones are not. Again, what’s a guy to do?

Facts about Fatherhood after Vasectomy

To get a handle on this, let’s start with the irrefutable facts of the case:

  • Where does conception occur? Vasectomy reversal allows for conception in the bedroom, whereas it occurs in a fluorescent-lit laboratory test tube with IVF – ICSI.
  • Who pays? If insurance does not cover either approach, then vasectomy reversal is always cheaper than IVF – ICSI.
  • Who gets procedures? Reversal involves surgery on the man but not the woman. IVF – ICSI involves procedures on both partners. Good to know if you like sharing such things.
  • How quickly can we get pregnant? Time to conception is generally faster with IVF – ICSI than vasectomy reversal.
  • What is the risk of twins? The chance of having twins or higher multiples is 1% with vasectomy reversal (i.e. sex) and 40% with IVF – ICSI.
  • What is the risk of birth defects? The chance of having a child with birth defects is twice as high (10% vs. 5%) with IVF – ICSI compared to sex.

The Problem of the Older Vasectomy

As I appraise patients of these facts in my daily practice, it recently occurred to me that the issue of the “older” this or that surfaces a lot. I have published research that speaks to the relative performance of vasectomy reversal and IVF-ICSI with female partners who are less than 38 years old. I can also address the success of either approach in cases of older men. But there is much less information about the true reversibility of “older” (more than 15 years old) vasectomies.  Is there any truth behind the statement that older vasectomies aren’t worth reversing? I really needed to answer this question and so I put my research hat on to do it.
Probably the biggest issue with the “older” vasectomy is that, just like a tire that is continually being filled, a physiological “blow out” of the system is more likely to be observed at reversal. It’s not dangerous or anything, but it does mean that a more “involved” procedure, termed epididymovasostomy, is needed at reversal to restore connectivity and fertility. And, by the way, the epididymovasostomy is one of the hardest microsurgical procedures to perform well on this good earth. So, knowing more about how often “blow outs” happen as vasectomies age could be very informative for doctors and patients alike.
For 25 years the prevailing thought among surgeons is that the rate of “blow outs” increases linearly as vasectomies age. Published algorithms and nomograms confirm the thinking that, given enough time, every vasectomy will “blow out” and need an epididymovasostomy instead of a vasovasostomy to restore sperm counts and fertility. And, as epididymovasostomy success rates are not as good as simpler procedures at reversal, this means that vasectomy reversal success rates should indeed fall with vasectomy age.
But what if it’s not true? What if the occurrence of “blow outs” does not rise along with vasectomy age? If true, then older vasectomies would be much more reversible than previously thought. And the return of sperm counts should be higher in older vasectomies than one would think. Voila, this is precisely what our new research shows and will be presented at our annual international urology meeting in Atlanta tomorrow. I guess that I agree with Don Miguel Ruiz when he said: “It is always better to ask then to make an assumption.”

The Findings

Abstract: The Need for Epididymovasostomy at Vasectomy Reversal Plateaus in Older Vasectomies
Paulani Mui and Paul J. Turek, The Turek Clinic, San Francisco, CA
Most vasectomy reversals require vasovasostomy (VV) for successful repair. However, as the obstructive interval after vasectomy lengthens, so does the rate of epididymal obstruction and the need for epididymovasostomy (EV). Since spermatid counts are lower in testes with chronic obstruction due to vasectomy (Jarow et al, NEJM, 1985), we hypothesized that decreased sperm production associated with older vasectomy age could protect the system from epididymal blowout. With this in mind, we sought to better define how the need for EV changes with an obstructive interval after vasectomy.
In a retrospective review of consecutive vasectomy reversals performed by a single surgeon, the relationship between the type of reversal procedure was correlated with age of vasectomy and the age of the patient. An EV was performed in the presence of occasional sperm fragments with creamy fluid (Silber score 4 fluid) or complete vasospermia (Silber score 5).
Among 165 patients who underwent reversal and who had adequate follow up, 65 men had either unilateral (n=39) or bilateral EV’s (n=29) for an overall rate of 40% (65/165) of reversals. Among all cases, the mean patient age was 44 +/-7 years. Median vasectomy age was 10 years (range 1 to 37). The rate of needing either unilateral (EV/VV) or bilateral EV increased linearly over vasectomy ages 1-21 years, but plateaus off (combined rate between 56%-75% of cases) from vasectomy ages 22-37 years (Figure).
Although the rate of needing either unilateral or bilateral EV at vasectomy reversal increases with vasectomy age, this relationship does not remain linear throughout all vasectomy ages. The rate of EV actually plateaus after 22 years of vasectomy, suggesting that down regulated sperm production or sufficient storage capacity exists to protect some older vasectomies from “blowout.”