Fertility Following Vasectomy
Vasectomy is a very common form of birth control used in the United States. Approximately 5 percent of men who have had a vasectomy subsequently change their minds, however, and want to have more children in the future. The good news is that there are several options with high rates of success that men can pursue to have more children who are biologically related to them.
When a man has undergone a vasectomy for contraception, the testicles continue to make sperm, but these sperm are reabsorbed by the body, since they are blocked and have nowhere to go. Any man considering have children following a previous vasectomy should have testing to make sure that he has continued good sperm production, since this is important for good fertility outcomes. FSH blood testing is more than 90 percent accurate in predicting that sperm production is still good (see “Hormone Testing and Interpretation” for more information on FSH testing). As long as sperm production is still reasonable, then post-vasectomy men who wish to have children who are biologically related to them have two options: sperm extraction combined with IVF/ICSI, or microscopic vasectomy reversal.
Sperm Extraction Procedure
If sperm production is still good, then a sperm extraction procedure is generally highly successful in terms of obtaining enough sperm for use in fertility procedures; the success rate is 90 to 95 percent. The "Azoospermia" section of this website has detailed information on the various sperm extraction procedures under the heading “Management of Obstructive Azoospermia”.
Cost of a Sperm Extraction
There is a wide range of sperm extraction costs- the highest cost that I have personally seen in Ohio was around $8000. For reference, in my practice the total cost for a sperm extraction procedure is generally around $3,000 ($1,000 for the procedure, $1,000 for the facility fee and anesthesia, and $1,000-1,500 for the fertility lab fee to process, freeze, and store the sperm). Insurance does not cover the cost of the extraction procedure in most states.
How Can Extracted Sperm Be Used?
The key point to note with a sperm extraction is that the sperm cannot be used for intrauterine insemination, as extracted sperm are not mature enough to swim up the fallopian tubes and fertilize an egg naturally. The sperm need to be used in conjunction with IVF/ICSI, in which a single sperm is injected into each retrieved egg at the fertility laboratory (see "Female Fertility Treatments" for more information on IVF/ICSI). The average cost of an IVF cycle in Ohio is $12,000-13,000.
If you are interested in this route, then the first step is generally for the female partner to see an IVF doctor to make sure that she is a good candidate for IVF. The IVF doctor usually works with a local urologist to perform the sperm extraction procedure. Unlike vasectomy reversals, most men do not need to travel to find an expert in sperm extraction, as this is a much less technically demanding procedure. As mentioned before, FSH testing on the man is recommended to make sure that his sperm production is still good prior to proceeding.
Microscopic Vasectomy Reversal
A microscopic vasectomy reversal is the second option to have a biologically related child following a previous vasectomy. The advantages of a vasectomy reversal include the fact that the procedure part is limited to only the male (as opposed to the extraction/IVF route, in which both partners need to have invasive procedures), it allows for natural conception to occur, and it lets the couple try for more than one child if they want without the need for additional procedures.
The goal of a vasectomy reversal is to surgically reestablish the flow of sperm from the testicles to the urethra through the vas deferens. The vas is quite small, with an outer diameter of 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 yet, with a diameter of only 0.3–0.5 mm (in comparison, the thickness of a standard sheet of copy paper is 0.1 mm). The use of precise surgical technique is essential to prevent scar tissue from blocking the channel again after a reversal. If the surgeon is performing a careful, two-layered microsurgical reanastomosis, the reversal procedure generally takes approximately two and a half to three hours of actual operating time.
Vasovasostomy vs Vasoepididymostomy
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, or cauterized during the original vasectomy are removed during the reversal procedure, so fresh, healthy tissue is brought together for optimal healing.
The other option is to connect the vas deferens to the epididymis, a procedure that is called a vasoepididymostomy (or vas-to-epididymis connection). The epididymis is the structure that wraps around the side of the testicle; it is where sperm maturation takes place. The epididymal tubules are smaller than the vas deferens, and therefore they can be blocked off with even very small amounts of scar tissue. Therefore, a vas-to-vas connection has a higher chance of success, and is always performed if possible.
It cannot be known until the reversal procedure is under way whether a vas-to-vas or vas-to-epididymis connection will be needed. The decision is made by the surgeon, who examines the fluid that comes from the end of the vas deferens going toward the testicle when it is opened. A drop of this fluid is placed on a glass slide and examined under a tabletop microscope in the operating room; the vasal fluid is checked individually on each side. Favorable fluid (clear or thin and milky in appearance, sperm or sperm parts present) indicates that the path 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, it indicates that one of the delicate epididymal tubules has previously ruptured under the back pressure of the blocked sperm. An epididymal rupture typically does not cause any symptoms (such as pain), but it does obstruct the transport of sperm beyond the rupture site. When this occurs, a vas-to-epididymis connection is needed in order to bypass the area of epididymal blockage, and the vas is attached to the epididymis at a point where sperm are found above the rupture site. The chance of needing a vas-to-epididymis connection is greater if it has been longer since the vasectomy was performed. If the surgeon does not know how to perform a vas-to-epididymis connection when necessary, then the reversal procedure almost certainly will not be successful on the side that requires it.
The chances for sperm returning in good numbers (when performed by a fellowship-trained microsurgical specialist) depends on the type of connections that were needed at the time of the reversal:
1) Vas-to-vas on both sides: 90–95 percent
2) Vas-to-vas on one side and vas-to-epididymis on the other: 75–80 percent
3) Vas-to-epididymis on both sides: 55–60 percent
You may see higher success rates posted on some websites. There are two things to keep in mind when assessing quoted success rates. The first is that you have to trust that the surgeon is posting true numbers, as there is no independent fact-checking system. The numbers listed above match closely with the peer-reviewed scientific studies, with verifiable sources, that fellowship-trained specialists have published over the years in scientific journals.
The second point to consider is what a particular surgeon is defining as “success.” The numbers listed above refer to the chances of a man who has had a reversal getting back to relatively normal numbers of swimming sperm, where natural conception would be a likely event. Some websites will list success rates of 98 percent or higher, but when you look into the description of “success” (if there is one), it may be defined as any number of sperm returning to the ejaculate. If only a handful of sperm are present following a reversal, the doctor may count this as a statistical “success,” but it certainly would not be one in terms of a couple’s chances of conception.
Vasectomy Reversal Cost
The average cost for a microsurgical vasectomy reversal performed by a urologist in the United States is around $10,000, although this can vary significantly depending on the region in which you live (New York City is generally going to be more expensive than Des Moines, Iowa, for example). When seeking a reversal specialist, you should be able to find out what the price will be by contacting the doctor’s office (if it is not listed on a website). Be sure to ask about any additional costs beyond the surgeon’s fee. Sometimes financing options may be available. High-volume reversal specialists are often able to negotiate lower facility fee prices with a surgery center, resulting in lower overall prices. For example, the total cost for a vasectomy reversal at my facility in southwest Ohio is currently around $6,300 (this is the total combined cost, including the procedure, anesthesia, and facility).
Optional Sperm Freezing
At the time of a vasectomy reversal, sperm can be frozen and stored as backup for IVF in case the reversal procedure is not successful. Sperm can be obtained from the vas deferens or directly from the testicle. My preference is to harvest testicular sperm, since these are fresh, newly made sperm, as opposed to the potentially old, stagnant sperm found in the vas deferens. Costs vary, but there is generally an additional charge for the extra surgery center time as well as a charge from the fertility lab for processing and freezing the sperm. In my practice, I personally do not charge more for extracting testicular sperm at the time of a reversal. The extra anesthesia and surgery center time costs $350, and the local fertility lab charges about $800 to process and freeze the sperm. The storage fee for sperm is generally around $275 per year.
Choosing a Vasectomy Reversal Specialist
As described above, the first step for a man considering a vasectomy reversal is to have an FSH blood test done, to make sure that his sperm production is still good. Once it has been determined that sperm production is still good, the next step is to identify the physician with whom you would like to have the procedure performed. The initial reaction of some men is to go back to the urologist who did their initial vasectomy, especially if they had a good experience with that doctor. The problem with this approach is that although almost all urologists receive adequate training and experience in performing standard vasectomies, very few of them learn the latest, most specialized microsurgical techniques for vasectomy reversals.
Choosing your vasectomy reversal surgeon is probably the single most important factor contributing to successful outcomes. Unfortunately, some men face a difficult decision when trying to figure out whom they should choose to perform their reversal. While almost all doctors who offer the vasectomy reversal procedure describe themselves as “microsurgical experts,” only a small percentage of them have truly undergone advanced fertility microsurgical training. This section is designed to help you identify which doctors are true specialists in male fertility microsurgery.
There are basically three types of doctors who offer vasectomy reversal procedures:
1) Non-urologists. These doctors are the “bargain" vasectomy reversal doctors who market themselves extensively on the Internet. They are almost never urologists, but typically doctors who trained in other fields, such as orthopedics or general surgery. Without even looking into their background training, you can almost always identify these non-urologists by their offer of a very cheap reversal ($3,000 or less) under local anesthesia in their office. I strongly urge you to be wary of any non-urologists offering cheap reversals under local anesthesia, regardless of how persuasive their websites may appear.
2) General urologists. These doctors have completed basic urologic training and are very proficient at treating general urologic issues, such as kidney stones and prostate problems. General urologists have learned the skills to allow them to safely operate within the scrotum. However, the teaching of advanced microsurgical skills is typically quite limited during general urologic training, with very few learning the latest reversal techniques. Thus, while they are certainly more likely to be qualified to perform a vasectomy reversal than a non-urologist, without additional focused training most general urologists are still not optimally trained to provide the most effective procedure possible.
3) Fellowship-trained microsurgical specialists. These doctors are board-certified urologists who have completed further advanced fellowship training in order to master the latest, most effective microsurgical vasectomy reversal techniques. Less than 1–2 percent of urologists choose to complete a full one-to-two-year fellowship training program in microsurgery, so these specialists are rather few and far between. Nevertheless, they are worth seeking out in order to have the best odds for a successful vasectomy reversal. Additionally, they have had focused, formal training in male fertility issues, and their input can be invaluable in helping to optimize fertility potential following a reversal.
Some couples just look for the cheapest procedure possible, or are in the unfortunate circumstance of absolutely not being able to afford anything more than $3,000 (even with available financing options). If price is the only consideration, then such couples may be content with seeing a “bargain” non-urologist for a quick (one- to one-and-a-half-hour) reversal procedure under local anesthesia. A certain percentage of these cheap, quick reversal procedures will be successful, and a particular couple just might get lucky.
However, for couples who have the resources, the services of a true fertility microsurgical expert provide their best chance of having a successful reversal. A couple’s first attempt at a reversal always offers the greatest chance of success, as any subsequent attempts have more associated scar tissue as well as an increased risk of needing a potentially less successful vas-to-epididymis connection. This is to say that if a first attempt at reversal fails, a second attempt may be possible, but it almost certainly will be more challenging, and success rates will be lower than can be expected for a first try.
The good news is that there is an easy way to identify a true microsurgical expert: simply ask the doctor (or the doctor’s staff) if he or she is a board-certified urologist who has completed a one-to-two-year fellowship in male fertility and microsurgery. (The difference between a one-year fellowship and a two-year fellowship is not significantly clinically, as the extra fellowship year is generally spent doing research in a lab.) Do not be afraid to ask this very important question!
For couples interested in a more detailed information on how to identify a true microsurgical expert, a full explanation can be found by visiting my website at www.vasectomyreversalohio.com.