How Successful Is Vasectomy Reversal?

With advances in microsurgery, the success rate for vasectomy reversal has increased dramatically, with up to 97% of people achieving patency (unobstructed sperm delivery) if performed within three years of their vasectomy. Even for people who had undergone a vasectomy 15 or more years ago, patency rates hover around 71%.

The success rate varies not only by how many years ago you had the vasectomy but also by the type of reversal surgery you have had (vasovasostomy vs. vasoepididymostomy).

This article explains how vasectomy reversals are done, the factors that influence success rates, and what to expect if you decide to undergo the procedure.

Does Vasectomy Reversal Always Work?

Vasectomy reversal is very effective, but it is not infallible. Many factors can influence the success rate, not only in terms of patency but, more importantly, in terms of achieving pregnancy.

A 2016 review in the Asian Journal of Andrology cited factors that influence success rates, as follows:

• Obstruction interval: This is the period of time between the vasectomy and reversal. Studies have shown that patency rates tend to be higher with obstruction intervals of less than five years compared to obstruction intervals of more than 10 years.
• Pre-vasectomy fertility: Generally speaking, if a person had fertility problems before undergoing a vasectomy, they are likely to have fertility challenges even after undergoing vasectomy reversal.
• Partner fertility: Having a female partner over age 40 decreases the likelihood of pregnancy after vasectomy reversal. The odds may be higher if the female partner was previously pregnant.
• Surgeon competency: Studies suggest that surgeons who perform more than 15 operations per year have higher patency rates than those performing less than six (87% vs. 56%, respectively).
• Surgery choice: Vasovasostomy is statistically more effective overall than vasoepididymostomy. With that said, vasoepididymostomy is a more technically demanding procedure reserved for difficult cases when there is an obstruction that affects sperm quality or count.
  

It's important to note that achieving patency after the reversal doesn't necessarily mean you will induce pregnancy. Older age and other factors may influence your ability to conceive with a partner, without regard to the success of the procedure itself.

Research from the landmark Vasovasostomy Study Group found that while 97% of people are able to achieve patency within the three-year obstruction interval, only 76% are able to conceive. After 15 years, the patency rate of 71% translates to a pregnancy rate of only around 30%.

Vasectomy Reversal With Vasovasostomy

Vasovasostomy (VV) is a surgical technique pioneered in 1971 that reconnects the cut ends of a tube called the vas deferens following a vasectomy. The vas deferens is the passage that connects the epididymis (where sperm is stored after leaving the testicle) to the ejaculatory ducts, where fluids are mixed in to create semen.

VV is the preferred option when there are viable sperm inside the vas deferens. This is determined during the surgery when fluids are extracted and examined under a microscope.

Viability is described by a grading system called the Silber scale that rates sperm quality, as follows:

• Grade 1: Normal motile (movable active) sperm
• Grade 2: Mainly normal nonmotile sperm
• Grade 3: Mainly sperm heads with no tails
• Grade 4: Only sperm heads
• Grade 5: No sperm

VV requires less technical skill and is generally pursued with grades 1 through 3 when there are no blockages in the vas deferens.

Vasectomy Reversal With Vasoepididymostomy

A vasoepididymostomy (VE) is a more complex surgery that connects the vas deferens directly to the epididymis. It is generally pursued when a blockage within the vas deferens prevents sperm from leaving the epididymis. The blockage, in turn, affects sperm quality and numbers.

The epididymis is a long, coiled tube where sperm go to mature after leaving the testicle. It is situated on the back side of each testicle and housed with the testicle inside of a sac called the tunica vaginalis.

A VE is performed by opening the tunica vaginalis and finding the best place to connect the vas deferens to the epididymis. With the flow restored, the sperm count and quality can often improve to where conception is possible.

A vasoepididymostomy is generally reserved for Silber scale grades 4 or 5, when there has been a prolonged obstruction interval.

Vasectomy Reversal Procedure

A vasectomy reversal is a specialty surgery performed with high-powered microscopes. It is typically performed on an outpatient basis by a surgical specialist known as a urologist. It can be done in a hospital or specialty surgical facility.

The reversal is most often performed bilaterally (on both sides), although some cases may be done unilaterally (on one side) if damage to one side is irreparable. Sometimes, a VV is performed on one side, and a VE is performed on the other.

The reversal can be performed under local anesthesia (which numbs the surgical site), though general anesthesia (which puts you to sleep) is generally preferred if there is a likelihood of a VE (such as for a person who had a vasectomy 15 or more years ago).

If general anesthesia is used, you must stop eating or drinking at midnight before your procedure. Certain drugs, such as bloody thinners and aspirin, must also be stopped one to five days beforehand.

Before Vasectomy Reversal

Before undergoing vasectomy reversal, the urologist will perform tests and evaluations to aid medical decisions. These include:

• A review of your medical history: The urologist will want to know when your vasectomy was performed, if any complications occurred, and whether you have any condition that might impede access to the vas deferens (like prior pelvic surgery or a history of groin hernias).
• A physical examination: The urologist will check for signs of hypogonadism (low testosterone), such as small testicles, and signs of poor sperm production, such as soft testicles. You will also be checked for hardened masses called sperm granulomas that can block the vas deferens.
• An evaluation of the female partner: This is to ensure that there are no fertility issues in the female partner that make the reversal unnecessary. Generally, females over 35 should be offered fertility evaluation.

No blood or imaging tests are needed before surgery unless there are particular concerns. If hypogonadism is suspected, blood testosterone tests may be ordered. If a vas deferens blockage is suspected, a magnetic resonance imaging (MRI) scan may be performed.

During Vasectomy Reversal

Vasectomy reversal is performed in a procedure room. You will be asked to undress and offered a hospital gown. Your pubic hair will be shaved, and an antiseptic will be applied to the surgical site.

Once anesthesia is administered, your vital signs will be monitored (including blood pressure, blood oxygen, and respiration rate) until the surgery is complete and you are safely in recovery.

While there are variations in surgical techniques, vasectomy reversals tend to follow a standard, step-by-step procedure, such as the following:

1. A small incision is made in the middle (or sides) of the scrotum.
2. Both ends of the severed vas deferens are extracted with forceps. The ends are snipped.
3. Fluids from the end nearest the testicles are retrieved and examined under a microscope.
4. If viable sperm are found, a vasovasostomy can be performed by stitching the cut ends of the vas deferens together with sutures that are finer than a human hair.
5. If no viable sperm or fluids are found, a vasoepididymostomy can be performed. This may require the surgeon to make the scrotal incision larger to extract the testicle. The testicle is extracted and a cut made in the tunica vaginalis to expose the epididymis. After an appropriate connection site is found, the end of the vas deferens nearest the penis is fed through a hole in the tunica vaginalis (to help stabilize it) and stitched to an opening in the epididymis. The tunica vaginalis is then stitched shut, and the testicle is replaced.
6. The exterior wound is closed with sutures.
7. The procedure is repeated on the other side through the same incision or separate scrotal incision.
   

A reversal generally takes anywhere from 2.5 to 4 hours to complete, although complicated cases can take longer.

Post-Op Instructions

Once you are wheeled into the recovery room, you will be monitored by a nurse until you awaken. A snack or juice may be provided. You will likely feel woozy or light-headed and feel pain or pressure at the surgical site. If you feel nauseous, let the nurse know so that an antinausea drug can be given.

Once you are relatively steady, care instructions will be provided by the surgical team. An over-the-counter painkiller like Tylenol (acetaminophen) may also be given.

You will need someone to drive you home. Check in advance with the nursing staff, as some facilities do not allow a ride-sharing service, such as Uber or Lyft, to take you home.

Healing From Vasectomy Reversal 

After surgery, you may have pain in the groin area for one to three weeks. Your scrotum (ball sac) and groin may also be bruised and swollen, but these should go away in one to two weeks.

First 24 Hours

Lie down as much as you can for the first 24 hours, and avoid showering until the next day. When you do shower, try not to soak the wound. Pat the incision dry. Do not take a tub bath for at least five days.

You can manage pain for the first 24 hours by applying a cold compress to the groin for 10 to 15 minutes several times a day.

Tylenol can also help, but avoid using nonsteroidal anti-inflammatory drugs (NSAIDs) like Advil (ibuprofen) without first speaking with your care team, as NSAIDs can promote bleeding.

Next 1 to 4 Weeks

Avoid heavy lifting for at least two weeks, including groceries and small children. During this time, wear a jockstrap or briefs to support the testicles.

Refrain from strenuous exercises for four weeks, including jogging, weight lifting, cycling, or aerobics. Sex should also be avoided for two weeks.

You should be able to return to work or daily activities in about a week or so. People whose job involves physical labor may need to wait longer. Ask your care team when it is safe to drive.

Follow your surgeon's wound care instructions, keeping the wound dry and clean to prevent infection. If you have strips of tape on the wound, called Steri-Strips, leave them on for a week or until they fall off.

Your surgeon may have you start to ejaculate daily at one to two weeks post-surgery.

At Vasectomy Reversal Follow-Up

Your surgeon will schedule a follow-up appointment in one to two weeks to see how the wound is healing and to remove the stitches.

A semen analysis (SA) is usually performed six to eight weeks after the surgery. This involves masturbating and ejaculating into a cup and having the contents examined under a microscope. This is repeated every three months until there is quality sperm in your semen or pregnancy is achieved.

For the vast major of people who undergo reversal surgery, sperm will be seen by the third month.

Sperm Count and Fertility After Vasectomy Reversal

As with a vasectomy, a vasectomy reversal neither affects your libido (sex drive) nor any of the physiological responses involved with getting or maintaining an erection.

For people seeking children, the aim of the reversal is to increase the sperm count to where conception is achievable. Around 20 million sperm cells per milliliter of semen (m/mL) is sufficient, although the ideal range is between 40 and 300 m/mL.

If semen quality is less than expected after initial testing, an NSAID like Advil may be recommended to ease inflammation that may be blocking the passage of sperm in the vas deferens.

If the surgery fails to improve sperm counts, repeating the surgery may be a reasonable option. This is because nearly half of all failures involve people who would have benefitted from VE but were given a VV instead. Some studies report success rates as high as 87.5% when VE is used the second time around.

If repeat surgery is not an option, testicular sperm extraction (TESE) may be recommended. This involves the retrieval of sperm from the epididymis or testicles, which can then be banked for future use in assisted fertility techniques (like in vitro fertilization).

Where to Have Vasectomy Reversal

Many hospitals and urology practices offer vasectomy reversal. Highly technical surgeries like VE have become more commonplace and are today considered a standard of care in many urology units.

Therefore, it's important to ask not only which types of reversal procedures a urologist is qualified to perform but also how many of them they perform each year. Quite simply, the more reversals a surgeon performs each year, the more skilled they will be.

Studies show that urologists who perform more than 30 reversals per year will use VE in 20% to 60% of cases. By contrast, those who perform less than 30 will use VE in only 0% to 20% of cases.

Summary

While there is a relatively high success rate for vasectomy reversal, the success rate is influenced by your age and how long ago you had your vasectomy. The highest rate of success is seen in people who had their vasectomy three years earlier; thereafter, the rate tends to decline.

Another factor influencing success rates is the type of surgery used. This includes a vasovasostomy which reconnects the cut end of the vas deferens. A more complicated surgery called vasoepididymostomy connects the vas deferens to the epididymis and is appropriate when there is a blockage that impedes the flow of sperm.

A vasectomy reversal is not only used to achieve pregnancy but can also be performed to treat postvasectomy pain syndrome (PVPS).