Reversal of Vasectomy and the Treatment of Male Infertility

Abstract

The pressure-mediated effects of vasectomy on the epididymis were identified in over 300 cases as well as how microsurgery of the epididymis may be used to solve this problem in many instances. This review deals with results obtained in these patients and addresses the problem of modifying the technique of vasectomy itself to limit the pressure effects and thus make vasectomy more reversible. Attention is also directed to how this new understanding has helped to improve surgical approaches to obstruction not caused by vasectomy. It was observed that the pressure changes were less pronounced when a sperm granuloma developed at the vasectomy site. In addition sperm quality in the vas fluid was always superior when a sperm granuloma occurred at the vasectomy site. The likelihood of finding normal sperm in the vas fluid at the time of vasovasostomy decreased as the duration of time since the original vasectomy increased. The duration of time since vasectomy correlates with the likelihood of pressure-induced rupture of the epididymis. It was concluded that the secondary effects of pressure build-up on the epididymis after vasectomy can prevent fertility. This is the case even following an accurate vasovasostomy. The longer the duration of time since and the greater the pressure build up the greater is the likelihood of epididymal extravasation and secondary obstruction. The presence of a sperm granuloma at the vasectomy site indicating continual leakage and reabsorption eliminates the risk of epididymal rupture. It is now known that in the special cases in which there are no sperm in the vas fluid or in which fertility does not result after a perfect vas reanastomosis bypass of the area of the secondary epididymal obstruction provides an opportunity for successful reversal. About 80% of the patients upon who a bilateral vasoepididymostomy has been performed have recovered normal semen characteristics. As this technique is very difficult it should only be attempted by an individual experienced in microsurgical techniques. A sperm granuloma at the vasectomy site does not cause any increased risk of scrotal discomfort and it ensures the continued integrity of the epididymis making successful reversal much more likely. When there are no more sperm in the ejaculate of patients in whom the follicle stimulating hormone is normal only 1 additional diagnostic test should be performed i.e. testicular biopsy. If this shows normal spermatogenesis the diagnosis is obstruction and microsurgery should be planned.