When it’s possible, the Dawson Microsurgery Clinic always encourages consultations and this is because it gives our team the opportunity to see if our patients are suitable for vasectomy reversals. Approximately 95% of men are able to proceed with a vasectomy reversal but we don’t want to see our patients suffer the inconvenience of a wasted procedure.
A typical consultation will include a discussion about microsurgery and the techniques we use; while there will also be counselling and an examination that allows us to see whether the sufficient tube remains for us to perform the reversal.
An appointment can then be made for your operation, yet it’s important to know that there is no standard vasectomy technique, so it’s important to acquire relevant information from our patients in their consultation. We can then offer you a personalised chance of success at the Dawson Microsurgery.
For overseas patients where consultations are not always possible, we offer an examination that’s immediately followed by an operation, but there is always a slim chance that a patient is not able to proceed on the day.
Our clinic manager Barbara Temple is available weekdays to offer preliminary advice and arrange bookings for consultations. You can learn more by speaking with her on 01429 282800.
The Dawson Microsurgery vasectomy reversal Blog – May 2014
The plain speaking voice of experience
Repeat reversal of vasectomy – how best to proceed after the initial disappointment of failure.
We have been listening to couples who call us for advice for over 15 years and a common story is that they have had a reversal which has either failed straight away or a low sperm count has faded away to nothing. Failure of reversal often leads to disillusionment, despondency and an end to their dreams of pregnancy after reversal. Some feel like giving up completely and some will reach for IVF treatment straight away. Make no doubt about it, the IVF clinics will welcome failed reversal couples with open arms and prise their cheque books equally open! We advise taking the time to remind yourself why you had the reversal in the first place and then take time out to examine why reversals can fail and what can be done to remedy that without resorting to IVF.
Remember that the pregnancy rates with IVF are on average around no better than 1 in 3 (often far less), so the majority, 2 out of 3 IVF treatments fail accounting for the couples who get hooked on repeated cycles of IVF.
Why reversal was the first choice?
For all the best of reasons! Reversal is effective, cost effective, leads to a natural conception without using drugs and gives an infinite number of chances at conception. As one of our patients wrote after having 2 children – “In 2007 I spent a couple of hours at your reversals clinic” and a week later “I was back at work (in Greece)”. Tobias was born in 2009 and Nikola was born in 2011”.
So why might reversal fail?
I don’t want to sound over simplistic here, but we know that vasectomy does not interfere with the production of sperms so the only reason for failure of reversal is blockage of the sperm carrying tubes. There are 2 of these, the epididymis and the vas. The epididymis collects sperms from the testis and the vas conveys or pumps sperms from the epididymis up into the body.
1. Blocked epididymis – ‘blow out’. Blow out is a blockage of the tiny tube that carries sperms from the testis along to the vas. The epididymis is a remarkable tube measuring 6 meters long and only a fifth of a millimeter in diameter. After vasectomy the pressure in the vas and the epididymis increases markedly (because the sperms cannot escape) and this can lead to a painless rupture of the tiny, thin walled epididymis. To the patient this is painless so he would not know it had happened. The chances of blow out depend on how many years have gone by since vasectomy, with each year adding 2% to the chances of blow out. So a man 5 years post vasectomy has a 10% chance of blow out.
2. Closure of the vas reversal connection Usually this happens because the surgeon
has performed an out of date reversal operation (even though it may be labelled as
‘microsurgery’), or he has not taken enough time and care on the procedure (it is not
uncommon for urologists to finish the whole reversal procedure in 40 minutes
against the benchmark 2-3 hours for best microsurgery).
OK, so how do we know which tube has blocked?
Testing to show the epididymis is free of obstruction. There is a relatively simple test that
can be done to detect blow out blockage of the epididymis. This is done during the reversal
operation. Here at Dawson Microsurgery we perform this test on all patients and it is done
by over 70% of American clinics but in less than 1% of clinics in the UK.
There is no test to show that the reversal connection of the vas has worked other than reoperating.
So, we don’t know which tube is blocked. Is it worth undergoing another reversal to find
Re-do reversal, going back in to find out what went wrong and re-making the connection is
almost always worthwhile. A paper from the USA (Paick et al 2002) reports successful rereversal
in 92% of failed reversals and 57% pregnancy rates. This fits exactly with our
experience here at Dawson Microsurgery.
This leads us to offer some very clear guidance
In the common case that following the first reversal that tests have shown even a tiny
number of sperms which may or may not be or have been moving then we can be sure that
there has been NO blow out and the cause of the failure is narrowing and possibly closure of
the reversal connection. Re-reversal in these cases will almost certainly be effective.
OK, but what if first reversal produced no sperms at all?
Well, with crude quick techniques it is common for the connection to fail but even with the
best, goldstandard microsurgery failure can still happen. After all, reversal involves
connection of a tube whose inner diameter is only one fifth of a millimetre and the slightest
trace of scar tissue can block the sperm channel. Indeed closure and scarring of the
connection has happened to us in the past and I am sure that if God himself performed
reversals he would still have occasional failures!
What about antisperm antibodies (ASA)?
It is a widely held belief among non-specialists and fertility doctors that these proteins can
stop or spoil sperm production and that reversal is ineffective. They use this as a justification
for moving straight to IVF. The evidence does not support this and we can only reiterate comments made before that;
Up-to-date microsurgical reversal is effective, cost effective, leads to a natural conception without using drugs and gives an infinite number of chances at conception. Only when all reversal options have been exhausted should couples resort to IVF.
Until next time
Dr Andrew Dawson Urological microsurgeon
Fortunately, most are suitable for vasectomy reversals (approximately 95%), but it’s important to have an initial consultation beforehand. The Dawson Microsurgery Clinic always encourages patients to visit and it gives us the opportunity to check that the sufficient tube remains for our surgeons to perform the reversal.
Our experienced assessment can save patents time and effort, but in cases where a pre-examination is not possible (such as out of town or overseas patients), we collect as much information as we can over the telephone. We then offer a ‘one-stop’ consultation and operation appointment with an enhanced deposit.
Our pre-op physical examinations include an assessment of the work necessary to repair the tube (vas), an estimation of the diameter and positioning of the vas, as well as ease of access. We also check each patient’s general health, while a consultation also includes an explanation on the factors of a successful operation, a review of research and literature for a reversal and a video of an operation taking place.
Our only aim is to help our patients regain their fertility and the first stage is contacting our clinic manager for preliminary advice and consultation bookings. For more information call us on 01429 282800.
Sounds good. Couples exploring the subject of vasectomy reversal will read many web sites from all over the world. One of the seemingly attractive ad-ons to the procedure is sperm extraction. ‘If the reversal doesn’t work then at least we have benefitted because we have extracted some sperms that you can then use’ is the line. There is a cost, often £400 or so (plus storage charges etc.) which is added to you bill. But is this a good idea?
Using the sperms requires IVF You would think that it should be possible to just implant the sperms into your partner in a simple way like artificial insemination and try to conceive that way. The reality however is that the number of sperms recovered is low, in the region of one million or so. Sounds a lot? Not really, the number of sperms in a normal ejaculate is 80 million per ml, or 160 million in total. So, our million sperms extracted is too small a number for conventional fertilisation and so requires a variety of IVF called ICSI to be effective.
Extracting sperms damages vital tubes.
This is a diagram of the testis and the tiny narrow sperm collecting tube, the epididymis which lies on top of the testis. Sperms mature in the epididymis, starting out as just a head then developing a rudimentary tail finally becoming the full swimming missile over the course of 2 months. The epididymis is 6 meters long and 0.2 millimeters in diameter, a fragile tube indeed.
Following vasectomy the epididymis is packed full of sperms and dead sperm debris, acting like a blown up bag or reservoir of sperms. Sperm extraction (PESA) is done by pushing a large bore needle through the skin and into the epididymis. It is possible, indeed likely that needling the epididymis in this way can rupture the epididymis and causes a blockage or ‘blow out’. Blow out is a scar that blocks the passage of sperms through the epididymis, preventing them reaching the vas which leading to failure of the reversal. So sperm extraction (PESA) may lead to failure of your reversal.
So when should sperm extraction done?
Only when all hope of successful surgery have been exhausted. In the UK reversal doctors outside this clinic do not test the fluid in the vas for early detection of ‘blow out’ so they don’t know at the time of reversal if this blockage has occurred. In fact we don’t recommend sperm extraction until the semen tests have been performed after reversal, until you have decided that IVF (ICSI) is for you and and you have chosen, after further research of course, your favoured IVF clinic.
When patients return with the new family, it’s the whole reversal process complete and a great source of satisfaction to all of us here at Dawson Microsurgery. Some couples travel a long way, 250 miles up the A1 for one of these couples. “Wouldn’t trust my balls to anyone else but Dr Dawson” is a frequent cry!
In the last month we have had three couples return for vasectomy with their complete families! The first family had one child, the second two children and the third had three Children! Here are their stories
19 years post vasectomy. It was a second relationship for Peter (now aged 54) and Tracy (age 40). Peter was 19 years post vasectomy when he came for reversal in 2008. The reversal went well although there had been a blow-out (see our blog on this subject) on one side. This left Peter with half his possible sperm count but thankfully his counts had been over 50 million sperms (per ml.) with only this one side. Peter’s fertility then had well and truly returned after his Dawson Microsurgery reversal. It took Tracy 11 months to get pregnant with Hanna. Both parents agreed the family was now well and truly complete and time to return to the safety of the vasectomy!
(Peter had an interesting experience with the Hoover when tidying up after the vasectomy shave – watch for this hilarious story in a future blog).
Change of mind after 8 years
Jay and Kelly had already had 2 boys when they decided on the vasectomy. It was right for them at the time, after all it is an expensive period , bringing up children. 7 years later however, everything looked different for the family, Jay had been promoted at work and his job was secure and they realised that they hankered after a larger family, maybe a girl this time? Fortunately Jay’s vasectomy had been well performed so readily reversed here at Dawson Microsurgery with excellent return to fertility. Kelly was pregnant with twins within 3 months, delivered just 13 months after the reversal!! Luckily a boy and a girl, so the family is well and truly complete and Jay was keen to return to his snipped state again.
3 children since the reversal in 2005!
Martin (now 52) and Karen (now 39) came to us for microsurgical reversal, 8 years ago in 2005. They had formed a new relationship wanted a family together. They hardly dared to believe that they could achieve their dream because Martin was 12 years post vasectomy. The reversal was difficult technically because the vasectomy had taken away most of the vas leaving only short remnants of tiny (we are talking about a tube with inside diameter less than 0.2 millimetres here) coiled vas for us to re-join. However, we have done thousands of cases and employ the right techniques and materials to succeed where others fail.
Following the reversal Martin’s fertility returned to normal quite slowly, taking 6 months to return to regain a normal sperm count. Karen’s first pregnancy ended in miscarriage then happily then the first boy was born in May 2007. And the children kept coming, with 2 further children over the years.
Martin and Karen dwarfing Nurse Carol (who cared for Martin during his reversal in 2005 and again in November 2013 for the repeat vasectomy!)
And here are Martin and Karen dwarfing Dr Dawson (after the repeat vasectomy).
And finally – a last word from the Dawson Microsurgery clinic.
Patients, couples look around on the web and find so many clinics that offer a reversal and assume that all operations are pretty much the same and often choose a provider close to their home, who may look capable on the web or who may be cheaper than the rest. The truth is that proper reversal needs proper microsurgery which is in very short supply in this country. Our operations take 3 hours and we limit ourselves to just 6 cases per week, maximum 2 per day. What others call success may amount to no more than a low level of fertility for a short time, sometimes as little as weeks. To achieve a high count for long enough to get pregnant, maybe more than once, requires a special care and skill. Much more information in our other blogs available through the web site.
A recent consultation raised some interesting discussion points which may be helpful to other couples contemplating reversal of vasectomy. We will call the patient John, a 43 years old London barrister who made the 3 hour train ride to the Hartlepool Dawson microsurgery clinic to get best advice on his way forward.
John has had 3 children with his first wife and the vasectomy was performed 9 years previously. Sagely john had frozen a sample of semen before undergoing the vasectomy. Sadly his marriage had ended and John was unexpectedly footloose and single again. He had not made a new relationship but wanted to and realised that any prospective new partner would most likely want to start a family. John also felt that he would feel to some extent re-rejuvenated by returning to fertility and was wanting advice on the best way to go about his reversal.
Using stored frozen sperms (IUI)?
Clearly John and his new partner would have the options of using the stored sperms or undergoing IVF. Undergoing IUI would not to do a lot for John’s self-esteem but let’s briefly examine these options. First, frozen sperm. This is frozen whole semen and anyone one would think that this gives the simplest route to get pregnant, just load up the turkey baster and away we go! The reality is not so encouraging from my experience. John is on the time limit for storing semen (10 years) after which the sperms do not defrost well. Reports from fertility clinics show that the number of useful sperms available after defrosting can be markedly reduced, the sperm bodies degrading and the motility of the sperms poor. So, we find that patients are being recommended to undergo IVF with frozen sperms. Not the simple, cheap straightforward procedure we were hoping for.
How about IVF?
Leaving aside the horror that any potential new partner would feel at this prospect, IVF would need to be done by ICSI. This is sperm extraction from John (PESA) by placing a needle through the scrotum to extract sperms, then egg extraction from her, test tube fertilisation then implantation of the lab. grown embryo. This whole process carries a pregnancy rate of around 20-25% for a 35 years old woman, is emotionally draining and costly at around £7000 per cycle.
Weighing up the choices
So, the alternatives are not desirable, how does reversal stack up? Examination of John has shown that his vasectomy has been performed well and that on both sides the tubes are repairable. Successful reversal relies on only 3 factors; presence of repairable vas, presence of sperms in the vas (82% chance of this) and finally excellent, proper microsurgery (e.g. multi-layer microdot vasovasostomy with a 98% success rate). So the chances of a return to fertility at Dawson microsurgery are 80-82%. Pregnancy chances? Well, in our audit of 208 couples 9-13 years post vasectomy (wives up to age 40) treated at Dawson Microsurgery, 82% became fertile again and we know of at least 41% that became pregnant. The procedure takes half a day, costs around £3000 and requires around 3 working days away from the desk.
Choosing the right time for reversal (or could a reversal delayed be reversal denied?)
OK, so reversal it is for John you may think! Yes, definitely, with the added benefits of the satisfaction of a happy return to full manhood and return to full ejaculatory satisfaction. But one final factor has to be taken into account, the possibility of scarring and potential narrowing even closure of the connection with time. What chance of this? Well, really skilful proper microsurgery is the first step in preventing scarring, so John should seek out a genuine microsurgery surgeon (one clue is the length of time the op. takes, it should be at least 2 up to 3 hours so no more than 6-8 cases max. per week). The other factor contributing to scarring is cautery at vasectomy. This subtly changes the minute structure and blood supply to the vas making scarring more likely depending on the degree of damage caused. I should reassure readers here that cautery is almost always used during vasectomy and in fact it is RARE for it to cause significant problems.
John then has a difficult decision – have his reversal now to feel back to normal, virile and fertile again or wait until he meets his new life partner. If he does this the downside to waiting is that with every year that goes by his chances of ‘blow out’ leading to ineffective reversal increases by 2% per year.
What would I do?
Without a doubt I would have the reversal now. If scarring happens I would just have another half day procedure to rectify the problem.
Whatever your choice John, we wish you well!
Post Vasectomy Pain (PVP)
The Dawson Microsurgery assessment and experience.
What is PVP?? The Dawson Microsurgery definition
• A chronic relapsing testicular ache whose onset may be as little as 8 weeks to as long as 5 years or more post vasectomy.
• PVP may occur immediately after ejaculation or the pain may be of insidious onset over subsequent days.
• The pain is chronic, lasting for years with relapses usually lasting 1-4 days though very variable in frequency
• Often the pain is unilateral or at least more severe on one side than the other.
• PVP should, where possible, be a diagnosis of exclusion after investigation has failed to identify any other lumbar of urological abnormality’.
We advise exclusion of lumbar spinal problems, prostatic disease, and varicocoele.
Spectrum of severity
As with other diseases there is a spectrum of severity with symptoms varying from trivial and short lived, to severe and persistent. At its most severe PVP can affect the patient’s everyday life leading to irritability, depression and relationship problems. GPs, urologists and ultrasound departments will all be familiar with vasectomy patients reporting post vasectomy discomfort. Most PVP suffers will be reassured by the exclusion of testicular malignancy by a normal US Scan but some will require intervention.
Examination generally shows a completely normal testis but a swollen, often tender epididymis in which there can be firm swellings, possible concretions due to sperm stasis. On the vas, sperm granuloma may be present but in our experience does not cause PVP.
Various suggestions have been made, neurological damage at the site of vasectomy, epididymal distension and formation of sperm granuloma. Investigation has shown that there are no histological correlations post vasectomy changes in the vas, epididymis or testis so the presence of PVP is an individual response to the vasectomy. At Dawson Microsurgery we believe that PVP is caused by pressure build up in the epididymis leading to distension of this delicate structure and its overlying fascia. Over the last 10 years we have performed reversal of vasectomy for approximately 24 PVP sufferers. We also have experience PVP as an incidental finding (over 100 cases) in men requiring return of fertility. Overall, reversal in this clinic leads to complete resolution of pain in over 90% of cases.
Various teatments have been devised for PVP. These include excision of the epididymis, converting the vasectomy to open ended and reversal of vasectomy. In our view reversal is the best option as this is a simple day case procedure without risk of significant complication and has a proven high success rate. Reversal of the vasectomy allows the accumulted sperms and fluid to drain freely thus allowing the epididymis to deflate and return to normal One word of caution, if the connection scars and closes the pain will return, so excellence of technique, quality and accuracy of microsurgery, is all important.
Dr Andrew Dawson Urological microsurgeon
Choosing a vasectomy reversal clinic – follow the doctors!
Get a few doctors together and ask them about their last operation. Maybe it was a slipped disc, gall stones, arthritis of the hip, maybe even a cheeky tummy tuck. No matter what it was you can be sure they did their research because they know that complications and operation failures do happen. Problems are not an act of God, problems are avoidable.
So how do doctors choose a doctor?
They talk to colleagues, read up on the subject often published articles on the internet then draw up a three point list;
1) what is the best technique, the goldstandard or benchmark?
2) who is specially trained in this specific method?
3) how many procedures does he do every year?
This almost always leads to ‘the man’ for the job!
Using the internet
The ‘web is a funny thing! For any given subject, it’s all there. The good, the bad, the ugly, the misleading the fraudulent and the excellent!! There is ‘hard’ and soft information. Hard facts from research papers and soft information, usually cuddly feel good pictures and unattributable quotes.
So here are my suggestions for reading between the lines of the UK vasectomy reversal web sites. It works for reversal but of course applies to most medical procedures.
Technique – getting the facts, knowing what standard to expect.
Nearly all the research on reversal on vasectomy reversal has been done in the USA and that is where to go to find the facts. No doubt in my mind that the American surgeons Dr Sherman Silber and Professor Marc Goldstein (famous for the multi layer microdot technique) are the ‘best of the best’. Their web sites give masses of reliable information, see www.infertile.com and www.maleinfertility.com . Both these centres have described techniques that have been tried and tested and shown to be the ‘best techniques’. If you want to see these same techniques, Drs Silber and Goldstein show their operations on Youtube, they are not grisly!
Check your UK surgeon uses a technique similar if not exactly the same as the best guys and has received the training in this technique. Look for a certificate!
Number of procedures
there is no doubt that focussing on this procedure brings experience and competence. As an example an orthopaedic surgeon may well super specialise say in knee joints and almost never do any other operation so he knows that procedure inside out which gives you best the patient results.
So, how many procedures is good and how many is enough? The good guys, our benchmark will perform one to two reversals per day taking around 3-4 hours per case and perform maybe 4 cases per week, 150 per year. However, more than this may not mean better! Some web sites in the UK claim their surgeon performs 6-8 reversals per day and 500 per year. OK, so that’s 500 cases per year and a throughput of 6- 8 cases per day means our surgeon is spending 12 to 16 hours of operating per day and that’s without a lunch break, toilet break or rest. He is doing this for 80 working days a year as well as holding down a full time urologist job, maybe being a prostate expert as well. Does this allow enough time to provide you with the results you expect?
What about technique?
There are a variety of techniques out there all of which aim to do the same job. They are not all the same, some are designed for quickness and some aim to avoid the technical difficulty of performing real microsurgery. So your surgeon should tell you exactly what he does. Choose a surgeon who uses a proven (published in the medical journals) technique and be wary of the individual surgeon doing his own thing. If his way is best you can be sure he would let us all know and we would all use his method! And what about the size of the stitches used? Our benchmark surgeons use proper micro stitches, sometimes 9-0 but usually 10-0 (higher numbers, smaller stitches). So what of claims such as the use of cardiac stitches? Sounds good? Well, cardiac stitches are at their smallest 7-0, not microsurgery stitches at all.
The web sites mention ‘success rates’, what does this mean?
It’s all about the babies!
Success in this context means simply that at some time after the reversal some of the tests showed some sperms for however short a time. This is the same as ‘patency’, so that the join was open at least a bit for a while.
But real vasectomy reversal success is about getting pregnant because getting pregnant means that the reversal has produced enough sperms that are motile enough to get through and do the job!
Many reversal sites hide behind the excuse that fertility involves the female which is an unknown factor. But that simply is not good enough! The published results on reversal manage to quote pregnancy rates and these are valid because over a large sample (say over 100 cases) the fertility of the females averages out. So my advice is ask to for pregnancy rates and don’t accept excuses because pregnancy is the only success you are interested in!
So, good luck with your research. Please do give us a call (on 01429 282800) or visit www.vasectomyreversals.co.uk for our impartial advice, but only about your vasectomy reversal! If it’s a tummy tuck you need, follow the other doctors!
Andrew Dawson Director Dawson Microsurgery Vasectomy Reversal Clinic
Couples are faced with the choice of IVF or reversal when they want to add to the family after vasectomy. Where do they turn for advice on what to do next? Maybe the GP, their friends and acquaintances, the internet? Many go to a fertility clinic for guidance. Continue reading →