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