Successful reversal depends on only 3 factors – Tube, sperms and surgical skill. There’s nothing we can do about the first two, you the patient bring those with you. But what we can do is to ensure that if the first two factors permit, we give you the very best chance of success that nature allows. That’s why the Dawson Clinic offers you a 98% patency rate ensuring that nearly every single operation is effective. This translates to a successful return to fertility rate of at least 90% after 5 years and 80% after 10 years. Similar rates apply to re-do reversals.
Here we mean of course that there needs to be sufficient healthy vas remaining after the vasectomy for the reversal surgeon to able to re-join at least one vas. (We are frequently asked whether long gaps can be bridged by artificial tubing. Sadly the answer is no. The vas is a living muscular tube that acts as a pump so artificial implants do not work well).
Overall nearly all men (more than 95%) have at least one tube suitable for reversal. Where the vasectomy has been done through an incision on each side under local anaesthetic and without diathermy (an intense electrical heat used to close the vas) the vas is likely to remain in best condition.
The value of pre-operative assessment in assessing the tube.
We are always very happy to see prospective patients for consultation and advice before deciding to go ahead with making a reversal appointment. We can learn a lot from gentle external examination. The vas is a very distinct, quite firm to the touch so we almost always make a good assessment of your suitability for reversal and even the likely outcome! A vasectomy that has been done towards the middle of the external part and has a short gap between ends (1-2cm) is best. If we also find a granuloma then success is almost certain. Very rarely we find that the vas has been so badly destroyed on both sides that attempting reversal is not worthwhile thus saving you the trouble and expense of a wasted procedure and advise on alternative steps. Fortunately, such bad news is a very rare occurrence.
With every reversal that we do we place some of the fluid emerging from the testis end of the vas on a microscope slide so check that sperms are present as in the photo above. This proves that there has been no ‘blow out’ blockage of the epididymis and that reversal will succeed. Blow out is a rupture of the very thin epididymis tube (only 0.2 mm in diameter) situated on top of the testis. It is caused by the back pressure of fluid trapped in the tubes below the vasectomy and peaks during ejaculation. Blow out is painless, so vasectomised men would not feel this happening. Statistically the chances of a man developing ‘blow out’ after vasectomy start at zero immediately after the vasectomy and increase by approximately 2% per year. There is one exception to this rule, and that is when a sperm granuloma is present. Granuloma is a firm swelling on the lower end of the vas and varies in size from a small pea to a Murray mint. It is caused by leakage of sperm from the cut end of the vas immediately after vasectomy and is quite common, about 1 in 3 men. We have found that where granuloma is present there is never a blow out, probably because it acts as a pressure release valve.
The above slide is from a patient who definitely has suffered blow out. It shows round cells only, no sperms or sperms fragments at all. Round cells are the broken down remnants of sperms and other cells.
Here, Carol is examining a specimen of vas fluid during the reversal procedure with the picture projected onto a video screen so the team can confirm that this reversal will succeed.
Surgeons who do not perform this test on the testicular fluid seen during reversal (and the vast majority have yet to adopt this procedure) cannot know what the true outcome of their reversal should be. If sperms are present then we should be capable of 100% success providing the tube is repairable. At Dawson Microsurgery we achieve 98% success or patency (professor Goldstein has shown 99.7% patency with the MMMV technique). If sperms are not present then conventional reversal surgery will not work and we can then advise couples of other techniques that may be required.
Across all branches of surgery there is a rapidly advancing trend towards specialisation. Performing large numbers of the same procedure by the same surgeon and the same team yields amazingly better results than general surgeons who do so many different procedures that they master none. Here at Dawson Microsurgery we specialise in nothing but vasectomy reversal, operating Monday to Friday, performing over 200 operations per year.
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