Vasectomy and its reversal

Abstract

Techniques, results, complications, and medicolegal aspects of vasectomy are discussed in this article. Emphasis is placed on techniques that prevent spontaneous recanalization of the ends of the vas deferens after vasectomy. Factors that affect the reversibility of vasectomy are discussed. New microsurgical techniques of vasectomy reversal are described, and results of these new techniques are compared with results of nonmicrosurgical techniques of vasectomy reversal. Indications for bypass vasoepididymostomy during vasectomy reversal procedures, as well as techniques for performing vasoepididymostomy, are discussed.

PIP: Frequently, patients inquire about reversible vasectomy devices, which would permit fertility if later desired. Prototype reversible vasectomy devices have been developed, but none has yet satisfied the requirements of assured permanent sterility with reversible fertility when desired. There are numerous technical factors that make the ultimate development of a satisfactory reversible vasectomy device seem unlikely. Compared with tubal ligation in women, vasectomy is simpler, less expensive, and safer. Vasectomy can be performed in the physician's office or in an ambulatory surgery facility. Vasectomy should be performed at a relatively high level in the straight scrotal portion of the vas. This level is recommended for vasectomy because later reversal of the vasectomy is easier if the procedure was performed at this level rather than in the lower, convoluted portion of the vas. After the vas has been transected, a portion of the vas is excised for identification. This identification is required for medicolegal purposes but serves no useful purpose in preventing spontaneous recanalization of the ends of the vas. Because of the extreme mobility of the vas, its severed ends may still come in contact after resection of as much as 2 or 3 cm of its length. Because of reports of spontaneous recanalizations and resulting undesired conceptions after originally successful vasectomies, the method used to seal the ends of the vas assumes paramount importance. Simple ligation of the ends of the vas, ligation of each end of the vas doubled back on itself, and application of metallic clips to the ends of the vas all have been advocated. Each of these methods has about the same rate of spontaneous recanalization postoperatively. Limitation of activity for 24-48 hours postoperatively, aspirin, and occasional use of an ice pack should relieve the usual pain after vasectomy. Couples must be cautioned that contraception is required after vasectomy until absence of sperm from the semen is documented. Local hemorrhage and wound infection occur in a small percentage of patients after vasectomy. A rare patient requires evacuation of a scrotal hematoma in the early postoperative period. Microsurgical techniques have improved considerably the results of vasovasostomy, which may be performed with local anesthesia on an outpatient basis. Factors affecting the success of vasectomy reversal are the obstructive interval (time from vasectomy until its reversal) and the sperm quality in the vas fluid at the time of the reversal procedure.