Ann R Coll Surg Engl 1997; 79: 420-422
Reversal of vasectomy using a macroscopic
technique: a retrospective study
Robert G Mason FRCSGIas* John C Bull FRCS
Senior House Officer in Surgery Consultant Surgeon
Philip G Connell BDS LRCP MRCSt
Senior House Officer in Surgery
Crawley Hospital, Crawley, West Sussex
Key words: Reversal of vasectomy; Vasovasostomy
Eighty-five men underwent vasectomy reversal in our Method
department between 1981 and 1994. All operations
were performed without the aid of magnification. The We identified all vasectomy reversal operations that were
results of semen analysis was available in 66 and the performed by one surgeon (JCB) from our theatre
patency rate was 74%. A postal survey was sent to records. To allow adequate post-procedure follow-up,
patients we could follow up, and among those who patients operated on after 1994 were not included. All
replied the pregnancy rate was 41% (16/39 respon-
dents). These results are similar to those found by patients were sent a postal questionnaire asking about any
others using a macroscopic reversal of vasectomy and subsequent pregnancies. The records of semen analysis
since the operator does not rely on the use of a were also reviewed. The operations were all performed
microscope, which both incurs an added cost and under the same conditions and the procedure changed
requires extra expertise, we feel that the operation as little. Patients were given a general anaesthetic, the vasa
described has a part to play in the management of were explored through two oblique groin incisions (all
men seeking reversal of vasectomy. patients had a bilateral procedure), and an end-to-end
vasovasostomy was performed. As the senior author has
presbyopic vision, he performed the anastomosis with the
aid of reading glasses. Neither loupes nor microscopes
Vasectomy reversal is required in up to 3% of men who were employed. A single layer transmural anastomosis
undergo vasectomy (1). It therefore has the potential to using eight 6/0 prolene sutures was performed and in all
impose a significant burden on any surgical practice. cases the lumen were stented with 1/0 nylon for 5 days.
Since the first report by O'Conor (2), many techniques The operation time averaged 1 h. After discharge, all
have been described, either macroscopic or involving the patients were followed up in outpatients for removal of
aid of loupe or operating microscope magnification, and the stents and given instructions to return in 12 weeks
varying success rates have been reported. We describe a with a semen sample. They were then discharged to the
method of macroscopic vasectomy reversal and the results care of their general practitioner.
achieved. We also review the results of similar studies and
highlight the main causes of failure.
In all, 85 patients were identified who had vasectomy
reversal performed between 1981 and 1994. They ranged
in age from 26 years to 53 years (mean 38.3 years).
Present appointments: Seminal analysis was available in only 66 (78%). Of these,
* Research Fellow,
Royal Postgraduate Medical School, London sperm were present in 49 giving a patency rate of 74%
t Senior House Officer in Plastic Surgery, St Thomas' Hospital, (Table I). Only 79 were sent a questionnaire (six lost to
London follow-up, or no address) and of these 39 replied, giving a
Correspondence to: Mr J C Bull, Consultant Surgeon, Crawley response rate of 49%. The results of our questionnaire
Hospital, Crawley, West Sussex RH 1l 7DH revealed that four had not tried for a pregnancy (10%), 16
Reversal of vasectomy 421
Table I. Clinical data and results of questionnaires (mean) Table III. Results of previous studies
Age at vasectomy reversal 26-53 years (38.3 years) No of Patency Pregnancy
Interval between vasectomy Author cases (%) (%)
and reversal 1-17 years (8.29 years)
Interval for successful patients 1-15 years (7.7 years)* White and Sheridan (5) 33 64 17
Interval for unsuccessful Lee (6) 300 84 35
4-17 years (8.0 years)* Dewire and Lawson (7) 32 89 41
Patency rate 74% Griffiths (8) 15 73 26.6
Pregnancy rate 41% Kessler and Freiha (9) 83 92 45
Sibler (10) 282* 91 81
* Difference not significant (P <0.1) Belker et al. (11) 1012*t 86 52
Wicklund and Alexander (12) 2685t 49 21
* Microscopic technique
Table II. Comparison of semen quality with pregnancy
outcome* t Collective review
Sperm count No of men (%) Pregnancy rate (%) suggest that a patency rate of between 84% and 92% is
Fertile 13 (37) 9/13 (69) possible and a pregnancy rate of 35% and 45% may also
Subfertile 12 (34) 7/12 (58) be achieved (Table III). A recent survey of Welsh
Azoospermia 10 (28) surgeons and urologists revealed that 43% used no
* Data from patients responding to questionnaire
magnification, while only 3% used a microscope (5).
Undeniably, microscopic repair, especially with a two-
layered technique, such as that described initially by
had achieved pregnancy (41%) and 19 had not been Sibler (13) and Fox (4) gives better results. However, not
successful (49%). only does the operator require an expensive operating
We also found that the time between vasectomy and the microscope but also the frequent use of the skills required
reversal operation varied from 1 to 17 years (mean 8.29 to maintain the necessary expertise. Whatever the
years). The mean time in 'successful' couples was 7.7 technique used, the most important considerations
years (range 1-15 years) and for 'unsuccessful' couples appear to be meticulous surgical technique to enable the
was 8.0 years (range 4-17 years), this difference is not production of a leak-proof anastomosis to prevent sperm
significant (P < 0.1). granulomata formation and subsequent scarring/vas
We looked further at the results of the group obstruction as well as a limited mobilisation in order to
completing the questionnaire (Table II) and their semen minimise disturbance to the blood supply. Variations in
quality as defined by the WHO (3). The criterion for operative technique exist, with some authors advocating a
normal fertility is a count of >20 million sperm/ml, side-to-side anastomosis (14) as opposed to the end-to-
progressive motility of 50% and morphologically normal end technique used in our study. The use of a luminal
forms in at least 30%. In total, 13 men (37%) had normal stent is also subject to debate (15), but we feel that it
postoperative sperm quality, 12 men (34%) were allows accurate opposition of the two ends of the vas
subfertile in one or more of the parameters, and 10 men during a macroscopic repair and that it prevents sperm
(28%) had no sperm present. Of the 13 with 'fertile' leakage during anastomotic healing. In our fairly large
counts, nine men (69%) had a successful outcome, study, 85 procedures were performed over 14 years giving
whereas for the 'subfertile' group seven of 12 had a an average of six per year. We believe this does not
successful outcome (58%). constitute regular use, and we have no other applications
for a microscope on a general surgery/urology firm.
Our results bear some comparison with other published
Discussion series on macroscopic repair (Table II) in terms of
patency rate, but obviously the pregnancy rate must be
As vasectomy is a popular and reliable form of birth examined with caution as only 39 patients (49%)
control, it is inevitable that vasectomy reversal will responded to our questionnaire, but this is likely to be
continue to be requested for a variety of reasons, most owing to the mobile population presenting for reversal of
commonly owing to a change of partner following divorce vasectomy as well as the possible bias of successful/
or separation (1). Vasectomy reversal holds a fairly low unsuccessful repondents. The length of time between
priority in an ever stretched national health service and vasectomy and its reversal has been found to have an
the provision of a quick, reliable and low cost technique is important bearing on the success of the operation (11),
therefore desirable. Many recent reports of techniques for but we found that there was no significant difference
vasectomy reversal have relied on the use of an operating between the means in our successful and unsuccessful
microscope and the results, both in terms of patency rate cases. Furthermore, it was found when looking at the
and pregnancy rate appear to be superior to those results of those with patent vasa after surgery, that an
achieved by surgeons employing a macroscopic techni- equal percentage of those operated on 10 years or more
que (4). after vasectomy, and those who were being reversed after
The best reported results of a macroscopic repair less than 10 years, had a normal sperm count. However,
422 R G Mason et al.
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