How is the vasectomy reversed?

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Unlike a vasectomy, a vasectomy reversal is a very complicated and time-consuming operation requiring very specific expertise. It is performed under an "operating microscope," a microscope that stands over the patient. The physician looks through the microscope at a highly magnified view during the procedure and this allows him to manipulate the small, fine instruments by hand.

In theory, a vasectomy reversal should merely involve reconnecting the two ends of the vas deferens that were cut during the vasectomy. This, in and of itself, is a difficult process because of the minute scale involved in the surgery. The diameter of the vas deferens is approximately the width of a piece of spaghetti and the threads (sutures) are finer than a human hair.

However, the procedure is further complicated by the fact that over time pressure builds up in the area where the sperm and fluid are being produced in the testicles but can not be released. This pressure may cause the epididymis (which is very thin walled) to leak and scar creating a blockage closer to the testis. If the two disconnected ends of the vas are reconnected but there is scar tissue and blockage at the level of the epididymis, the sperm will not be transported out. And the vasectomy will not be successful. It is therefore critical that, during the course of the procedure, the surgeon assess if this type of scarring and blockage has occurred and operates accordingly.

Therefore the microsurgeon's first job in the operating room is to evaluate at what point whole sperm appears in the vas deferens. The microsurgeon generally begins at the very end of the vas deferens and makes minute incisions sequentially back towards the testicle and evaluates the quality of the sperm and fluid found there using a separate high powered microscope also present in the operating room. The sperm quality is generally categorized into 5 grades:

Grade 1: mainly normal motile sperm
Grade 2: mainly normal non-motile sperm
Grade 3: mainly sperm heads, without tails
Grade 4: only sperm heads
Grade 5: no sperm

The point at which the microsurgeon will usually make the reconnection (or anastamosis) is the first point at which they see either fluid with sperm in it or fluid that, due to its color, indicates there is no blockage closer to the testicles.

If there are whole sperm or if there is a certain quality to the fluid, then a vas-to-vas connection or anastomosis may be made. This is called a vasovasostomy. If there are no whole sperm and there is thick white fluid, the vas should usually be connected to the epididymis at the level above the blockage. This is called a vaso-epididymostomy.

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