Vasectomy Reversal: Provider and Patient Considerations

Additional Info

• Audio File:uf_health_shands/ufhs076.mp3
• Doctors:Campbell, Kevin
• Featured Speaker:Kevin Campbell, M.D.
• Guest Bio:Kevin Campbell, MD is an assistant professor of medicine in the Department of Urology at the University of Florida College of Medicine.
  
  Dr. Campbell received his undergraduate degree in biology with honors from Louisiana State University and his Master of Science degree in cell and molecular biology from Tulane University. He earned his medical degree with research distinction honors at LSU shortly thereafter.
  
  He completed his internship in General Surgery and his residency in Urology at the University of Florida where he served as a UF Administrative Chief Resident. Dr. Campbell most recently completed his fellowship in Reproductive Medicine Surgery at Baylor College of Medicine.
  
  Dr. Campbell specializes in Men’s Health including fertility management, hypogonadism and testosterone therapy, and the treatment of Peyronie’s disease. His clinical interests also include erectile dysfunction, male prosthetic urology, sexual disorders, as well as medical and surgical management of benign prostatic hyperplasia.
  
  His research interests focus on male reproductive solutions involving restoration of sperm production after hormonal or medical suppression.
• Transcription:The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
  
  Melanie: Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And joining me today is Dr. Kevin Campbell. He's an Assistant Professor in the Department of Urology at the University of Florida College of Medicine, and he practices at UF Health Shands Hospital. Dr. Campbell, it's a pleasure to have you with us today to talk about vasectomy reversal provider and patient considerations. Can you first start by explaining a little bit about the prevalence of vasectomy and the prevalence of this procedure?
  
  Dr. Kevin Campbell: Certainly. And thanks for having me back, Melanie. It's always good to talk with you guys. And this is something that I'm passionate about being in the field of men's health and fertility and infertility. And so vasectomy reversals are something that is very central to fertility in men who have undergone vasectomies, because vasectomies are pretty common. Five hundred thousand men each year undergo a vasectomy. And of those 500,000 men, about 20% of those have some desire for future fertility and 6% of those 500,000 men will undergo a vasectomy reversal.
  
  So this is certainly something that's on the minds of some of these guys who undergo a vasectomy, though not everybody will undergo a reversal and some people will use other forms of of assisted reproductive therapies for a pregnancy. However, when we're looking at the aspects of contraception and sterilization, vasectomy is a safe and proven form of male contraception. So I tell guys the best way to do a vasectomy reversal is to not have a vasectomy. Although, certainly the vasectomy is something that many men will go through. And so having a vasectomy reversal as an option I think is fantastic for guys.
  
  Melanie: Well then, for other providers counseling their patients, Dr. Campbell, please describe the workup for patients interested in vasectomy reversal. What are the certain criteria in order for this to even be an option?
  
  Dr. Kevin Campbell: Certainly. So for a vasectomy reversal, a lot of the workup involves a basic encounter, including a history, a physical exam and often a laboratory evaluation of men who are considering a vasectomy reversal. And we're taking a special care to look at the reproductive history, the prior history of paternity, partner characteristics, what they're willing to go through from a financial standpoint or a surgical standpoint, if they've had histories of potential insults to the testicles and fertility such as chemotherapy, radiation, febrile illnesses and also their surgical history. Did they have complications with their vasectomy, other scrotal surgeries? And even other considerations too, such as use of testosterone, because we do know that testosterone therapy can decrease a patient's fertility.
  
  And so once we do that with the history, we'll also do a physical exam. And so we're looking for different scars in the inguinal region or the groin indicating possible previous procedures. A scrotal examination is going to give us a lot of information because, when we do have vasectomy, we essentially interrupt the highway of sperm leaving the testicles. So we block, we cut and we cauterize or clip the vas deferens and sometimes remove a segment so that sperm aren't able to traverse that segment anymore. And so when we're looking to reverse that, we are noting if there's a big gap, if there's a lot of induration or inflammation behind the blockage on the testicle side, where sometimes there's additional inflammation, which can be a prognostic indicator of how well the vasectomy reversal is going to take. Now, we also note the testicular size and consistency. And if the testicles are very soft, that might indicate a decreased sperm production, or if they're nice and taut, then you might think that there's going to be a lot of sperm production and we just have more of an obstructive picture from the prior vasectomy.
  
  So these are some things we consider on a history and physical, and we'll often get a laboratory evaluation as well, looking at the patient's testosterone and some of their sex hormones, including a FSH or follicle-stimulating hormone and LH or luteinizing hormone, because that's going to tell us if the patient is having a lot of their own sperm and testosterone production. So that's going to be the initial evaluation in men undergoing an evaluation for a vasectomy reversal.
  
  Melanie: Well, thank you for that. And before we get into an outline of some of the surgical techniques and procedures, speak about provider and patient considerations. What are some of the factors you consider when choosing to perform this? Is there counseling involved? Why is that important?
  
  Dr. Kevin Campbell: Yeah. So this hits on a very important part for fertility care, and that's a lot of the counseling. Because oftentimes with healthcare and medical care, there's a set right answer and a set pathway. And when we're talking fertility, there's usually a couple of options or discussion points that we should hit.
  
  So vasectomy reversals are good for men who are averse to multiple interventions. Potentially, they may not have a provider who can perform in vitro fertilization or other assisted reproductive techniques or there may be other considerations such as post-vasectomy pain syndrome or the desire to have a natural pregnancy without assisted therapies that go into the counseling. And certainly, when we talk about partners, that becomes a big part of the workup as well. After a certain part or after a certain age, a patient and their partner may be recommended to undergo assisted reproductive therapy or, after a certain point, they may not be a very good candidate for something like IVF and so a vasectomy reversal again becomes a better option for these couple. So a lot of counseling goes into the decision making process of whether to proceed for a vasectomy reversal.
  
  Vasectomy reversal is a very safe procedure and it's often done in the operating room with some general anesthesia so that the patient is asleep during the procedure. And the procedure is done as an outpatient procedure. And oftentimes we get return of sperm to the ejaculate within six to eight weeks, although we're following up the patients at every three-month intervals to make sure they're having sperm return to the ejaculate.
  
  Melanie: Can you outline any surgical techniques and procedures that you would like other providers to know about and how important is the experience of the clinician in this decision and in these procedures for better outcomes?
  
  Dr. Kevin Campbell: That's a great question and a great point to hit on. A lot of the success for a vasectomy reversal depends on the provider experience and the intraoperative decision-making. Vasectomy reversal can be considered a very straightforward or a very difficult surgery. About 50 to 60% of the surgery is all microsurgical suturing and tying of knots with sutures that's finer than a human hair. And so whenever the procedure is done, the prior vasectomy site is excised or cut out to unblock the testicle side or the sperm-producing side of the the prior vasectomy. At that point, we'll look at the sperm under the microscope. And this is very important because this is where much of the decision-making process occurs. If there is sperm in that fluid that's coming out of the testicle, then we know that the testicle side is unblocked and we can proceed by hooking the two ends up together for a regular end-to-end vas-to-vas or vasovasostomy. And that has about a 90% to 95% success rate in having sperm return to the ejaculate
  
  If we make that incision and unblock the vasectomy and we don't see any fluid coming from the testicular side of our vas, then there's very high potential that there's additional blockages closer to the testicle, either from inflammation scarring or just time from the vasectomy to the vasectomy reversal. And so in that case, we have to start evaluating the vas deferens and the epididymis next to the testicle as the epididymis is the portion of the sperm tube or vas that exits the testicle. And so in that case, we might be taking the end of the vas and hooking it up to the epididymis to bypass any of these secondary obstructive points for what's called epididymovasostomy. And that has about a 60% to 65% chance of returning sperm to the ejaculate.
  
  Now, oftentimes we don't know which one of these we're going to be doing until we're in the operating room. And so it's very important to have a skilled microsurgeon who is able to evaluate the sperm under the microscope and perform either one of these procedures. Oftentimes, we will be able to make an educated decision or guess if a patient will be undergoing a vasovasostomy or the more complex epididymovasostomy based on their time from their vasectomy. If it's been within 10 years, often we'll be able to do a vasovasostomy. However, if the procedure has been 10 years out or more, it's a high likelihood that we may be prepared to do an epididymovasostomy because of secondary obstruction for prolonged blockages. So again, a lot of this is intraoperative decision-making, so it's very important that the skilled microsurgeon performing the procedure has the ability to do both of these.
  
  Melanie: Thank you for that. Now, can you discuss the postoperative considerations following vasectomy reversal, some of the variables that may influence reversal success rates?
  
  Dr. Kevin Campbell: Yes. So you hit on a very important topic and that's postoperative care. So after a vasectomy reversal, in theory, there is sperm returning to the ejaculate right afterwards. Now, this sperm is often not the healthiest sperm because it's been blocked in the vas for some time, so it'll have short tails, lower motility, and potentially additional changes in morphology and changes to the DNA integrity of the sperm. So we anticipate the first sperm that's making its way back to the ejaculate to be rather unhealthy. And so, we check sperm counts and motility and other sperm parameters every three months following the procedure. And we anticipate to see a low motility right after the procedure. But the farther out we get and the more unblocked sperm and healthy sperm making its way into the ejaculate, we anticipate a higher rate of pregnancy the farther out we get up until six months or even a year following surgery. So oftentimes, we'll be checking the semen analyses multiple times after surgery. We also do this because, even in the best hands, the connection between the vas deferens during the vasectomy reversal can scar down. And so if we do see that scarring occurring, we know that sperm are going to start to bottleneck and back up behind that scar tissue. And so we want to try and save as much sperm as possible and either freeze that sperm or use assisted reproductive therapies to try and assist in a pregnancy to try and give the patient and their partner the best chance of a healthy and positive outcome.
  
  Melanie: As we wrap up, this is so interesting and you're such a great guest, Dr. Campbell, let other physicians know what you would like them to know about vasectomy reversal at UF Health Shands Hospital and when you feel it's important they refer their patients.
  
  Dr. Kevin Campbell: So at University of Florida at the Men's Health Clinic and the Fertility Clinic, we're happy to see all patients who are interested in a vasectomy reversal. A lot of what goes on, as we talked about, is a lot of patient counseling. So sometimes we talk to the patients and they are very excited about proceeding with a vasectomy reversal. And other times, they might find that there's another outcome or another course of action that would be better for that individual couple. So we really try and tailor the care towards the couples and not put them in any sort of non-Ideal category for them. So we really like to make a patient-centric decision here. So I would say if you're considering referring a patient to the men's health or infertility clinic, we would be happy to see them and discuss this further.
  
  Melanie: Thank you so much, Dr. Campbell. What an informative podcast. And to refer your patient or to listen to more podcasts from our experts, please visit ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. For updates on the latest medical advancements, breakthroughs and research, follow us on your social channels. I'm Melanie Cole.
• Hosts:Melanie Cole, MS
• Post Test URL:https://cme.ufl.edu/mededcast/