Approximately 10% of men who undergo a vasectomy later decide that they would like to have more children. The decision to have more children can be prompted by many factors including remarriage, religious reasons, death of a child, or changing economic or social circumstances. After a vasectomy, the testicles continue to produce sperm and in many cases these sperm will continue to mature in the epididymis and can be found in the vas deferens up until the portion of the vas deferens that is transected during a vasectomy. A vasectomy reversal involves finding where the vas deferens has been blocked, opening the tube and sewing the two ends together using very fine sutures.
There are several different techniques and approaches including the microscopic approach, as well as the robotic approach. Dr. Mistry approaches the vasectomy reversal in the operating room with the patient under a general anesthetic. The procedure can take between one and a half hours to three and a half hours depending on patient anatomy and other circumstances. Dr. Mistry generally performs a microscopic double layer vasovasostomy. Those patients that require a vasoepididymostomy will undergo a 3-stitch intubated technique.
The success rate of the vasectomy reversal depends in large part on the capabilities and experience of the surgeon, however, there are factors that are beyond control that relate to anatomical changes that can occur after a vasectomy. It is due to these anatomical changes that not all vasectomy reversals are successful and that vasectomy reversals performed after 10 years from the time of vasectomy have a lower rate of success.
If motile sperm are identified at the time of the vasectomy reversal they will be collected and offered to the patient to be frozen for use with in vitro fertilization (IVF), if necessary. This added service is provided at no cost although there may be some charges associated with the freezing process. This will ensure that patients who have motile sperm at the time of the reversal will not have to undergo another procedure. Despite initial success, there’s a potential that’s a vas deferens could become blocked again due to scar tissue. This can occur at a rate of 15% per year.
The recovery from the surgery lasts about a week and a drain is typically placed to help with post-operative swelling. Success of the procedure will be determined with a semen analysis at 6 weeks.
Men’s Fertility Center Of Austin Procedure Video: Vasectomy Reversal
What is a Varicocele?
Varicoceles are one of the most common causes of male infertility. Varicoceles are veins that are in the scrotum and drain the testicles that are enlarged. This enlargement can cause the testicles to function poorly.
The testicles are outside of the body in a scrotal sac for a very important reason. The proper production of sperm relies on a slightly lower temperature than body temperature. In addition to being located outside of the body, the testicles also have another mechanism to help them stay cool. This involves an arrangement of the artery that brings blood to the testicle and the veins that take blood away from the testicle in such a way that the blood is actually cooled as it is delivered to the testicle.
In approximately 40% of infertile men and 20% of men in the general population the valves that keep the veins that drain the testicle flow in one direction can fail, causing a varicocele.
In extreme cases, a varicocele can even be seen through the skin and can resemble a bag of worms. In more subtle cases, however, a slight enlargement in these venous structures can be felt when the patient holds his breath and pushes down. This is called a Valsalva maneuver and will be part of the male fertility examination.
A scrotal ultrasound can sometimes find these varicoceles however we generally feel the physical exam is the most definitive diagnosis.
By interfering with the temperature regulation of the testicles, a varicocele can impact sperm quality. There’s also a consistent and notable effect on hormone production. It can be expected that normal testosterone production can increased by about 20% after a varicocele is repaired.
Microscopic Varicocelectomy Varicocele Repair
A varicocele repair involves tying off the veins that have valves that are malfunctioning so that the body can produce new veins that have better internal structure.
There are several methods to approach a varicocele repair. The preferred method of the Men’s Fertility Center of Austin is the microscopic sub-inguinal varicocelectomy. This involves an incision made in the lower abdomen to access the testicular cord which is inspected microscopically. We then tie off the abnormal venous structures while taking care to avoid injury to the artery and vas deferens.
Other Varicocele Repair Procedures
Our approach is one of the most common employed by the most advanced male fertility specialists in the world. There are other approaches, however, which we may employ in special circumstances. These can include the laparoscopic varicocele ligation, which the Men’s Fertility Center of Austin does not employ as our primary repair due to the high likelihood of damage to the testicular artery. There are additional open approaches including a retroperitoneal varicocele ligation. Many male fertility specialists will perform an inguinal microscopic ligation which necessitates a longer recovery. Because we want our patients to get back to a normal life as soon as possible, we employ the sub-inguinal microscopic varicocele approach.
Recovery after such a procedure can take about a week and can include some bruising and a feeling of scrotal swelling. In general, this procedure is well tolerated has few side effects, which can include recurrence of varicocele, hydrocele formation, and testicular pain. We anticipate that 80% of patients will develop better semen parameters as well as improved testosterone levels.
The utility of a varicocele repair in improving a man’s fertility is debatable and not the correct course of action for all couples. Moreover, there are some cases in which a varicocele repair may be used in a couple even though they may be undergoing in vitro fertilization (IVF). This special circumstance usually involves a couple where the initial IVF was unsuccessful and a high degree of sperm DNA fragmentation or DNA instability has been found.
Men’s Fertility Center Of Austin Procedure Video: Varicocele
Sperm Extraction for IVF
There are several reasons a man may need to undergo a sperm extraction procedure. These can include a prior vasectomy or failed vasectomy reversal, anatomic blockage of the reproductive system or to extract sperm directly from the testicle in some severe forms of infertility.
Percutaneous Epididymal Sperm Aspiration (PESA)
Percutaneous epididymal sperm aspiration
involves the use of a needle passed through the skin into the epididymal tubules where sperm naturally mature. This procedure can be about 90% effective in men who have a prior vasectomy but the success rate can be significantly lower in men who have no sperm in the ejaculate with unknown cause. Recovery for this procedure can be relatively quick and most men can return to normal duties within 24 to 48 hours. The sperm retrieved from this method is immediately evaluated by an andrologist and the sperm is frozen for use in conjunction with in vitro fertilization (IVF). This procedure is most commonly performed in an advanced reproductive facility.
Microscopic Epididymal Sperm Aspiration (MESA)
Microscopic epididymal sperm aspiration generally follows an unsuccessful percutaneous approach. An incision is made in the scrotum and the testicle is carefully brought to the surface and inspected. The epididymal tubules, where sperm naturally mature, are inspected microscopically. Individual epididymal tubules are then carefully incised and their contents aspirated. The fluid is then inspected microscopically and sperm that is found is preserved. This sperm generally is then used in conjunction with IVF with the help of an advanced reproductive endocrinologist.
Micro Testicular Sperm Exploration (micro-TESE)
Micro testicular sperm exploration is the most extensive sperm extraction procedure and is only performed by specially trained male fertility specialists. This procedure often follows the microscopic epididymal sperm aspiration and involves an incision in the testicle itself and a careful microscopic exploration that can last several hours. The cells responsible for producing sperm are extracted and inspected microscopically to look for evidence of mature sperm production. This sperm can be frozen and used in conjunction with IVF.
Dr. Mistry has performed more advanced sperm aspiration procedures than anyone in Austin in the last 10 years. We use several different facilities depending on where you are referred.
EEJ Services are a unique offering at the Men’s Fertility Center of Austin. Fewer than 50 medical facilities in the United States possess the technology to provide this service that allows men unable to ejaculate to conceive a child. Conditions that lead to an inability to ejaculate (anejaculation) include:
- spinal cord injury (SCI)
- multiple sclerosis
- severe erectile dysfunction
- diabetes, and
- following certain abdominal surgery
Electroejaculation (EEJ) is safe and effective, sperm can be used for intrauterine insemination or in vitro fertilization. The procedure is generally performed under a general anesthetic although some patients can be treated in the office without anesthesia.
The cost of the procedure ranges from : $4500-6500.
Patients are first assessed as appropriate candidates with an office visit. In many cases laboratory tests are performed. We would like all female partners to have a fertility doctor that has examined them. Those patients that are coming from outside of Austin may request an initial telephone consultation.