An estimated 2% to 6% of men undergoing vasectomy may request a reversal at a later date. In the United States, divorce with subsequent remarriage is by far the most common reason given for requesting reversal. In developing countries, the death of a child is the most common reason. In Bangladesh, for example, 5% of all couples who choose sterilization experience the death of a child within one year after the operation. Before the refinement of microsurgical techniques, results of vasectomy reversal were relatively poor, with pregnancy rates varying from 5 – 30%. The technical problems inherent in creating an accurate, leak-proof anastomosis of structures with a luminal diameter of only 0.3 mm are formidable. Microsurgical techniques of reversal now result in return of sperm to the ejaculate in over 90% of men and yield pregnancy rates in the patient’s partner of better than 50%.
We have developed a microsurgical multi-layer technique of vasovasostomy that facilitates precision suture placement. The technique involves mapping of the planned suture exit points with “microdots” placed on the cut ends of the vas deferens with a microtip marking pen. Exactly six mucosal sutures (double-armed 10-0 monofiliment sutures) are used for each anastomosis. The anastomosis is completed with six muscularis sutures (9-0 monofilament) and six adventitial sutures (9 – 0) and six 8-0 nylon sutures approximating the vasal sheath.
In a series of 194 consecutive vasovasostomy procedures using this technique, a patency rate of 99.5% was achieved at Cornell. Pregnancy rates of 54% (crude) and 64% (excluding female factor infertility) were observed for the first 100 subjects of the cohort. (Boorjian SA, Lipkin M, Goldstein M. J Urol 171:304-306, 2004; Goldstein M, Surgical management of male infertility IN: Campbell-Walsh Urology, Elsevier, Philadelphia; 2015, Chapter 25)
Surveys of multiple US centers reporting results for ICSI and vasectomy reversals calculated vasectomy reversal to cost $25,475 per live delivery in 1994 dollars whereas sperm retrieval with IVF were calculated to cost $72,521 per live delivery in 1994 dollars. (Lee R, Li PS, Schlegel PN, Goldstein M. Urol Clin of N Am 35:289-301, 2008). Lee et al. concluded that the most cost-effective approach to post-vasectomy infertility is microsurgical vasectomy reversal.
The microdot technique ensures precision suture placement and facilitates the anastomosis of lumens of discrepant diameters by exact mapping of each planned suture. The microdot method separates the planning from the placement. Patency rates using the microdot technique approach 100%. (Goldstein M, Li PS, Matthews, GJ. J Urol, 159:188-190, 1998)