Vasectomy is one of the most widely used contraceptive methods worldwide. It is estimated that vasectomy accounts for approximately 8% of all contraceptive methods used globally. On the other hand, about 6% of men who undergo vasectomy later seek medical assistance to become fathers again.

Most common reasons that lead vasectomized men to seek reversal include:

• New marriage

• Loss of a child

• Desire to have another child within the same relationship

• Psychological intolerance to sterilization

For vasectomized patients, surgical reversal offers the best chance of achieving fatherhood. With the introduction of assisted reproductive technologies, contrary to what many believe, surgical reconstruction has become even more strongly indicated.

Approximately 15 years ago, when a vasectomized patient underwent reversal, conception relied exclusively on natural reproduction. In cases where vasectomy had been performed many years earlier (more than 10 years), semen quality could be significantly compromised.

However, with the availability of assisted reproductive techniques, once the anastomosis is patent, if sperm quantity is insufficient for natural conception, the patient may be enrolled in an assisted reproduction program. The advantage is that sperm can be collected through masturbation, without the need for any additional surgical intervention.

Although vasectomy reversal can be performed without the use of a microscope, the best outcomes are achieved with microsurgical techniques.

Preoperative Care

It is essential to evaluate the female partner to ensure that she does not present any absolute contraindications to pregnancy. If the partner has tubal disease or any other indication for in vitro fertilization (IVF), vasectomy reversal is not recommended.

In such cases, the best option is to perform MESA (Microsurgical Epididymal Sperm Aspiration) followed by ICSI (Intracytoplasmic Sperm Injection).

Intraoperative Considerations

Although reconstruction may be performed without magnification or using surgical loupes, the best results are obtained with surgical microscopy, with magnification ranging from 15 to 25 times.

Currently, two main surgical techniques are used:

• Single-layer technique (Howards):
  The needle passes through the lumen of the vas deferens and traverses all tissue layers using 9-0 mononylon sutures (four cardinal stitches), followed by reinforcement stitches in the adventitial layer.

• Two-layer technique (Silber):
  The first layer involves mucosal approximation using 10-0 mononylon sutures, followed by muscular layer approximation with 9-0 sutures.

Both techniques yield excellent outcomes. Based on our experience, patency rates of approximately 90% and paternity rates around 75% can be expected.

If pregnancy does not occur naturally after surgery, the female partner should be reevaluated and the most appropriate assisted reproductive program should be proposed.

Medical Literature References

• Lipshultz LI, et al. Surgical management of male infertility. In: Wein AJ, et al. Campbell-Walsh Urology, 9th ed. Philadelphia, PA: Saunders Elsevier; 2007.

• Practice Committee of the American Society for Reproductive Medicine. Vasectomy reversal. Fertility and Sterility. 2008;90(Suppl):S78.

• Vasectomy reversal. UrologyHealth.org (American Urological Association).

• Lipshultz LI, et al. Techniques for vasectomy reversal. Urologic Clinics of North America. 2009;36:375.