Best Life Microsurgery Clinic - Seven Must Know Facts Before You Chose To Have Vasectomy Reversal

 

What is Vasectomy Reversal?

Vasectomy reversal (Snip Reversals or Reversal of Male Sterilisation) is the operation to identify the cut ends of the vas (which has a minute diameter of 0.2 - 0.4 mm)  that carries sperms from the Testis to the penis and reconnect them to give a chance to become fertile again.

The main principles of this operation include the following

1. Achieve the best possible alignment of the minute openings (lumens) of both cut ends that could be of different diameters

2. Connect them in a leakproof manner, as leakage can cause blockage of the connection

3. Preserve the blood supply to the vas throughout the procedure, as careless handling may compromise the blood supply and cause scarring & blockage

4. If there is blockage upstream at the level of the epididymis, then a procedure of connecting the vas to the epididymis (Vasoepididymostomy) will be needed. A reversal service cannot be complete if the surgeon does not take steps to diagnose the blockage and perform this procedure. Simply connecting the vas end to the other end will not work.

If these principles are not adhered to, the operation will likely fail due to blockage at the connection.

Seven  Facts You Must Know about Vasectomy Reversal

1. Vasectomy is a reversible operation with success rates most of the time, contrary to the wrong opinion even from healthcare professionals. 

As the first point of contact, many couples seek advice from local fertility clinics. Unfortunately, most fertility clinics offer them the only option of IVF. Couples are not usually told about the option of vasectomy reversal, which could offer them the possibility to conceive naturally.  IVF does involve invasive and intrusive procedures for both partners, and it's not a natural way of conceiving. Vasectomy reversal may be the appropriate first-line option for many couples, allowing them to conceive naturally. Of course, IVF will be a more appropriate option for some couples, as mentioned below at the last fact.

2. How do you identify if the clinic you are considering does the real microsurgery?

Real Micro-surgery is the game changer in the outcome of Vasectomy reversal. The multilayered technique of the reversal is the current Gold-Standard, described with diagrammatic illustrations in the last section of this page. 

Do not hesitate to ask the surgeon or the clinic the following questions.

• How long does it take to operate, and how many layers is the connection?  Proper three-layer procedures on both sides will demand an operating time of an average of 3 hours.
• Do they connect the inner layer (mucosal layer) separately? This is the important, technically demanding and time-consuming part of the operation.  In some places, they seem to do a second layer with tissues around the vas after a full-thickness connection and call it a multi-layer procedure. 
• What stitches (sutures) do they use?     The finest sutures are called 10-0 or 9-0 stitches which contain needles as thin as the hair. Most will need 10-0 stitches to connect the inner layer separately. These needles cause minimal or no trauma to the tubes.  Bigger the number before 0 (zero) finer the stitch. 
• How many procedures do the surgeon and team perform? The recommended critical minimum number is at least 12 per year. The bigger the number of procedures done in the right way, the better the outcome will be. At Best Life, we perform 15-20 procedures per month.

Many surgeons use 6-0 stitches containing a much bigger needle. Using bigger sutures with bigger needles causes more risk of trauma to the fine vas, which can cause blockage after the reversal. Three layered technique provides better alignment and leakproof connection of the vas ends.

3. Does the surgeon check for blockage upstream or Blow out and examine the fluid from the end of the vas attached to the testicle under the high-power microscope? 

Blow-out or obstruction of the epididymis happens after vasectomy due to back pressure build up in the long thin tube called epididymis before it continues as vas. Simply reconnecting the ends of the vas will not work if there is a blowout. This situation will need an even more delicate operation called  Vaso-Epididymostomy. The surgeon and the clinic should have the skills and resources to perform Vasoepididymostomy to deal with blockage upstream that can happen in 2 out of 10 men who had a vasectomy more than ten years ago. There can be other challenging situations during the reversal procedure. Please see our separate page on Difficult Situations (Click Here). 

This microscopic examination of the fluid is so vital for the following reasons. 
a. It will help to diagnose blockage at the level of the epididymis and decide the appropriate procedure, either vasovasostomy (connecting vas to vas ) or Vaso-Epididymostomy (connecting vas to the epididymis). 
b. It will be helpful to predict the outcome more accurately  
c. If there is a failure, it will be helpful to more accurately decide the reason for failure and counsel the patients if  a redo-reversal will be helpful. For most patients who come to us for redo-reversal, unfortunately, we don't get this information from the other clinics.

Unfortunately, many surgeons do not perform this necessary test and blindly perform the same vasovasostomy procedure in all patients.

4. How are the Reversals done in the UK?

 Not all surgeons do the operations to the same excellent standards for various reasons. Check out below to learn more, and don't hesitate to ask what method they are doing. Unfortunately, there is no standardised way of reversing vasectomy in the UK. The reversal operations are done in the following ways. The type of procedure is chosen mostly due to limitations in the surgeon's experience, resources, the need to limit the operation time and the need to offer the procedure cost-effectively. Therefore it may not necessarily be only in the interest of the patient. So you must research and choose the clinic and surgeon diligently.

Reversal without Microscope and using larger stitches with bigger needles (substandard currently, and don't even consider this option)

Surgeons use magnifying loupes that give almost 2-3 times magnification, and they use bigger  6-0 stitches that contain a needle that is as thick as half of the lumen of the vas. This is a very basic way of doing this procedure. The tube ends are joined with six stitches on a single layer. It may take 60 to 90 minutes to do this procedure. This is a no-go area if you want to have a predictable result. 

Reversal using Operating Microscope but larger needles and stitches (Not current Best Standard)

Surgeons use similar material as above but with the help of an operating microscope. Here the operating microscope provides a bit more magnification. But its magnification power is not used as surgeons choose the easy and less demanding way of using larger sutures (with larger needles) and conventional instruments. The operation is done in one layer of 6 - 8 stitches and will take about 90 minutes. This technique is widely used in the UK to drive down costs by limiting the expensive operating theatre and surgeon time while claiming it as microsurgery (arguably incorrect in our opinion). This procedure will work only if the quality and dimensions of the tubes are relatively straightforward. But the patient or the surgeon cannot ensure that until at the time of the operation. 

Reversal using an operating Microscope and Advanced Multilayer  Microsurgery (Current Best Standard) and the ability to do the correct reversal procedure, including Vaso-Epididymostomy.

The best possible alignment of the tubes can be only achieved by multilayer microsurgery reversal using very minute 10-0 or 9-0 stitches. It is so important to connect the vas's inner layers (mucosal layer) separately to keep the connection site (anastomosis) open or patent. In real life, during the operation, the inner layer can look very collapsed, with the diameter of the opening varying from 0.2-0.4mm. That is the reason multilayer surgery carries a distinct advantage. Two different surgeons (Silber and Owen) initially described this method using two layers in 1977. They described a two-layer technique that raised the successful outcomes from over 40% to over 90%.

Further development brought by Professor Goldstein at New York’s Cornell University was called Microdot Multilayer Microsurgical Vasovasostomy (MMMV), the world’s gold standard procedure. This involves using three or more layers to reconnect the tubes. This helps realign the tubes of varying diameters even amid challenging situations such as extremely thin ones.

5. Does the age of the man and the longer time interval since vasectomy rule out the option of Vasectomy reversal?

The testicles produce sperm even in older men (Guess what is 'Old'). There is an age-related decline in sperm quality as men get older. But unlike women who stop being fertile after menopause, men continue to produce sperm well into old age. Of course, one should think about the physical challenges of becoming a dad again as they age. We don’t define what is old. It is up to the individual to decide that. So don't resort to IVF just because of age. Longer time since vasectomy adversely influences the outcome, but not the only factor and does not compromise the results completely. With vasoepididymostomy, the success rates can still be up to 50%, even in men who had a vasectomy more than 20 years ago.

6. Is the Vasectomy Reversal a complete answer to my dream of having a baby?

A resounding 'NO'.  It is only a part of the game in your ultimate expectation of having a baby. Vasectomy reversal only addresses the malefactor, possibly bringing him to a fertile state. Pregnancy chances can be compromised by the quality of sperm, which is not directly influenced by the reversal operation and any other fertility issues with the female partner. So, your partner's needs must be considered before you decide about the reversal. If your partner has any fertility issues, it is better to get checked by a female fertility specialist. In such couples, IVF may be more appropriate.  But it is still worth exploring both options. 

7. Is the meaning of success for the vasectomy reversal and IVF the same? 

Not really. One important point you need to know in choosing between Vasectomy reversal and IVF is how you interpret the figures quoted as success. Success is defined as the patency rate, not the pregnancy rate for vasectomy reversals. Patency rate means the presence of sperms in the semen after the reversal operation. The pregnancy rate may be much lower than the patency rate due to other factors, including partner factors. For IVF, success is defined as the pregnancy rate. Of course, the reversal operation gives you the possibility to have a child naturally.

What do we offer at Best Life Clinic? Only the Current Best Standard

We offer the same advanced Microdot Multilayer Microsurgical Vasovasostomy (MMMV). This service is unique in the UK.  We are cost-effective and maybe even cheaper than some clinics offering basic procedures. You can easily identify how long the operation takes and what size stitches the surgeons are using. Please do not hesitate to ask that question. We have not seen many surgeons in the UK fully transparent that they do this multilayered procedure though this is the standard of care in most male infertility centres in the United States. This operation usually takes three hours using minute 10-0 and 9-0  sutures. The full magnification power of the operating microscope will have to be used during the difficult and minute steps of the procedure. 

We also perform Vaso-Epididymostomy in the event of Blow-out that is diagnosed during the operation. So there is hope even if there is a blowout. At the time of the procedure, we regularly check multiple samples of the fluid from the testicular end of the vas. This ensures that our procedure has the highest possible chances of success. 

Which Clinic should you choose?

Please do your research and read through the materials on our website. Based on that, it is up to you to make your informed choice. You may wish to choose a clinic close to you geographically, but ensure you get the best standard of care. The surgeons using basic techniques may claim that their techniques are working. Nature's healing mechanism is indeed so wonderful there is even a chance of a spontaneous natural reversal in one out of 2400 men undergoing vasectomy. So all procedures will work to some extent, but do you want to settle for something less than the current best standard? If the surgeon can do only one type of basic reversal procedure, the outcome is left to the chance of you being the right patient for that surgeon. But it should be the other way around. The surgeon should have the skills and resources to make the procedure right for you as per the needs arising during the operation. The needs can be very challenging such as loss or damage to a long segment of vas, extremely thin vas, varying diameters of the cut-ends of the vas, vas being cut very close to the epididymis and blow outs. 

We can assure you that we are capable and resourced to deal with these Challenging situations because of our unique factors and resources mentioned below.

• Ability to offer Advanced Multilayer reversal
• Allocation of four operating hours per patient. We dedicate the full four hours session for each patient. Maximum, we perform two operations per day. We have performed 650 multilayered reversals by the same surgeon. 
• Resources & skills to do vaso-epidydimostomy at the same sitting  
• The all-inclusive cost for the procedure (Click here for the information on  Cost)

Listen to the Surgeon for a comprehensive Overview 

Practical Aspects of the Reversal Service at Best Life Clinic. 

For more detailed information on the vasectomy  Reversal journey with us, please visit our web page ' by clicking the link below.

 

The vast majority of our patients decide after a remote video consultation except those who desire to come for a face-to-face consultation or those who seek this operation for post-vasectomy pain or if we sense any high-risk factors in their clinical information provided. You will have the opportunity to discuss with the surgeon, Mr Manohar Jesuraj, the full details of the reversal specific to your situation, possible outcomes, risks and alternatives. Then you will receive a written summary of the consultation with some other information, including a web page link to available dates for the procedure over the coming months. There is no obligation for you to get back to us. We do not pursue patients after consultation unless they return and book the procedure. We aim to give you balanced information and help you decide. If you would like to benefit from this consultation, please complete a detailed questionnaire at this link. Consultation

Booking for the procedure

After receiving the consultation documents and information about the reversal, you may get back to us with your chosen date and pay the deposit to book a date for the procedure. Click for details of the Fee and Deposit.

Operation
Lasts approx. 1½ to 2 hours on each side.

• Usual Approach via a single horizontal or vertical incision
• We locate the vas and the site where the original vasectomy blocked the tube.
• Then we section the tube above and below this area to locate fresh open vas. At this stage, we check that the reproductive tract is still functioning by flushing the upper vas with saline and sampling fluid from the testicular vas under the microscope.
• Vasovasostomy ie. joining the ends of the vas together using special, very fine stitches thinner than a human eyelash (10.0 Nylon). The medical description of our operation is 'Multi-layer, Microdot Microsurgical Vasocasostomy'. In this exquisite procedure devised by Professor Goldstein, the inner layer of the vas that carries the sperms is microsurgically stitched together, followed by the muscle of the wall of the vas. Then the overlying tissue is closed over the top of the repair for strength and to ensure blood supply.
• In selected cases with definite signs of a blowout, we perform Vasoepididymostomy. This is an even more time-consuming and delicate procedure

Afterwards.
There are one of two scars, approx. 3 cm long - one on each side of the scrotum. We usually close these with a dissolving stitch buried under the skin so that there is no need for further visits to the Clinic. After taking tea and biscuits, the patient is accompanied home to rest.

On the night of the operation
We recommend that you stay the night in a local hotel if you live further than an hour's drive away. We can recommend the local hotels which are relatively less expensive. 

Return to work.
You must rest completely for  3-5 days and then return to normal activities five to seven days after the operation. You should avoid strenuous work for three weeks and avoid contact sports or bicycling for 4-6 weeks.

How will I know if the operation was successful?
We recommend an initial semen test for 12 weeks post-operatively, by which time we would expect a return of small numbers of sperm to the semen. Return to full fertility can take up to 12 months (in some cases, up to 18 months).   We request that your local GP arrange further tests at a nearby pathology lab. Your GP may decline to arrange this as an NHS patient. If that happens, we can request that you take it to a local fertility clinic and pay the appropriate fee to complete the test. Since most of our patients come from distant places in the UK and abroad, we have not included any cost of post-operative tests, including semen tests, in our fee.

We are pleased to offer our assistance in interpreting the test results and facilitating communication with your GP free of charge for a period of up to 12 months after the procedure. We are here to help and guide you every step of the way.

What are my chances of becoming fertile again?
This depends on many factors but chiefly the length of time since your vasectomy was performed. This is because the likelihood of the tubes being blocked increases with each year; however, the operation is successful in more than 80 % of men who had the reversal within up to 10 years after vasectomy. Even if the vasectomy was done more than ten years ago, there is still a worthwhile chance of success. For full details on the expected outcome, please click Chance of Success. 

Diagrammatic Illustration  of Our Reversals Procedure

Reversal by Our Gold Standard Technique

Introduction – it is natural to think that a reversal is a reversal and that all operations are roughly the same, so it is OK to shop around for the cheapest. So this presentation is to explain why we use the MMMV procedure, which takes about  3 to 4  hours to perform using expensive materials and gives the world’s best reversal results.

1. This is a diagram of the normal vas – a tiny (0.2 mm) sperm channel surrounded by a strong muscle coat and, beyond that, a layer of connective tissue, sinews and blood vessels. The overall diameter is around 2 mm.

2. Following vasectomy, which blocks the vas, there is high pressure on the lower testis side caused by the force of the sperms trying to escape. This causes the central sperm channel on the testis side to enlarge and dilate so that when we come to remove the vasectomy scar and rejoin the tube, the two ends of the vas look like this;

3. The simple method of reconnecting the tube is to stitch together the ends using a stitch that goes all the way through all three layers of the vas. This combines the very narrow end of the body side of the vas with the dilated testicle end of the vas, leaving a shelf where the two meet, as shown in the diagram. The technique is quick for the surgeon, who can often manage 6 or 8 daily operations. Surgeons doing this procedure usually use size 6-0 stitches with thicker needles. Such stitches can be handled by conventional instruments rather than real micro-surgical instruments. That will enable the surgeon to do the procedure quickly. ( Remember, less operating theatre time, more number of procedures, more profit  for the surgeon and the hospital!!) In such procedures, the operating microscope works similarly to a  magnifying loupe rather than being put to its full use.

4. The consequences of joining the vas in this way are as shown in this diagram, a narrow channel is formed for the sperms to swim through under pressure leading to low sperm counts, poor sperm quality (because they expend too much energy swimming through a narrow junction) and early scarring and closure of the join. This technique is used all across the UK and in clinics that perform reversals quickly with up to 6-8 patients in one day.

 

5. Professor Goldstein developed the Multi-layer microdot reversal (MMMV) at New York’s Cornell University to improve the pregnancy rates of reversals and make them as free from scarring as humanly possible. Results from Professor Goldstein’s trial of this method show that he has a 99.7% success rate with this technique and a pregnancy rate of well over 50%. Here is how it works. Of course, the dimensions of the vas are so small that special instruments have been developed for our use. First, six microscopic ink dots are placed on the ends of the vas to be joined, each at the same distance from the skin of the sperm channel. Next, a single micro stitch, a needle on each end, is placed through each of the six dots, and the stitch is tied together. This joins together the skin layer of the vas very accurately, opening up the narrow end of the vas and gently narrowing the wide testicular end resulting in a smooth, step-free join that is wide open, allowing the maximum number of high-quality sperms to pass through. Because there are no rough edges in the joint, it is rare for scar tissue and closure to form.

 

6. The next or second layer of stitches brings the thick muscular layer on the vas together in a leakproof join, and finally, a third layer of micro stitches joins the outer layers of tissue and blood vessels.

We can assure you that we are capable and resourced to deal with all of these Challenging situations because of our unique factors and resources mentioned below.

We are here to help with the assurance that Best Life Clinic always offers the current Best standard of service and try our best to make the procedure right for you.  So call us today Tel: 01642 939798 or Text us on 07305916901

 

This service and the highly experienced and dedicated team are based at Best Life clinic in Stockton on Tees, and Mr Manohar Jesuraj, Consultant Urological surgeon, leads the service. This service is going from strength to strength with a team of highly experienced nurses and support staff.