With the patient under anesthesia, a 1-2 inch incision is made in the scrotal skin over the old vasectomy site. The two ends of the vas deferens are found and freed from the surrounding scar tissue. A drop of fluid from the testicular end of the vas is placed on a glass slide and examined using a light microscope. This is a crucial part of the operation because the information obtained is used to decide what type of microsurgical reconstruction needs to be performed. Since the testicle continues to produce sperm after a vasectomy, the fluid in the vas should contain sperm. There are 3 possible scenarios that may be encountered when examining the vasal fluid. The first and best scenario is that the vasal fluid contains whole sperm. The second possible finding is that the fluid is thin and copious and contains only sperm parts or no sperm. The third is that the fluid is thick, pasty and contains no sperm. This last scenario usually means that a "blow out" or rupture has occurred in the epididymis. Sperm leak out if the pressure in the tubule becomes greater than the resistance in the wall of the tubule, similar to the way a pipe breaks in the basement when the water pressure gets too high. The body tries to heal this tubule and a scar forms. This causes a second blockage in the epididymis, which needs to be bypassed to allow the sperm to get out into the vas. If this second blockage is present and is not recognized then the operation is doomed to failure.

Micro Surgical Vasovasostomy

If the vasal fluid contains sperm then the two ends of the vas deferens can be sewn together. This procedure is known as a vasovasostomy. The associated pictures were taken through the operating microscope during a vasovasostomy performed by Dr. Werthman. An artist drawing is depicted to the right for illustration purposes. The lumen or channel inside the vas deferens through which the sperm swim is only 0.2 to 0.3 millimeters in diameter (about the size of a pen dot). An operating microscope is used to magnify the operating field up to 16 times. The vas can then be better visualized and the sutures can be precisely placed. You can now easily understand that without the use of the microscope this operation would be very difficult, if not impossible to perform successfully. All studies have demonstrated that microsurgical vasectomy reversal is more successful than those procedures performed without the microscope or with loupes (magnifying glasses worn by the surgeon).

The technique we prefer is a two or three-layered closure using 10-0 and 9-0 suture (half the thickness of a human hair). We place 6-8 interrupted sutures in the mucosa or inner layer of the vas to ensure that the repair is water-tight (figure 2). This is very important because one reason that vasectomy reversals fail is that sperm leak out from the vas at the surgical site and cause inflammation and a new blockage. The muscular layer of the vas is then re-approximated adding strength to the repair (figure 3). The surrounding connective tissue is also brought together as a third layer to take any tension off of the repair site. The skin incision is then closed.