My spouse had a vasectomy in 2000 and an unsuccessful reversal in 2008. We are considering a second reversal.
1. What things should we look for or consider when choosing a doctor?
2. Would you normally recommend a revision surgery on a failed reversal with the original vasectomy being so far out?
3. Is there anyway to know whether a V-E is needed prior to surgery?
4. Can a redo be done in a VV fashion? If so, why would the first have failed?
5. What is a good price range for this surgery?
It is always possible to do another reversal but the details of the first surgery are important in predicting whether another surgery would be possible or could be successful. Most likely a VE would be needed but, again, the details of what was found and what was done at the first surgery may be important. For those of us who perform vasectomy reversals at a high level, we just do what we need to do at the time of surgery, whether that is a vasovasostomy or vasoepididymostomy depending upon the findings during the surgery. Pricing is difficult but the important details are that an operating microscope needs to be used, anesthesia (in my opinion) should be employed. Pricing which is far below the norm is a red flag. I have a special arrangement with Boston Medical Center and the anesthesia group here that allows us to have a fixed price that is about as low as is reasonable. I cannot/should not give out pricing here but feel free to visit my website at robertoatesmd.com for the details.
Hope this helps,
Dr. Oates
Published on Jul 11, 2012
1: You should choose someone who has done hundreds and experienced in redo reversals and doing the V-E.
2: You probably consider IVF options however there are urologists who specialize in repeat vas reversals. If you consider a second reversal choose one of these doctors. Dr. Silber in St. Louis comes to mind and is easily found on the internet.
3: No. The doctor would probably check the fluid at the vas reversal site and if poor look for the area of obstruction in the tubules of the epididymis to find good fluid and do the reversal there.
4: Yes if the fluid is good at the time of the procedure. Clear fluid with sperm. If your husband has no sperm no then failure could be from the scarring of the new repair after the reversal or there was a blockage at the epididymis and this has prevented sperm getting from the epididymis to repair site.
5: Price varies. The most expensive urologists have to use the hospital, general anesthesia and maybe have a niche in ball park of 12-20 thousand. Urologists who have their own facility and general anesthesia 6-10 thousand and then those who use an office and local anesthesia with oral sedation 1800-5000 dollars.
Those are very good questions and your situation is tricky. Good luck.
Published on Jul 11, 2012
1. Consider the experience of the surgeon
2. Failed reversal vs first time reversal - outcomes are similar
3. Difficult to predict - since 17 years after vasectomy - VE may be needed at least on one side
4. VV or VE depends on the intraoperative identification of sperm in vasal fluid (Ramasamy et al. Andrology 2014) - in fact unto 30% of the time in repeat cases, the VE was not done even if it was indicated (http://www.fertstert.org/article/S0015-0282(08)02537-5/abstract)
5. Around 10K
Published on Jul 11, 2012
The most important thing to consider when thinking about having a vasectomy reversal is choosing your surgeon wisely - this goes ten-fold for a redo reversal. It is essential to choose a surgeon who is a fellowship training microsurgeon, meaning that they completed not only their 5-6 year residency in urologic surgery, but also completed a 1-2 year fellowship in microsurgery and reconstruction.
It is important to ask how many reversals the surgeon performs weekly, and the surgeon should be able to quote their personal success rate, and it should be very high. Microsurgical technique and experience is crucial to the success of a vasectomy reversal, as are the findings at the time of the reversal. I regularly perform microsurgical vasectomy reversals, and do see a fair number of reversal done elsewhere that are not successful.
My first question is how that reversal was performed (i would request operative report), and what the finding were at the time of surgery. I do recommend a revision surgery especially if the first reversal was not done microsurgically. There is no definitive way to know if an epididymovasostomy is needed prior to surgery, but risks for EVs include length of time from the original vasectomy (over 10 years), and length of the lower vasal segment (high is better). With that said there is no cut off past which I would not perform a reversal or a redo, but length of time is something to consider. The redo is approached exactly the same as a primary reversal. The area of original blockage as well as the new anastomosis is located, and the vas deferens is transected below this site. The vasal fluid is examined for its consistency and fluidity, as well as for the presence of sperm. Depending on the quality of that fluid, I would decide on either a vasovasostomy or epididymovasostomy. The alternative to doing a redo reversal is sperm retrieval - usually percutaneous epididymal sperm aspiration and in-vitro fertilization/intracystoplasmic sperm injection.
The most common reason a reversal fails is that the anastomosis doesn't "take" as you are relying on the two ends of the vas deferens to grow back together (assuming a vasovasostomy was performed), and this is often about technique. Scarring can occur and the reversal not work. Reversals performed non microsurgically have a significantly high failure rate, but even reversals performed by the microsurgical standard of care fail despite a good surgery being performed and good postoperative recuperation. The other reason a reversal can fail is from an obstruction in the epididymis being present and not recognized and an epididymovasostomy not being performed when needed. When asking about fees its important to find out the total fee for the procedure, as many websites advertise only the surgeons fee or the professional fee. Since the surgery is done in an operating room under general anesthesia, there are fees for facility and anesthesia services as well which need to be quoted. As a total price - including surgeons fee/professional fee, facility fee, and anesthesia fee - prices range from $10,000 - $20,000 depending upon the geographic region of the surgeon.
Published on Jul 11, 2012
It is more likely that you will need a VE (probably about 75% chance), but you never know until you check the vasal fluid microscopically. You should definitely work with someone who does VE's on a regular basis. Previous failed procedure was likely due to either needing a VE but the original doctor only knew how to do a VV, or scar tissue formation during the healing process re-blocked the vasa. Average price for a VR by a true reversal expert (not a non-urologist who does a quick procedure under local anesthesia) is about $10,000--here in Ohio, the price is $6,300, so there is definite regional variation. Your other option is to do a sperm extraction + IVF.
Published on Jul 11, 2012