R eversing a vasectomy is not merely a matter of "reconnecting the tubes" – apart from the technical ability required from the Urologist performing the surgery, there are crucial decisions that he will need to make during the operation. It is his ability to correctly combine all of these factors that will ensure the highest chance of success for you, the patient.
The vasectomy reversal operation is started by making an incision into the skin of the scrotum just above each of the testicles. The incisions are usually about 20mm long but may be extended in complicated cases in order to free up more of the vas deferens. The area of the previous vasectomy is identified and the two tied-off ends of the vas deferens are exposed. The next step is to excise these closed-up ends – this will leave two healthy ends of vas deferens that can now be sewn back together.
But first the Urologist will have to make an important decision…
After a vasectomy the testicles continue to produce sperms, but because the vas deferens had been tied off, these sperms cannot be transported away from the testicle and epididymis. The consequence is a build up of pressure inside these structures. The epididymis is a very long and thin tube that is rolled on itself hundreds of times - over time, the pressure increase inside it will cause damage to the epididymis. This will eventually lead to blockage of the epididymal tube (Image 1). The longer the time since your vasectomy, the bigger the chance of you having damage and obstruction of the epididymis. And you've probably figured the rest out – there is no use re-connecting the vas deferens "downstream" if there is an obstruction in the epididymis "upstream" from it.
1 What are your chances of having epididymal obstruction?This risk increases with time since your vasectomy, but even if your vasectomy was less than 5 years ago, you have about a 40% risk of epididymal obstruction. This risk increases to 75% if more than 10 years have passed since your vasectomy. Patients with epididymal obstruction need an operation that is completely different to the routine re-connection of the vas deferens!
2 How will the Urologist know whether there is epididymal obstruction and what are the options if it is present?
Certainly, just re-connecting the vas deferens will be a waste of time. The worrying thing is, that of all the Urologists who perform vasectomy reversal surgery in South Africa, almost none of them have the equipment or skill to deal with epididymal obstruction. In most cases they will simply continue with re-connecting of the vas deferens and this is bound to fail. Epididymal obstruction is identified by microscopic examination of the fluid that comes out of the vas deferens on the testicle side. I do this examination myself in the operating room using a separate microscope with 400X magnification.
If sperms are present in this fluid (Image 2), I will continue with re-connecting of the vas deferens. If sperms are not present (Image 3), it means that there is an obstruction in the epididymis. In these cases, I will perform an operation to connect the vas deferens to the epididymal tube in an area in front of the blockage – this procedure is referred to as vaso- epididymostomy.
The American Society for Reproductive Medicine issued the following guideline in 2008:
"Since it is seldom possible to determine pre-operatively if vaso-epididymostomy will be required in a man undergoing vasectomy reversal, only surgeons skilled in both vaso-epididymostomy and vasovasostomy should perform vasectomy reversal"
3 Connecting vas deferens to vas deferens – vasovasostomy
During the early stages of your vasectomy reversal operation, I will collect fluid from your vas deferens and examine it under a microscope with 400X magnification. The presence of sperms in this fluid will indicate that there is no obstruction in the epididymis, and in these cases I will continue to perform vasovasostomy. The two ends of the vas deferens that have been prepared are placed next to one another under the operating microscope that provides 24X magnification (Image 4).
Re-connection of the two ends is done in two layers to provide a watertight seal. The inside lumen / canal (diameter 0.4 – 1.5mm) is sewn first using a special 10-0 nylon suture (Image 5).
Although this suture is mostly used for very delicate eye- and heart surgery, leading Urologic micro-surgeons worldwide also use it for vasectomy reversal. The suture is barely visible with the naked eye and is only 0.02mm thick. Although this suture is very expensive, it has the major advantage of causing minimal inflammation, thus preventing the formation of scar tissue and subsequent blockage of the vas deferens. These complications are more common when thicker sutures are used.
4 Connecting vas deferens to epididymis – vaso-epididymostomy
Epididymal obstruction is present in cases where microscopic examination of the vas deferens fluid shows no sperms (Image 3). If this is the case, I will proceed with the vaso-epididymostomy procedure.
The open end of the vas deferens is loosened up and brought into position next to the epididymis. The area of epididymal obstruction is identified and care is taken to connect the vas deferens to the epididymis in an area in front of the obstruction. The extremely thin epididymal tube (0.08mm) is identified and a small opening made into it. The vas deferens is then sewn to this opened tube, thus providing a passage for sperms and bypassing the site of blockage in the epdidymis (Image 6).
After completing the vasectomy reversal on the right and left sides, the scrotal skin incisions are closed. For this I use a suture that dissolves after about 3 weeks. A tight dressing is placed on the scrotum to prevent bleeding. You will be able to go home later that same day (ie no need to overnight in hospital) and will receive a prescription for pain medication. You will not be allowed to drive a car for the first 24 hours after the procedure, so be sure to have someone available to take you home from the hospital.
Because of the small size and delicate nature of the tissues involved, this operation is not quick to perform. It usually takes 3 hours, depending on whether vasovasostomy or vaso-epididymostomy is needed. Remember that reconstructions have to be done on the right and left sides, and each side involves a double layer closure with multiple stitches.
Because of the precision and concentration required, I do a maximum of only two cases per day. A micro-surgeon should never be rushed!
Because of the long duration of this procedure I absolutely prefer my patients to be under general anaesthetic. Some Urologists will offer vasectomy reversals under local anaesthetic or conscious sedation only – these are mostly colleagues who do not use the operating microscope.
The anaesthetists fee for sedation only (“twilight anaesthesia”) is not significantly less than for a general anaesthetic. During a microsurgical vasectomy reversal my patient needs to lie absolutely still for the entire duration of the surgery. Because it is a long procedure (3 hours), an awake patient is bound to become uncomfortable and restless. Even the slightest movement at a crucial moment may compromise the success of the operation.
I use only specialist anaesthetists who have many years of experience. In contrast to certain general practitioners who also provide anaesthetic services, these specialists have undergone at least 4 years of intensive training in an academic hospital and obtained a specialist degree from a reputable university. Their practical experience and theoretical knowledge is superior and they are highly trained to deal with any kind of situation that may arise while you are asleep in the operating theatre. I do not compromise on quality in this regard, because as a patient your life is literally in their hands!
You should take it easy for the first few days after the operation and will usually be booked off from work for 3 days. Locally applied ice packs in the first 24 hours as well as a tight scrotal support garment for a few days, are very effective in preventing post-operative pain and swelling. I will provide you with a prescription for pain tablets as well.
You should avoid heavy physical activity for approximately 3-4 weeks - remember that this is operation is performed on very delicate structures which need time to heal and to regain adequate strength in the areas where the reconstructions had been performed. For this reason you should also abstain from sexual activity for at least 3 weeks.
Sperm analysis tests are done at 3 months, 6 months and 12 months after the operation. The tests will provide us with valuable information regarding the success of the operation and quality of the sperm.
Vasectomy reversal is generally a safe procedure. Complications are very uncommon and in the unlikely event that they do arise, conservative (non-surgical) management is successful in almost all cases.
There is virtually no bleeding during the operation. It is also quite uncommon to have bleeding on the inside of the scrotum (wound hematoma) in the days following your surgery. Should this occur, management will usually involve a course of antibiotics and anti-inflammatory medication, as well as tight fitting scrotal support. Most of these hematomas will resolve on their own and there will be no long term effects. It is important that you take it easy for the first few days after your surgery in order to further reduce the risk of a wound hematoma.
Once you are asleep in the operating theatre, the anaesthetist will inject you with an antibiotic – this is standard for all surgical procedures and is sufficient to prevent infections after vasectomy reversal. There is no benefit in routinely taking an additional full course of oral antibiotics after your operation – in fact, this practice increases the resistance of germs to antibiotics. Wound infections may rarely occur after vasectomy reversal, and will usually be managed with a course of oral antibiotics.
Failure of the operation:
There is no Urologic surgeon in the world that will give a 100% guarantee of success for vasectomy reversal. Even if the operation itself was successful (resulting in a patent vas deferens and sperms present on post-operative semen analysis), it is still not a guarantee that your female partner will become pregnant ("Patency rate" vs "Pregnancy Rate" - see Terminology). You and your partner have to take the risk of failure of the operation - even though it is relatively small - into consideration before making a decision about vasectomy reversal. It is very important to me that my patients have realistic expectations of the outcomes of this procedure. (See "Success Rates").
Good day Dr Zarrabi I hope you are keeping well. It has been 10 months since we did the Varicocele repair and a lot has happened since then and obviously it’s been quite a journey. But needless to say it was not all in vein. Hence my e-mail to you today. If you recall we went back to the Aevitas about August for one last Invitro (6th). The result was that we had a better count and better mobility due to the Varicocele repair as what we ever had before with the previous 5 Invitros. And I am very pleased to announce that E had a successful/positive result and she is 3 and half months pregnant now. We would just like to express our Sincere Gratitude to you and your staff for all your assistance and prayers through the whole process. Kind regards,
We want to thank you and Dr Zarrabi for being kind and gentle…. There is such a huge difference in patient care, follow-ups and bruising between the previous Dr and Dr Zarrabi’s offices. I thank God that we went to your practice and I will let you know if there is a little heart beat inside of me… Lots of Love.
Good day Dr Zarrabi Trust you well. I just wanted to say thanks very much for your professionalism and great help on my husband’s operation. Today I have a very healthy active 9 month old son thanks to you. At one stage we had just given up because nothing happened but then this miracle came along. Keep up the great work. Thanks and regards,
Dear Dr Zarrabi We have the best, if not surprising news, 'M is PREGNANT!!! She been feeling funny in the latter part of August as I was starting my course of prelox. We are overwhelmed and overjoyed. Thank you, thank you so so much.
Good morning Gillian I just want to send you this email to say a big thank you for all your assistance in making our trip a success. We are safely back home and everything with M is going great so far. Dr Zarrabi really is the best! I will keep you posted on any further developments. Thank you kindly and have a blessed day.
Hi Doctor Baby girl YP was born on the 12th of April 2017. You do amazing work and she turns 3 months old tomorrow. See pics attached… Regards
Dear Dr Zarrabi A and I feel truly blessed to have been able to have this reversal done by Dr Zarrabi. The fact that he is able to even perform an operation of this nature is truly amazing and we are fortunate to have somebody in South Africa that has the skillset to perform Micro surgery reversals. I imagine it must be very rewarding to make such a positive difference in people’s lives. In addition to this we found it to be easy and hassle-free to undergo the surgery in spite of the fact that we live more than 1500 kilometres away. Thank you for the professional, efficient and friendly way that you assisted us throughout this process. I will be sure to let you know as soon as A is pregnant (she may already be). Once again thank you.
Good day Dr Zarrabi Thank you so much to You and your Staff. We (my Wife) recently did a blood test; and it came out positive - that she is pregnant. Thank you soo much Dr Zarrabi; thank you for helping us in our journey.
Thank you so much, doc I truly appreciate all your support and valuable information. I hope your stay in the USA is amazing, you have been the most amazing medical professional i have ever dealt with and I'm extremely grateful that you've helped me all along. Kind regards,
Good day Dr Amir / Gillian and Team I hereby would like to thank you all for the excellent and friendly service we received. Everyone on the doctor’s staff was professional and efficient, they made me feel at ease in a stressful situation. I felt that I made a good choice in coming here and, as a group, each of the staff members cared for me and wanted to help me get better. I was thoroughly impressed with the facilities and services at the hospital. Everyone knew what needed to be done, at what time and did it with a smile and compassion. Any questions that myself or wife had was answered quickly and with a friendly disposition. In closing, I would like to thank you for all that you did even after I was dismissed and had a little complication Dr Zarrabi assisted and was ready to take action. It is professionals as yourself and facilities like your hospital that made me decided to use you from the beginning. Regards,
Dear Dr Zarrabi We are not sure you will remember us, amongst all your clients! D and I came to see you in November 2013 for a vasectomy reversal procedure. You were a little concerned that his vasectomy was 15 years in the past and he was 55 at the time. We visited your practice this month while in Cape Town for the first scan of our expected little one - we wanted to share the good news with you! We did conceive within 3 months of the procedure but had an early miscarriage and what with the ups and downs of life over the last 2 years didn't get this far until now. SO - D is in peak condition and our baby is due on Christmas day this year. Thank you so very much for all the microsurgery and D says please send him 1000 business cards to hand out wherever he goes! We will send you a picture of the three of us for your collection when baby is born. With heartfelt gratitude and deepest thanks.
Dear Dr Zarrabi We are writing to you to thank you for your amazing care, concern and professionalism. Since meeting you we have has such a wonderful experience working with you. Thank you for everything!! It is greatly appreciated. Wishing you a good evening. With gratitude,
Hi Amir Hope all's well on your side. I am pleased to announce that L is pregnant - exactly 1 year to the day of the reversal! We had it confirmed with a blood test today. We just thank you for your skill and optimism. Just interested to know... Have we set a new record for length of time between vasectomy and reversal: 18 years ;-) thanks again to you and your team. Cheers D.
Liewe Dr Zarrabi Ons wil u net graag in kennis stel dat die prosedure wat u gedoen het suksesvol was. Ons moes nog gaan vir die sperm analise, maar ons het vroeër uitgevind ons is swanger. Ons is nou 6 weke swanger, en wil u net baie hartlik bedank vir die suksesvolle operasie. Baie Dankie
Hallo Dok, Lyk my jou operasie was ‘n reuse sukses. My vrou is nou 11 weke swanger. Dit het ons dus so 1 jaar en 3 maande geneem om swanger te raak. Groete,
Hi Amir Weereens baie dankie vir jou hulp! Dit was n great ervaring! Baie profesioneel! World Class!! Groete
Dear Dr. Zarrabi, Hope you are well. I just want to say thank you for a fantastic service and care I received. It was nice to chat with you first and it made me feel like I am in the right hands. The staff in the clinic were also great. Warm and kind and understanding. A service that stands out compared to other clinics or hospitals where nobody comes to check on you and you never see anybody around.
Hallo Dokter Zarrabi Ekt gister met my sussie en swear ‘n koffietjie gedrink en hierdie ‘great’ storie gehoor van hoe u hulle hanteer en versorg het. (eintlik gebless het!) My mond het oopgehang, want mens hoor dit min. Dankie Dokter, ek eer en respekteer jou daarvoor. Alle sukses met jou praktyk en drome vorentoe. Vriendelike groete
Hello Dr. Zarrabi, It has been a hectic couple of months. I have great news, M is 11 weeks pregnant and to top it off I didn’t even go for the sperm test. We found out the week that the test was scheduled. Thank you! You have worked miracles we never in our wildest dreams thought that it would happen so soon. We will keep you updated as the pregnancy progresses and might even come introduce the little one next time we are in Cape Town. Regards
Dear Dr Zarrabi, Many thanks to you and the gift that you have given to me. I really wish that I were in Cape Town to celebrate with you. Thanks once again for your great skill and miraculous hands.
Hi Doc, Just a quick email to share our wonderful news - we are pregnant!!! We can't thank you enough for all you have done, and not giving up when most doctors probably would have just shrugged their shoulders. I know you were a tool in the Great Healer's hands, but nonetheless, a BIG thank you!! Can't wait to send our updated family picture. Have a wonderful, blessed day!
Dear all, After much soul searching, S and I decided to reverse his vasectomy and try naturally before resorting to other options. S had his vasectomy reversal done by Dr Amir Zarrabi. We never got to do the 6 month sperm test as I had fallen pregnant. The pregnancy was uneventful and our son was delivered at 39 weeks.
Hi Dr, Thank you so much for this report!! I am in tears right now, I did not even realize how much I was stressing about this until I got your e-mail!! You really have made this year the best one ever and we will highly recommend you to anyone we can. Your support and complete handling of our case including your after service has been so amazing! We are both so grateful to you. Kind regards,
Dear Dr Zarrabi This letter is long overdue…but for a very happy reason. My wife and I would like to express our heartfelt appreciation for the efforts you made and the application of your considerable skill in reversing my previous vasectomy done 13 years ago. Before proceeding with the surgery you fully explained what we could expect in terms of a timeline, and we complied with all the steps along the post-surgical way. As per your instruction we were supposed to have a sperm analysis done 3 months after the operation but when my wife missed her date we knew something was going on and I didn’t even have to go for the sperm test. We were ecstatic to learn that the surgery was successful and that I was once again delivering viable “swimmers”! We are now 12 weeks pregnant and all thanks goes to you. Doctor we are so blessed to came across your information on the website just when we were at our lowest. We have been through ICSI twice, as we thought it would have a better chance of success. With even everything as normal and positive as could be both sessions was unsuccessful. It costed us a fortune and we didn’t realize that if we did our homework properly the first time, we could had our baby in our arms right now. That is why we are extremely thankful that you have done such a great job. We never doubted you once…we just knew this was it. Words are a poor conveyance of the gratitude we feel, but please accept them with the knowledge that you have made us very happy as a result of your outstanding skill and diligence. Warmest regards,
Hi Doctor Amir, We hope that you and your family had a wonderful Christmas and new year. We have some wonderful news, D is pregnant!! This miracle was conceived naturally!! She is just over five weeks today and we are both over the moon. We would like to thank you again for all that you have done for us to make this miracle happen! We will keep you updated. Kind regards,
Dear Dr Zarrabi, As you can see from the attached pics, our 2015 started off extremely well, all thanks to you... KL was delivered via c-section at 08:31am on Friday the 2nd Jan 2015. Weighing 3.22kg and measuring 51cm. She is gorgeous! I'd like to extend a very big thank you to you and your staff for making our dream come true. A is thrilled to be a big sister. Take care and best regards,
Good day Dr Zarrabi We are happy to announce the birth of our baby girl TH. She was born on the 4th of February 2015 weighing 3.350kg. This was a miracle to us. We would like to thank you for making our dream come true by resulting in a successful vasectomy reversal on my husband G in October 2013. Thank you so much doctor!