Reverse Vasectomy

In 1994, Chris Maslak went through a vasectomy he thought would be final. He was 37, and neither he nor his wife wanted children. But they wound up divorcing, and Maslak remarried. This time, his second wife, Lisa, was eager to get pregnant -- and for the first time, the young businessman regretted his decision to get sterilized.



Although his doctor had told him the vasectomy was permanent, Maslak sought out different specialists for advice. Surprisingly, doctors told him that through surgery, fatherhood was possible again, even after five years of being sterile. They gave the operation a 50 percent chance of success.



The first time, the reverse vasectomy was unsuccessful. But Maslak didn't give up. He had a second operation, a seven-hour procedure that wound up costing more than $10,000. And this time, the Maslaks beat the odds. On April 5, 2000, three months after the second operation, the Maslaks discovered they were going to have their first child.



Reverse vasectomies on the rise

A quarter of a century ago, if a man changed his mind about a vasectomy he'd received, doctors would have quietly informed him that the prospects of fathering a child were slim or nil. Doctors sternly caution men to consider a vasectomy only if they are absolutely sure they don't want children, and if they're uncertain about fatherhood, to gather sperm beforehand to store in a bank.



But years after getting a vasectomy, some men do reconsider their decision, and they're turning to doctors who can help them undo the effects of the surgery. Today men who get their vasectomies reversed have anywhere from a 30 to 75 percent of getting their partners pregnant, depending on how much time has passed since they underwent their vasectomies, doctors say. Reversing a vasectomy is considered so reliable that as early as the mid-1990s, some clinics advertised money-back guarantees on vasectomy reversals, and several private practice physicians and clinics still offer it today.



"Techniques have advanced considerably. Success rates have more than doubled," says Dr. Marc Goldstein. A professor of reproductive medicine and urology and co-executive director of the Cornell Institute for Reproductive Medicine, Goldstein has performed vasectomies since 1977. With rising rates of divorce and second marriages, the trend to postpone child-bearing to later years, and more effective surgical procedures, men as well as women are getting involved in fertility operations. More men who had their vasectomies up to a decade or more ago are having their vasectomies reversed, doctors say.



Men seeking to reverse their vasectomies are still in the minority, however, and that's because doctors tell patients they shouldn't consider it a temporary procedure. Studies show that only about 2 to 6 percent of the half-million or so men who seek vasectomies each year -- or up to 30,000 men annually -- will change their minds.



High cost of reversal

Why don't more men consider it? To begin with, undoing a simple, 30-minute vasectomy costs many times more than getting one. A vasectomy ranges in price from $350 to $1,000, but it can cost from $5,000 to $13,000 to reverse the procedure. And while many health insurers cover vasectomies, they rarely cover the surgery to reverse them.



Doctors say that psychological issues complicate the matter as well. Some men, they say, are ashamed for people to know they had a vasectomy in the first place. "Some men equate infertility... with not being strong or not being potent, when it really has nothing to do with those things," says Philip Werthman, MD, director of the Center for Male Reproductive Medicine and chief of urology at Century City Hospital in Los Angeles. "No one wants to publicly admit they have a problem."



Unfortunately, that's one reason why many infertile couples turn to more expensive, complex infertility procedures, such as in vitro fertilization, to achieve pregnancy, Werthman contends.



And some physicians may discourage men seeking to undo their vasectomies. "There's a pervasive opinion from family docs that vasectomies aren't reversible," Werthman says. Many women seeking to get pregnant often look for advice from gynecologists, who, Werthman contends, are usually more familiar with female infertility treatments and aren't aware of the success rates for reversing a vasectomy. Such doctors should consult a urologist who specializes in male infertility, he says, but some fail to do so.



To reverse a vasectomy, doctors use one of two procedures. In a vasectomy, surgeons cut the vas deferens, the tube that allows sperm to flow from the testicles through the penis; the most common way to reverse the procedure, called a vasovasostomy, involves sewing the severed ends of the tube back together. In a more complicated procedure, it may be necessary for the doctor to attach the tubes directly to the testicles, an operation known by the tongue-twisting name vasoepididymostomy.



The latter can be a more complicated and expensive procedure if the tube or surrounding blood vessels are scarred. But to some men, the costs are secondary. In an era of second and third marriages, a man's ability to reproduce may make a difference to a new, often younger spouse.



Dr. Eugene Fuchs, a professor of urology at Oregon Health Sciences University, says many of his patients seeking reverse vasectomies are older men who have remarried. "It's because of divorce and remarriage," he says, "that there are more couples showing up at the doctor's office later in life."



Except for his relatively young age, 30-year-old journalist Don Mitchell is typical of the men seeking reversals today. He decided to get a vasectomy as a young man of 22 because he had already fathered two children and believed he wanted no more. But after a divorce at 26 and a second marriage, Mitchell and his new wife Tammy decided they wanted children.



Although thrilled with his choice, Mitchell admits that a second round of fatherhood will take some adjustment. "It's taken a while to warm up to the idea of having to get up in the middle of the night again," he says. "I had two children at such a young age that I felt like I missed out on the spontaneity of my early 20s. But it came down to the fact that I wanted to celebrate our marriage with a child."



Money was also a factor for the Mitchells. They weighed the costs of going through in vitro fertilization (IVF) and found that the cost of a reverse vasectomy, about $6,000, was less than a third of the cost for an IVF.



Reverse vasectomy and IVF costs

Goldstein encourages couples considering the two surgeries to think about a reverse vasectomy if possible. If the man has a vasectomy reversal and can thus impregnate his partner the natural way, the procedure will never have to be done again, he explains. But if the couple decides on IVF (in which sperm and egg mix in a laboratory dish), the woman would need to have surgery to remove her eggs and undergo a second procedure to implant the fertilized eggs into her uterus. Often it's necessary to repeat the procedure several times. And with the costs ranging from $15,000 to $20,000 per procedure, "it can cost three times as much to go through IVF," Goldstein says.



The average success rate of IVF is 30-35 percent if the woman is under 35, according to the
American Pregnancy Association. Of course, the age of both partners is a factor. But the average success rate reported for reverse vasectomies is slightly higher, according to one new study.



Today, men who have their vasectomies reversed have a 43 percent chance of getting their partners pregnant, according to a March 2002 study published in the journal Fertility and Sterility. Those chances depend on the age of the mother, and they drop off if too much time passes after the vasectomy. But even patients who waited more than a decade had good success rates with surgery.



Patients who wait 15 to 19 years between a vasectomy and a reversal had an average pregnancy rate of 49 percent. If they waited 20 to 25 years, the rate of impregnating their partners dropped to 33 percent, according to the Fertility and Sterility study.



Not every reversal is successful the first time, of course, and the presence of sperm after surgery doesn't guarantee a pregnancy. But recent reports are encouraging. One study of 41 men found that even when a second operation was required, 79 percent of the men saw sperm return, and 31 percent were able to impregnate their partners. (Thirty-eight of the men had gone through one previous attempt at reversal, and three had undergone two prior procedures. For most of the men, about ten years had passed since the original vasectomy.)



A complicated surgery

Of course, reversing a vasectomy isn't always a quick procedure. It can involve hours of microsurgery to sew up the loose ends of the vas deferens, the tiny tubes that carry sperm from the testicles into the penis. Goldstein compares it to sewing the ends of a tube the width of spaghetti or fine yarn. The passage inside the tube that carries sperm is even smaller, about the width of three hairs on your head, and because the tubes are surrounded by sensitive tissue, it can be a painstakingly long procedure, he says. Often, when Goldstein finds the two severed ends of the tube, they vary in size. After years of disuse, one side atrophies, and the other side becomes enlarged.



"What you end up having to do is sew up a garden hose to a fire hose," Goldstein says. Sometimes, even when doctors are successful in reattaching the tubes, the body produces an immune reaction to the sperm that kills them off. If that happens, doctors may try to side step the problem with steroid treatment, which treats the immune allergic reaction. If this doesn't work, they may have to use sperm collected from the testicles when a reverse vasectomy takes place in order to fertilize an egg. That's done either through IVF or through ICSI -- intracytoplasmic sperm injection -- in which a single sperm is manually injected into an egg.



In the case of Chris Maslak, the second surgery lasted seven hours because Goldstein had to reconstruct surrounding veins in addition to reattaching the tube itself. Chris Maslak downplays the pain involved, but he and other men say it's not easy.



"I have a history of not doing well under general anesthesia," Maslak says. "It took me a long time to come around. I was getting sick, and I couldn't wake up. That was the touchy part for me. A day and a half later, there was still blood coming out."



Mitchell, an athlete in high school who has been in the surgery room eight times, said he still wasn't prepared for the three-hour-long operation. "I've always been able to handle the pain. I've had my tonsils taken out. I've had screws in my knee. I ruptured a disk a few years ago, and the surgery only took an hour and a half," Mitchell says. Although his doctor assured Mitchell that he would be back at work three days later, it was almost a month before he felt normal. But he thinks the weeks of aches and pains he went through is fair, considering that his wife will have to carry a child for nine months and suffer through labor. "I kid my wife," Mitchell says. "I'll say, You won't be the only one who went through pain for this child."



All the pain paid off, however. In late August, the Mitchells discovered that Tammy was pregnant. Their baby, Jason Donald, was born May 9, 2001. Despite some initial fussiness, the boy finally sleeps through the night, Mitchell says. "We can't believe how fortunate we've been."