Can I be a father after a vasectomy?

Previous vasectomy

Infertility in men who had family planning surgery (vasectomy) is a fairly frequent problem as the circumstances of every person do change and lead to a reconsideration of situations previously thought irreversible. Human Reproduction is a specialised area of medicine which shares the knowledge of reproductive Gynaecology and Biology. It has developed the techniques to identify and treat sometimes complex sterility cases, and has enough resources to help patients who want to have a child after having undergone a vasectomy. The current therapeutic procedures are:

In Vitro Fertilisation (IVF) with intracytoplasmic sperm injection (ICSI); sperm is retrieved from a testicle, epididymis or deferent duct.
Microsurgical repair of the seminal duct (vasovasostomy)

The factors which determine the choice of the therapeutic procedure are first of all the woman’s age (older or younger than 35), and the likelihood of more than one pregnancy in the future.

In the case where the woman is older than 35, and/or the couple do not want to have another child once they have had the first one, the recommended treatment is surgical sperm retrieval in conjunction with IVF-ICSI.

With this alternative the time between carrying out the treatment and the possible resulting pregnancy is quite short and, when no other pregnancy is desired, it is not necessary for the couple to take contraceptive precautions.

If repermeability of the sperm ducts is required in order to bring about a spontaneous pregnancy, then the appropriate treatment is a microsurgical repair of the deferents. When the outcome of the operation is satisfactory and there are again spermatozoa in the ejaculate and a spontaneous gestation occurs, the couple must take contraceptive precautions if they do not wish have more children.

Moreover, with this technique the time needed to see the results is longer and, therefore, it is not advised for women older than 35.

In the cases when after a vasovasostomy a pregnancy does not occur due to the absence of spermatozoa in the ejaculate or a lack of them to cause a spontaneous pregnancy, Assisted Reproduction Techniques (FIV-ICSI) can be considered.

Infertility study

This is made up of a series of tests and analysis which are undertaken in order to investigate the theoretical fertility of the couple before considering an IVF-ICSI cycle:

For the woman

A basal temperature chart from the last few months in order to see if ovulation happens and, if this is the case, on what day of the menstrual cycle.
A blood test is also carried out to check that there are no hormonal alterations (FSH, LH and Estradiol)

For the man

Under local anaesthetic, a microsurgical sperm aspiration via deferent duct or epididymis is carried out. Depending on the quality of the semen sample an IVF-ICSI cycle may be carried out. Once it has been studied, the sample is frozen to be used in IVF-ICSI. If the sample obtained is not of satisfactory quality, then a testicular biopsy (a testicular tissue sample is taken) is performed to retrieve sperm. This procedure can be done on the same day.

Further checks

When it is suspected that there is an endometrial pathology, a hysteroscopy is carried out. This is an examination of the uterine cavity undertaken without an anaesthetic. Hysteroscopy helps diagnose certain malfunctions and recommends the appropriate treatment. For example, if a myoma or a polyp are found they have to be removed. This can be done during the same procedure or it could be necessary to schedule in a later appointment.

RECOMMENDED ASSISTED REPRODUCTION TECHNIQUES

In general, when the woman does not have a sterility problem, a semen sample of sufficient quality (to retrieve enough spermatozoa from the ejaculate) has to be obtained to fertilise the eggs.

Assisted Reproduction treatments are a series of delicate techniques carried out jointly by gynaecologists, andrologists and biologists in specialised centres.

Microsurgical sperm aspiration via deferent duct or epididymis

This procedure is carried out under local anaesthetic. By means of a surgical magnifying glass the deferent duct is separated and an incision is made to place a fine catheter inside it. The use of finely calibrated equipment allows for a small quantity of liquid to be gently aspirated. This liquid is studied under a microscope in order to identify and retrieve the spermatozoa which are then frozen to be used in the egg fertilisation. This process can also be carried out in the epididymis according to the opinion of the andrologist in each case. If it is known in advance that quality sperm can be obtained, this procedure may also be carried out on the same day as the follicular puncture, when the woman’s eggs are collected.

In Vitro fertilisation with intracytoplasmic sperm injection

The quantity of sperm obtained via deferent or epididymal aspiration is always insufficient for an IVF treatment without an intracytoplasmic sperm injection.

IVF-ICSI is a precise technique which follows a strict procedure with sophisticated equipment and proves invaluable in skilled hands. In this case the fertilisation, as its name implies, does not occur in its natural environment but in the laboratory.

The first step in this technique is to gain a pharmacological control of the woman’s cycle. To do this specific fertility drugs are administered to the patient over consecutive days. Moreover, a pharmacological stimulation of the ovulation allows several eggs to be produced per cycle, which increases the chances of success as the best ones can be chosen.
The ovulation monitoring is done with ultrasound scans and a series of periodical tests. When there are enough follicles of sufficient size the egg collection takes place controlled by ultrasound. It is an ambulatory procedure which is carried out under sedation in the operating theatre.
This procedure is called ICSI from English and stands for Intra Cytoplasmic Sperm Injection. It consists of the insemination of each egg via the injection of a single sperm inside a specific part of the cytoplasm by means of a micromanipulator attached to a microscope.
Before being used for the fertilisation, the spermatozoa have to be thawed and prepared in the laboratory (when they are not used fresh). At the same time the eggs are prepared: the outer layer is removed from each of them.
After two or three days after ICSI, the best embryos obtained as a result of the fertilisation are selected. From those two or three are transferred into the uterus of the woman. The transfer technique is similar to Artificial Insemination but it is carried out with an ultrasound scan. Normally only one embryo implants but sometimes more can develop.
The unused embryos are frozen in liquid nitrogen (cryopreservation) and can be used in a later attempt if the pregnancy does not occur on the first attempt. Obviously, it simplifies the process and makes it cheaper, although the pregnancy rates decrease.

What is a vasovasostomy?

Apart from IVF-ICSI, a vasovasostomy can be considered. This is a precise surgical procedure which aims to rejoin the deferent duct incised as a result of the vasectomy. The vasovasostomy is carried out under local anaesthetic. The surgical magnifying glass is used as the spermiduct has to be restored joining both ends. First new tissue is created removing the scarred proximal and distal ends (the ends where the deferent was cut) and then brought together and stitched with very fine thread.

Once the vasovasostomy is performed several months have to pass for the results to be seen (for enough spermatozoa to be present in the ejaculate). Although vasovasostomy appears to be a simple solution for the vasectomy, in reality this technique is somewhat complex:

Though not usual, sometimes it is impossible to carry out the vasovasostomy correctly as the ends of the deferent duct break away and remain far from each other.
Even if the surgery is successful, the result is not always guaranteed as it is not enough to just join both extremes of the deferent duct together. Its ability to transport the seminal liquid has to be recovered but the outcome of the procedure is unknown at the moment of the surgery. Spermatozoa may not be present in the ejaculate.
Although the two previous difficulties can be overcome successfully, the quantity of the ejaculate or the sperm count might not be insufficient to carry out Artificial Insemination. Therefore, IVF-ICSI treatment has to be considered as in the above case.

All considered, when a couple want a child after having had a vasectomy it is nowadays more advisable to do IVF-ICSI. On the other hand, when a couple want to begin a new family and have several children, vasovasostomy can be a practical alternative, especially when the woman is young enough to remain fertile for some years.