Spontaneous recanalization of the vas deferens after vasectomy

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A proportion of the emails I get are from students and journalists asking for information and clarifications for the work they are doing. Some of them are simply being lazy and expect me to do their homework / write their article for them, others ask interesting and incisive questions. One such question I was recently asked was from a journalist doing an article on spontaneous recanalization of the vas deferens, and she was asking exactly how it happens. It's a very interesting question, and one that deserves an answer!

What is recanalization?
Spontaneous recanalization is where the vas deferens manages to "grow back" and reverse the vasectomy making a man fertile again. Because a vasectomy has recanalized, that doesn't mean a full restoration of fertility. Any re-growth is likely to be a channel that is much smaller than the original vas deferens was, hence fertility is likely to be much reduced.

There are two categories - early and late recanalization. Early recanalization is most likely to happen in the first few weeks following vasectomy before having been given the all clear. Many of the statistics of failure will refer to this period. Statistics are typically 0% - 1% of vasectomies, and are usually referred to as "Technical failures". Technical failure does not necessarily mean that the vas deferens has recanalized - it often means that the semen analysis still shows live sperm after a set period - often 16 weeks. All men take varying lengths of time to clear, and it's not unusual to take in excess of 16 weeks. Most men will clear eventually. It's not possible to give percentages of recanalization and late clearance as most studies cease monitoring men after a set length of time. Hence the expression "Technical failure" - all men who haven't cleared at the end of the set time of the study for whatever reason.

Late recanalization is where the all clear has been given, and the vasectomy spontaneously reverses itself at a later date. Early and late recanalization should not be confused - nor should the statistics.

The reason doctors want you to go back for semen analysis after vasectomy is to make sure that a technical failure hasn't happened. Bottom line is that you aren't clear until it has been proven by semen analysis, and it's the patients responsibility to supply samples as indicated by the doctor.

From this point on, this page will discuss late recanalization of vasectomy - early failures should be picked up by semen analysis as above.

How often does it happen?
All birth control methods have a risk of failure, but vasectomy is the most reliable of all the methods available. According to the UK national sterilisation guidelines (2004), the failure rate of vasectomy should be quoted as approximately 1 in 2000 (0.05%) after clearance has been given.1 Therefore the chances of a vasectomy spontaneously reversing itself are actually very rare. According to Harvard Medical School, "Vasectomy can reverse itself, but it is a very rare event. It develops in only about .025% or one in 4,000 vasectomies".2

It should be appreciated that as late recanalization is in fact very rare, the research into it's exact causes is limited by the small number of subjects being available at the time any particular study is being undertaken. Very often the published literature is in the form of individual case histories, as opposed to larger studies.

How is it physically possible for the vas deferens to re-join?
There are two recognised mechanisms for late recanalization to happen. The first is initiated by the formation of sperm granuloma's, and the second is micro-recanalization through scar tissue. In addition, there are other factors such as length of vas deferens excised, technique used and experience of the surgeon.

Sperm Granuloma:-

After vasectomy, sperm often leak from the vasectomy site or from a rupture in the epididymis. Sperm have very strong antigenic qualities - the immune system views sperm as foreign agents and attacks them. Sperm leakage provokes an inflammatory reaction. The body forms pockets to trap the sperm in scar tissue and inflammatory cells. Firm balls of tissue (sperm granulomas) about one-half inch in diameter then form in about 60% of vasectomy patients.2 Studies into recanalization look for possible causes. In the case of granuloma's, most studies report a strong correlation - one study reports the presence of granuloma's as "A constant".4

What happens is that a nodule in the vas deferens arising from a granuloma progresses to a benign malignant growth known as Vasitis Nodosum. This growth can join up with the distal vas allowing sperm to flow. Studies report that vasitis nodosa is more common than sometimes thought,7, 9 and although it's growth can cause recanalization, it's a rare occurrence.7

Scar tissue:-

If there is a lot of scar tissue after vasectomy, a process called Microrecanalization can happen allowing sperm to wriggle their way through new, and very small channels in the scar tissue. The reason that this happens is one of the bodies many self healing mechanisms. "Microrecanalization provides protection of the testis and maintenance of spermatogenesis in man after vasectomy".8

The formation of microchannels is believed to be associated with poor technique during the vasectomy procedure. E.G. loose tightening of vas at the vasectomy procedure, over-tightness that broke the vas, in which lumen opening was exposed, tying of the cut vas stopped local blood circulation which resulted in burst of tubes at nearby location and increased pressure inside lumen after vasectomy near the testicle end forced the tying thread to cut the tube open.5

There are a few studies that have looked at scar tissue samples taken from men after vasectomy. One study found microchannels in "smooth muscle, connective tissue and scar tissue, in each segment, testicular, central and abdominal, in the presence or absence of the vas deferens.8 Another found "a series of spontaneously recanalized ductus deferens and those of the contralateral ductus deferens displayed many tortuous epithelial tubules growing from the mucosal epithelium of distal stumps intruding into the fibrous scar tissue toward proximal stumps. 1 of the growing gland-like tubules might perform the spontaneous recanalization".12

Is there any way of avoiding it?
There are surgical techniques that have been proven to minimise the risk. Firstly, a technique called fascial interposition added to the standard procedure is now accepted as the most reliable method of performing vasectomy. In the standard technique, a short piece of the vas deferens is cut and removed, and the remaining two ends are tied. Fascial interposition involves pulling the sheath covering the vas deferens over one severed end, then sewing it shut to create a natural tissue barrier. The aafp site has some photographs and an explanation.

Some of the early studies3,10 report that using fascial interposition, recanalization is reduced to zero. These studies are quite small. A Chinese study6 of 7 techniques involving 2713 men found that vasectomy plus interposition is the most reliable vas occlusion technique. A review of previous studies16 published in 2004 concluded that "Five comparative studies including one high quality randomized clinical trial provided good evidence that fascial interposition increases the occlusive effectiveness of ligation and excision".

Secondly, there is strong evidence that using cautery to seal the ends increases reliability. Combining fascial interposition with cautery provides the highest level of occlusive effectiveness.16

Thirdly, the length of vas segment removed may have a bearing on how reliable vasectomy is. It should be pointed out that using fascial interposition and cautery remain the most important aspects. One study14 found that "Physicians with a high rate of success removed a significantly longer section of vas than physicians exhibiting higher failure rates. At least 15 mm. of vas should be excised to maximize the success of the procedure. Excised vas segments less than 15 mm. had up to a 25-fold greater incidence of failure". Another study13 recommends removal of 3-5 cm.

There is a version of vasectomy called the "Open Ended" technique. Here, the testicular end is not closed. Provided fascial interposition and cautery are used on the other ends, this technique is still as reliable as standard techniques.16


Similar pages:-

How sperm are reabsorbed into the body
The spermatic cord
Vasectomy statistics
Comparitive failure rates of other birth control methods
Vasectomy FAQ

Sources

1 RCOG. UK national sterilisation guidelines 2004.

2 Harvard Medical School "Well connected", 2001.

3 Recanalization rate following methods of vasectomy using interposition of fascial sheath of vas deferens. Esho JO, Cass AS. J Urol. 1978 Aug

4 Spontaneous recanalization of the vas deferent after vasectomy: report of 2 new cases. Bibliographic review Canovas Ivorra JA, Tramoyeres Galvan A, Sanchez Ballester F, Ramada Benlloch F, De la Torre Abril L, Ordono Dominguez F, Navalon Verdejo P, Zaragoza Orts J. Arch Esp Urol. 2004 Sep;57(7):743-5.

5 Multiple tiny channels, a type of reanastomosis after vasectomy: a pathological study of 38 cases Wei C. Shengzhi Yu Biyun. 1987;7(1):61-2.

6 Relationship between vas occlusion techniques and recanalization. Li SQ, Xu B, Hou YH, Li CH, Pan QR, Cheng DS. Adv Contracept Deliv Syst. 1994;10(3-4):153-9.

7 Vasitis nodosa Llarena Ibarguren R, Vesga Molina F, Marin Lafuente JC, Pertusa Pena C. Arch Esp Urol. 1997 Jun;50(5):534-6.

8 Microrecanalization after vasectomy in man. Freund MJ, Weidmann JE, Goldstein M, Marmar J, Santulli R, Oliveira N. J Androl. 1989 Mar-Apr;10(2):120-32.

9 The significance of vasitis nodosa. Kiser GC, Fuchs EF, Kessler S. J Urol. 1986 Jul;136(1):42-4.

10 Late failure of vasectomy. Lancet. 1985 Apr 6;1(8432):794-5.

11 Delayed spontaneous recanalization of the vas deferens. Sherlock DJ, Holl-Allen RT. Br J Surg. 1984 Jul;71(7):532-3.

12 The mechanism of spontaneous recanalization of human vasectomized ductus deferens. Hayashi H, Cedenho AP, Sadi A. Fertil Steril. 1983 Aug;40(2):269-70.

13 Failure following fertility vasectomy Mellin HE, Bauer HW, Rattenhuber U. Med Welt. 1980 Nov 21;31(47):1723-4.

14 A clinical study of vasectomy failure and recanalization. Kaplan KA, Huether CA. J Urol. 1975 Jan;113(1):71-4.

15 Spontaneous recanalization of the vas deferens after vasectomy Fischer J. Andrologie. 1972;4(3):259-60.

16 Vasectomy surgical techniques: a systematic review. Labrecque M, Dufresne C, Barone MA, St-Hilaire K. BMC Med. 2004 May 24;2:21.

Disclaimer:- Information contained within this site is intended for the purpose of general information ONLY, and is not medical advice. For medical advice please consult a qualified Physician.