Post Vasectomy Pain Forum

An in-depth discussion about reversal

So much information, studies, etc, about reversal/s is hidden in countless random threads on this site. I wanted to create a thread that can be added to and shared via copy and paste with ease. We don’t have a dedicated thread for in-depth reversal data, in-depth reversal discussion, etc. Now we do.


This thread spun out of the thread below. Who would ever imagine so much reversal stuff would be hidden there? Nobody would. I am beginning this thread with an edited version of my final post.


Given @stk input that is based on his medical training, his job, etc, I tend to think his theories regarding MRI, etc, have some legitimate merit. I have some ideas as to why medical practitioners are not doing such screening prior to a reversal, but they are just ideas.

A couple studies that should also be considered.

A few more pages that are relevant to this conversation.

Efficacy of vasectomy reversal according to patency for the surgical treatment of postvasectomy pain syndrome.

https://www.nature.com/articles/ijir201217/

A 10 year study.

https://www.researchgate.net/publication/20441545_Pregnancy_after_vasovasostomy_for_vasectomy_reversal_A_study_of_factors_affecting_longterm_return_of_fertility_in_282_patients_followed_for_10_years

An interesting page with a lot of relevant VR stuff, including a VR study utilizing stents to no avail…

Vasectomy and vasectomy reversal : development of newly designed nonabsorbable polymeric stent for reconstructing the vas deferens.

https://scholarlypublications.universiteitleiden.nl/handle/1887/4964

Changes in the epididymis after vasectomy: sonographic findings

Obviously, results vary significantly man to man.

Scrotal sonograms were obtained in 31 men before vasectomy and at 2 and 12 months after vasectomy to determine the effect of the surgery on the sonographic appearance of the testis and epididymis. The sonographic appearance of the testis was unchanged after vasectomy. However, in 14 men (45%), there were persistent changes in the epididymis. These consisted of enlargement (14 patients), development of cysts (11 patients), and an inhomogeneous echo pattern (five patients). The presence of these sonographic changes was unrelated to symptoms. The history of vasectomy in men referred for scrotal sonography should be noted so that the altered sonographic appearance of the epididymis may be interpreted properly.

https://www.ajronline.org/doi/10.2214/ajr.152.3.531

Nerve damage, nerve regeneration, nerve regrowth, etc…

Some in-depth VR history…


I have a hard time supporting the literature, or I do not support the literature that suggests long term patency in 90% of VR cases.

I have also heard several second hand testimonials that came from well researched reversal surgeons straight to the men that posted them online that do not support the 90% data either. I could elaborate on many levels regarding the long term patency discrepancies aspect, but I digress for now.


In my case, I have heard all kinds of crap as to why both of my reversals failed. I think those ideas are more talk or personal opinion that are not based on fact than anything else.

In my case, my vasectomists tried and true vasectomy technique was to remove considerably more than 1cm of the vas deferens when he did his closed ended vasectomys in 2010. I refer to his methodology as the butcher version.

I certainly didn’t know any better at the time, but based on everything I have learned over time, the butcher version is not a good thing if a man might want to have a reversal and long term patency after the fact.

Tack on several other variables and things start to get rather sketchy. Whatever the case, long term patency is a crap shoot, and the same can be said about reversals for pain in general.

Anyone that has done their homework on reversal for pain statistics knows the odds of success. Some say it’s a low as 50%. Some say it’s as high as 90-95%. A lot of times it’s said to be as high as perhaps ~85%. I have always supported the ~75% statistic myself. Perhaps it’s as high as 80%. Who knows. I could post a list of reference to such data, but not today.

On a final note, I am quite aware that there is more going on with reversal for pain than just fertility. I am also quite aware that all reversals are not created equally, and there are many variants of vas to vas (vasovasostomy) specifically.

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I have read countless old posts on this site over the last couple days and one thing that stands out is - there is so much conflicting information.

Lots of conflicting personal opinions from laymen, and lots of conflicting opinions that came second hand from many PVPS reversal surgeons themselves. In some cases, some of what is going on in the big picture of reversals for pain is completely contradictory to studies like the one below that I posted in the OP.

Re - Efficacy of vasectomy reversal according to patency for the surgical treatment of postvasectomy pain syndrome.


That said, it would be very difficult to write a long post that would sum up everything I have read or heard over the last decade+. It would be easier to post titles to informative threads for you to find and read yourself.

One thing that should be obvious to anyone that is really crunching this reversal stuff is - within the nerve damage Q&A link in the OP, notice that the healing timeline involved with first degree nerve damage is almost identical to the typical congestion resolution timeline.

That kind of stuff is definitely relevant regarding why this stuff is so trivial. A man could be suffering from congestion related, nerve damage related, or both at the same time and there is not a tried and true 100% definitive way to tell the two apart without a significant margin of error.

Congestion resolution timelines vary greatly source to source, but 2-12 weeks is a pretty typical timeframe that is sold to us beforehand, and such statistics can be found all over the place.

The 2-12 week timeframe isn’t uncommon and it is sited in the risks section in my informed consent paperwork. That timeframe begins the day of the vasectomy. Some websites suggest it takes longer than 12 weeks to develop congestion. Some websites suggest that congestion risks begin around 12 weeks post vas. Again, there is a lot of conflicting information within urology on this topic. I have covered this topic in many other threads. There doesn’t seem to be a one size fits all answer.

Blue balls (epididimal hypertension) is listed as a risk in my informed consent paperwork. It sites the risk in the former timeframe, not the latter timeframe. That timeline begins immediately post vasectomy or within a matter of days. The difference between the two may be a clue to your case specifically. May be a clue isn’t to be confused with it absolutely is.

I highly doubt my informed consent paperwork was written or composed by my vasectomist. It looks like it was printed out from somewhere else within the commons of modern medicine. It looks pretty typical, professional, etc.

One of many things within the nerve damage Q&A link in the OP that stands out to me is Mechanism of Injury

Damaged nerves due to a cut heal better than the ones from a crush.

That statement certainly doesn’t align to well with countless statements from many laymen, urologists, pvps reversal surgeons, etc. In many cases, what they have to say regarding hemoclips is completely contradictory. Are hemoclips not crushing, pinching, squeezing, etc?

Hemoclips are not used in every variant of vasectomy, but they are used very commonly. Are hemoclips a key proponent of PVPS? Hard to say. They generally are not brought up in PVPS literature, but get brought up on occasion. I have seen many documented incidences where the hemoclips did seem to be key to a man’s PVPS. Several such stories have been posted on this site.


One thing I keep seeing over and over again on this website is something that I would refer to as disinformation, or the alike. For instance, "I had a closed ended vasectomy and I was leaking sperm, I had sperm granuloma, but I wasn’t congested.

Huh?

That is an example of an oxymoron. If you the reader don’t know what an oxymoron is, look it up.

Sperm Granuloma Pain

In most cases sperm granuloma is asymptomatic but if it show symptoms, then pain is the main common symptom. Patient may feel pain around testicles specifically in the groin area. Either left or right groin is involved. Pain may spread through out testicles and lower abdominal area. In some cases, patient feels no pain before vasectomy. But after vasectomy, patient may experience pain in groin and lower abdominal region. If pain is the primary symptom of sperm granuloma, then pain after vasectomy is called as congestive epididymitis. Pain severity is dependant on the size of sperm granuloma lumps.

What is a granuloma?

A sperm granuloma is a small mass or lump that may develop following a vasectomy. Essentially, the lump is an inflammation that is created by extravasated sperm. Extravasated means that the sperm leaks or is being forced out of the cut end of the vas deferens.

https://www.vasectomy-information.com/lump-after-vasectomy/


What does sperm granuloma have to do with reversals? In however many cases, it seems to have a lot to do with it. Reversals seem to be poorly understood as a whole, but some of us well researched veterans know that in however many cases sperm granuloma is relevant to this topic.


For those who are doing a lot of homework of their own, here is a limited short list of very informative and in some cases mind blowing threads to read through. I won’t post many links as you can type some of the thread titles into the search bar on this site.

-PVPS after reversal nerve pain
-2 months post reversal checking in
-Vas reversal chances
-Vasectomy reversal improvement
-13 months 10 days post - love your opinions on next steps
-Reversal recovery journal
-Reversal with Dr Marks tomorrow morning 15 years post vasectomy

A very informative thread


Whatever the case, as I previously said, I am completely aware that there is more going on with reversal for pain than just pressure pains, congestive pains, etc.

In however many cases, some of the things to consider as the mechanisms for pain are the bi products of congestion (including damage). The bi products of improper healing. The bi products of scarring. The bi products of an improperly done vasectomy. The bi product of hemoclips. The bi product of cauterization. Nerve damage. And so on…


I have seen countless examples where the man had a reversal for pain with an experienced reversal surgeon and it didn’t help. The reasoning as to why gets very complicated and there doesn’t seem to be a generally accepted one size fits all answer. I tend to think some common sense will go a long way here, but keep in mind that some aspects of PVPS seem to go beyond anyone’s pay grade.


A very short breakdown…

Some reversal surgeons do not remove the hemoclips during their vas to vas reversals. Some don’t aim for fertility. In some cases, there is no SA required after the fact. Some VR surgeons don’t clean up much if any of the scarring. Some do, some don’t, and some preform other tricks instead. Some don’t remove the granuloma/s and some do. Some preform a single layer technique. Some preform a multi layer technique. Some will not preform a vas to epi connection (vasoepididymostomy) and others will.

Which version, methodology, etc, is best? You must do your own homework and decide which VR surgeon you feel comfortable with. I have seen a little bit of everything on this website alone.

If you are new to these kinds of topics, I’m sure you would’ve never imagined VR was so complicated beforehand.


On a final note, if you are new to this topic, and don’t understand so much about so much of this PVPS stuff, there are countless related and relevant write-ups all over the internet. Some people prefer to reference such and such study from places like PubMed. Some site reference from this PVPS surgeon, from that PVPS surgeon, from another VR surgeon, etc. Such studies, material, etc, can be found all over the internet. Countless such things have been posted in random threads all over this site alone.


Two in depth articles that dive into many potential complications, theories to consider, etc, that are involved with vasectomy complications, PVPS, etc.

https://www.vasectomy-information.com/post-vasectomy-pain-syndrome-scientific-review/

https://onlinelibrary.wiley.com/doi/full/10.1002/j.1939-4640.2003.tb02675.x

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I think it’s fair to say that the typical heard mentally or understanding of VR for pain involves just congestive symptoms, fertility, etc, and that is completely understandable.

I also think it’s fair to say that a significant amount of people don’t think this out well enough. They don’t do enough homework to connect a lot of dots, etc. That is completely understandable too. There was a lengthy point in time where I was like anyone else. I was new to these topics, I was unaware of so much, and I had the typical heard mentally about VR for pain, among other related things as well.


Hopefully nobody assumed that I do not support various non typical versions of vas to vas (vasovasostomy) for PVPS.

What I have said to many people many times is - get it right the first time. In other words, don’t submit to a variant of vasovasostomy that you do not understand, that you know nothing about, that may not be the correct choice for your perticular symptoms, that doesn’t fit your goals, etc. I have seen to many men learn the hard way, including myself.


If a man has tell tail signs or predictors regarding the congestive end of the spectrum, would it make any sense to choose a variant of VR that doesn’t seem to address those issues?

If a man has tell tail signs or predictors regarding hemoclips, would it make sense to choose a variant of VR that doesn’t address those issues?

If a man has tell tail signs or predictors regarding scarring or potential nerve entrapment at the proximal end/s of the vas, would it make sense to choose a variant of VR that doesn’t address those issues?

What if the man has a combination of such tell tail signs? What variant would be better or best then?

These are some of the things that every man should be aware of and considering for himself. Any experienced PVPS VR surgeon or any VR surgeon in general should be helping you consider such things before they recommend any sub variant of VR to you.


In however many cases, it seems that the ~majority of PVPS VR surgeons and VR surgeons in general do address many, if not all of the potential possibilities for pain in one swoop.

In other words, they do a clean up of both the proximal end of the vas that includes the removal of anything and everything that is visually damaged. Anything and everything that wasn’t there prior to the vasectomy - sperm granuloma, scarring, hemoclips, etc, and a clean up of the abdominal end of the vas during the VR procedure. Generally speaking, they are aiming for fertility.


This is where things start to get more complicated.

There are a significant amount of men that do not have any of the tell tail signs of congestive related complications. Many of them never had hemoclips used during their vasectomy either. Whether their pain began in the former or the latter timeframe, they don’t seem to have any tell tail predictors that would lead them or their doctor’s or surgeon’s to assume anything obvious as the source of their pain.

I’d guess that in many cases, the man or even his wife, etc, isn’t to thrilled with the idea of being fertile again as part of a surgical option for pain relief.


Obviously, there are sub vasovasostomy options (variants) that do not involve fertility as part of the outcome. In theory that can be supported in many ways, I can understand how such sub variants of VR are a realistic option for a some men.

There seem to be several sub variants of vasovasostomy for pain that don’t address fertility as part of the outcome. In some cases, the vasovasostomy methodologies are quite contradictory or completely different than one another. The methodologies I have seen posted on this site are completely different in comparison.

In some cases, the hemoclips and scarring is removed from the proximal end of the vas. In other cases, the hemoclips are not removed. The amount of scarring removed from the proximal end of the vas varies significantly, and so on. To accomplish this, in some cases, tricks are preformed on the proximal end of the vas that don’t get brought up often, if hardly ever, on this site.

One example - there is a variant of vasovasostomy that is known to be used by a respected PVPS reversal surgeon that I have only seen described once in 10+ years. It was posted on this site several years ago. Prior to those perticular post/s, I was completely unaware of it. At this point, I have not included any direct reference to that information in this thread. If you are interested in learning more about this particular sub variant, you will find those posts.


A bit about pain relief statistics.

Given everything I have said up to this point, I find it interesting and a bit odd that a handful of respected PVPS VR surgeons in north america site success rate statistics that are very similar to one another. All of them are doing their vasovasostomy’s a bit differently to some extent. Some are doing them considerably differently, and some are doing them completely differently than one another. How is this possible? How are they all siting and achieving similar pain relief statistics? My best guess is - that answer is hidden somewhere in the details.

Pre screening men or the intellectual lead up to a potential VR should involve many things I have previously addressed. But the kicker is - generally speaking, that’s not the case. If you understand everything I have previously addressed, you understand that pre screening and intellectual lead up to a potential VR may be of some value regarding what variant or version of VR may be better or best for you, not what version is better or best for the next guy.


Please also understand that a considerable amount of the stuff that I previously addressed is happening in the world of VR for fertility as well. Such as - what is being removed, what is not being removed, what gets mucked around with, what doesn’t get mucked around with, tricks, etc. When you get a clear view of what is going on within the big picture of VR for fertility alone, it will make your head spin at least once.

I have heard all kinds of rationale regarding my last paragraph at minimum, but it’s difficult to understand how there can be so many completely contradictory discrepancies within the same field of work. Everyone seems to think their methodology is the correct one, the best one, the safest one, etc. Really?

How can a highly experienced tried and true hand reversal surgeon that is on top of their game, has specialized in VR specifically for decades, is known to get it right the first time by taking their time and only preforming one reversal a day, takes pride in being regarded as one of the best hand VR surgeons in the world, has helped men with pvps for well over a decade, etc - all to have their methodology corrected or dismissed by another PVPS VR surgeon, or other specific fertility VR surgeons? WTH is going on here? How is this possible? Is anyone truly correct? Is there really a completely right or completely wrong answer? I do have my own opinion on this matter, but I’m not thinking there is a one size fits all answer. Whatever the case, I digress.

Please note that highly experienced VR surgeons that specialize in VR only and only do one VR per day seem to be far and few in-between. It seems that the majority of VR surgeons specialize in multiple urological surgical procedures, not just one. They are also commonly known to preform multiple procedures in one day. Who would you trust or recommend to do such a task when experience level and the alike seems to be key to specific aspects of VR? I am sure that many of them are well qualified, but you must decide for yourself.


Some of my last thoughts for today involve the statistics regarding how many men are made worse by VR.

There are a few different ways to look at how many men are actually made worse by VR. One must start by considering a few different things - including the time frame of more pain post VR, different or new symptoms, the severity, and so on.

I have seen testimonials from men that were definitely made worse by VR that made a near full recovery over a period of years after the fact. The data is limited. There are a variety of reasons as to why the majority of men do not continue to update their stories online. It’s impossible to know what happened to everyone that claimed to have been made significantly worse that simply stopped posting updates.

One must also calculate the idea of proper pre VR screening that includes trying to weed out men that a specific variant of VR doesn’t seem to fit their bill, if any of them do.

Doesn’t seem to fit their bill, might not have any effect on them, won’t have any effect on them, or it could make them worse are completely different things. It’s all a roll of the dice. I’m absolutely certain that there are men with PVPS that are not good candidates for any version of VR, but statistically, I have no idea how many men are not good candidates. I think some common sense will go a long ways regarding who is a good candidate and who isn’t.

Generally speaking, in pain forums like this one, the majority of men would not refer to VR surgery or the recovery as a walk in the park. There does seem to be a time frame that the majority of men seem to fall into. All at the same time, there doesn’t seem to be a one size fits all answer. Results certainly vary man to man.

I have seen all kinds of supposed typical, yet contradictory post VR for pain time frames regarding when the man should start to see improvement, when they should consider moving forward with something else, and so on. Such testimonials regarding typical time frames have been posted by members of this site straight from the source/s.

Over the last decade+, I have seen countless examples of why a man should consider waiting longer than what was recommended to them by their in perticular PVPS doc post reversal. I have seen countless men make significant improvements well beyond what was told to them by their PVPS surgeons. I have seen countless men get better or make significant improvements in the ~6-18+ month post reversal time frame.

Based on what I have seen, the ~6-12 month time frame seems to be more typical, but it’s not a hard fast rule. Some men hit their goals a bit sooner, and some men hit their goals a bit later. Whatever the case, in the majority of cases ~6-12 months seems pretty typical to me.

Obviously, there are or can be signs, predictors that a man is not trending in the right direction, and maybe he should reconsider all of his options. Including, but not limited to - waiting things out for an extended period of time. I’m certainly not a fan of anyone rushing into yet another surgical corrective procedure without exhausting concervative options, without giving your body plenty of time to potentially get it together, heal itself, etc.

Generally speaking, I try to encourage men to wait things out post reversal and stick with concervative options, etc - because I have seen to much. It seems that anything is possible.

Statistics, regarding what the actual PVPS VR ~authorities have to say regarding how many men are made worse by VR…

I have heard all kinds of stuff. Some say things like - nobody has been made worse. Some say it’s extremely rare. Some site the contraversial 1-2% AUA statistic that is associated with vasectomy. Considering everything, it’s hard to know what the actual statistics really are. Obviously there are inherit risks that come with any such surgical procedure. I think some common sense will go a long ways regarding this aspect too.

Assuming you digested everything I have said up to this point - given what I have read, seen, and heard over the last decade+, the number of men that are made worse in the long run seems to be quite low. But, that doesn’t mean that you won’t be the first, or that it can’t or won’t happen to you.

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Thanks for this very interesting. Proves vasectomies are not the best and I liked your piece that mentioned that not enough research is done for either the vasectomy or the vasectomy reversal. Men would like to trust the medical profession but I for one don’t . It’s a money game and the turnover for vasectomy is huge. For vasectomy reversal is even greater

I don’t trust the medical profession any longer, either. Yes, some individual doctors and practitioners, but the industry as a whole is a money game. I sometimes wonder if the one-sided view of vasectomy is money driven (probably at least partially) or simply a lack of a consolidated source (due to lack of incentive).

On reversal, from a pain perspective, I’m still not convinced the reversal in June 2006 was what led to me being pain-free from November 2006 through April 2016 except for a 5-month relapse starting November 2008. The longer 2016-2018 relapse convinced me forever that I’m dealing with a damaged left GF nerve that responded to pain meds 2008-09 and numerous blocks 2016-18.

No regrets on the reversal. I think it’s possible that the granuloma and scar tissue removal helped me and helps others. In my case, also, I’m convinced the reversal restored my PSA and T-levels to normal levels. But, from a pain relief standpoint, I think reversal is a coin toss.

You’re welcome.

Given everything that I am aware of, I don’t trust the medical system either, but if a man is looking for a way out of the hell that PVPS is or can be, reversal is one of few surgical options and a man is going to have to trust some aspects of the system. There is no way around it.


I will be brainstorming another write up regarding reversals. I’m not sure what I will cover next, but I have some ideas.

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The purpose of this write up is to give anyone that is not aware of yet another aspect of VR a heads up. Like previous write ups, this write up is not intended to be the end all be all regarding vasovasostomy, reversals for pain, reversals in general, etc. I am only providing enough information to give anyone that is relatively new to this topic a headstart.

Please understand that based on what I have seen over the last decade, the majority of reversals for pain were not preformed at a pain specific hospital, clinic, etc. They were not preformed by a pain specific specialist, etc. In countless cases, the VR surgeons are not doing anything differently with their fertility patients vs their pain patients.

Are there pros and cons regarding consulting with a VR specialists that specializes in pain, vs the vast majority that don’t? Sure there are. I think some common sense will go a long way regarding such pros and cons. Based on what I have seen and what I am aware of, consulting with a pain specific VR specialist is not a must do. Keep in mind that experience level and methodology seems to be key to many aspects of VR. Please do what you think is best for you.


My research yielded several vasovasostomy methodologies, terminologies, etc. I am not going to post links to reference all of the relevant literature, pictures, opinions, etc, that I came across.

Single layer technique

Modified single layer technique

Two layer technique

Multi layer technique

Multi layer technique seems to be a broad generic term. I wouldn’t refer to the terminology as a specific technique exactly. Multi layer seems to mean just that, and there is a reason many VR surgeons preform multi layer techniques, which includes several advanced multi layer techniques.

Three layer technique

Four layer technique

I’d guess that the vast majority of men and woman that are new to this topic would’ve never imagined so many different vasovasostomy techniques existed.


There are several threads on this site that contain debates regarding which version or methodology is better or best for men with PVPS. Which version is better or best for fertility in general. That debate many potential pros and cons, including the number of sutures used and the size of sutures used regarding specific in perticular VR surgeons. That describe various unique tricks that some specific VR surgeons are known to preform. How many incisions were made on the scrotum - one or two? That describe or debate many aspects of vasovasostomy in general.


Who is right and who is wrong? This, that, and the other? Like everyone else, I do have my own opinions, but I am not thinking there is a one size fits all answer. Again, you must do your own diligent research and make educated choices and decisions for yourself. Nobody has to live with them but you.


I have read countless positive testimonials from men that had a reversal with someone that gets little to no recognition on websites like this one. A reversal surgeon doesn’t have to be famous to get a fair shake.

That ^^^ is a true and accurate statement, but I also want everyone to be aware of the contents of a single link to some reference that everyone should be aware of before you commit or submit to anything. IMHO, it’s a must read, and everone should take specific aspects of it’s contents into serious consideration.

What Are the 20 Questions Everyone Should Ask When Choosing a Vasectomy Reversal Doctor?

https://www.dadsagain.com/questions/


Unique tricks that some specific VR surgeons are known to preform

A link to an interesting thread.

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