Patient Name:

Age:

Date:

Procedure: Vasovasostomy/Vasoepididimostomy

Indications:

Patient is a male patient with a previous vasectomy that would like to have reversal to restore his fertility.

Alternatives:

Alternatives are artificial reproductive techniques for intracytoplasmic sperm injection (ICSI), donor sperm or adoption.

Risks/Complications:

The risks and complications of the procedure where extensively discussed with the patient. The general risks of this procedure include, but are not limited to bleeding, transfusion, infection, wound infection/dehiscence, pain, scaring of tissues, failure of the procedure, potential injury to other surrounding structures, deep venous thrombosis, pulmonary embolus, myocardial infarction, heart failure, stroke, death or a long-term stay in the Intensive Care Unit (ICU). Additionally, mentioned were the possible serious complications of the anesthesia to include cracked teeth, airway damage, aspiration, pneumonia, spinal head-ache, nerve damage, spinal canal bleeding and malignant hyperthermia. Your anesthesiologist will discuss the risks and complications in more depth separately. Additional procedures may be necessary.

The specific risks of this procedure include, but are not limited to: failure of the procedure to allow transmission of viable sperm into the ejaculate, chronic epididymal or testicular pain, late stricture, may need to wait up to one year before the procedure can be called a failure, complete breakdown of the re-anastomosis if strenuous activity or ejaculation occur within 2-3 weeks after the procedure, there may be abnormal spermatogenesis secondary to autoimmune antibodies or other cause that despite adequate anastomosis of the tubes there will be no viable sperm elements in the semen, if the procedure fails additional procedures may be necessary to determine the patency of the connection or to provide sperm for artificial reproductive techniques in the future.

You understand the procedure, general and specific risks as discussed and agree to proceed with the procedure. You also understand that not every possible complication can be listed in this counseling note and additional risks are possible, although unlikely.

Physician's Signature: ________________________________ Date: __________________

Patient Signature: __________________________________ Date: __________________