Let’s Talk About the Snip: The Truth About Vasectomies

0:00You know Roald Dahl. He thought up Willy Wonka and the BFG. But did you know he was a spy? In the new podcast, The Secret World of Roald Dahl, I'll tell you that story and much, much more. What? You probably won't believe it either. Was this before he wrote his stories? It must have been. Okay, I don't think that's true. I'm telling you. I was a spy. Listen to The Secret World of Roald Dahl on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts. I actually drop better when I'm high. It heightens my senses, calms me down. If anything, I'm more careful. Honestly, it just helps me focus.

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2:35Listen to Math & Magic on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts. Let's talk about it. Let's talk about it in the bedroom. Let's talk about it. Let's talk about it in the bedroom. Welcome to the mailroom. Welcome back to the mailroom, guys. Dr. Jesse Mills here with my indomitable producer, Jordan Runtah, the sultan of sound. Roll to my stone in the studio again for another episode of the mailroom. It's March. And March, I don't know how things are going in Brooklyn. The poppies popping and the daffodils out. We have poppies here, I guess. You have daffodils. but tell me the frost is freezing my friends no someday we're gonna have this amazing conversation because i feel like you know i'm always talking about great it is in santa monica but brook i mean it's like this new york city it's like an amazing town there's so much give me give me like your top two great things you did last week because you're in new york city that i probably couldn't do in los angeles that's i mean good pizza good jazz okay yeah other than wear a sweater since Chet Baker's passing we got great jazz here what are you talking about that's true okay yeah go down to Venice the Blue Notes opening out here I mean yes but alright so you go to a good club went to Vanguard you know me I'm old school come on yeah baby awesome the pizza thing again I don't want to talk disparagingly of LA pizza but you're right it's a lot easier to find really good pizza in Brooklyn we have our spots California Pizza Kitchen Yeah, oh, scum.

4:20Ouch. Ouch. No, they're a big sponsor of UCLA Health. Oh, oh my. Okay. So there's nothing wrong with CPK. They've donated a lot of money to the Department of Orology, so I'm actually a big fan. Big fan. Okay, well, so the other thing that happens in March is basketball, right? Basketball tournaments, men's tournament, NCAA tournament, women's tournament. And so what happens during these tournaments? Well, they're crazy. I can't say they're mad because it's actually copywritten, but it's their crazy time. And why? Because there's 32 games that happen, you know, over a day. So imagine if you're a huge basketball fan and you're thinking, I need a really good excuse to not do anything.

4:59I need to tell my partner, my kids, my dog that I can't take them out for the next couple of days, but they don't want to buy that. Well, so what if it's basketball? Just, you know, watch a couple of games and call it good. But what if you had something done like a surgery, like a procedure, for example, Jordan? Talk to me about this, right? There's surgeries that you have to have, right? I mean, like you can't decide to schedule an appendectomy during the March basketball tournament, right? You can't just say, well, I guess you could. You could lie about it. But say, oh, I had my appendix out.

5:30I can't take out the trash for the next two days. But no, no, it's actually one of the best times to get a vasectomy, which is what we're going to be talking about here in the next little bit. I am so, so pumped to bring on our guest today, Dr. Jay Sanlo, who's chair of urology at Medical College of Wisconsin. I'll do a little bit of an introduction, but before I do this, I just want to put you on the spot for a second, Jordan. All right. Are you ready for this? Absolutely. You're not nervous? I wasn't until you asked me. Okay. Well, that's usually how it works. Well, I'm going to just throw this out at you.

6:04So there are two forms of permanent birth control that are available to couples. Okay, this is a test. This is your medical knowledge test. So for a guy, that's a vasectomy. For a woman, it's a tubal ligation. So a tubal ligation, abdominal procedure, they make an incision, they go in often with a scope. But there are complications. It requires anesthesia. It requires some recovery time that's a little bit more significant. A vasectomy takes, I don't know, it takes me about five minutes. It probably takes Dr. Sandlow about an hour and a half, but we'll talk about that. But it's a very short procedure.

6:40Usually we do it with just a local, and it's done through tiny little poke holes. Sometimes we don't even use a scalpel at all. So what do you think with those parameters, what do you think is more commonly performed in the United States, Jordan? Tubal ligation, answer A. Vasectomy, answer B. I'm sure it's answer A, tubal ligation. Look at you. Right. Yeah. Yeah. Yeah, but I don't know, Jay, if you have new numbers on this. Yeah, it's exactly right. Yeah, yeah. There's somewhere north of seven, 800 ,000 tubal ligations done every year in this country and about four to maybe 500 ,000 vats. So it's about a two to one ratio somewhere in there of women that are undergoing tubal, which is a way more invasive approach.

7:21And we can have all kinds of discussions about why that is. Obviously, the most important one probably is the dog in the hunt, that a woman is going to have a much larger seven and a half to eight pound dog in the hunt at the end of a pregnancy than a guy, but yet it's still there. So I'm going to do a formal introduction because Dr. Sandler, I've known him literally my entire career. In fact, I owe my mentorship that he was my first mentor in urology. He was the guy that really got me into urology and male fertility specifically. So he is currently the chair of urology at Medical College of Wisconsin, but he also, as AMI, a fellowship-trained surgeon, he actually did a very prestigious American Foundation Urologic Diseases Fellowship, which is now a Urology Care Foundation Fellowship.

8:12But that was a two-year research plus surgical exploration into microsurgery. So the guy is, he's vetted. He's a true academician through and through. He spent his entire career in the academy. Where I got to first meet him was when I was a medical student at the University of Iowa. And he was about, gosh, a couple years probably into practice by that time. And I was a second-year urology, I'm sorry, second-year medical student. I really knew I wanted to do surgery. I went to urology interest group. I met Jay and somebody else named Dick Williams, who's a legend in the field who unfortunately lost way too young to lung cancer.

8:53But he and Jay were at the surgical interest booth. It was sort of like speed dating for surgeons when we knew we wanted to do something. I went to neurosurgery. I'm like, I'm not those guys. I went to ENT. I thought, I don't love snot that much. So I'm going to walk away from there. and I talked to these two guys and Dick Williams had a little a faucet pin on his lapel like he's he's like I'm just a glorified plumber and then Jay was there just like looking like he was it was like a fraternity rush party he was this tall athletic buff just super good looking guy I'm like holy crap like this is the this is the fraternity I want to pledge to I want to be a urologist and then I got to hang out with the residents at the time and it was a vasectomy reversal which we're going to talk about in the next episode that I was watching Jay do.

9:42And it wasn't just a skill. It wasn't just the way that he was doing this incredibly precise surgery with these sutures that are finer than human hair that you can barely see without a microscope. But he was having so much fun doing it. And I thought, okay, if a guy can be in this good shape and seem to have the quality of life he has and do what he could do with a microscope and make babies where otherwise men and women couldn't have babies. This is what I got to do. So that's my intro, Jay. I'm grateful to you for bringing me into this field when, you know, all of about 30 years ago, when you were 15 or so, you were doing surgery at that early age, because you still look like you're about the same as when I saw you all those years ago.

10:25So welcome to the mailroom. Well, thanks, Jesse. A couple of things you didn't point out. One is that it took me eight years to do what most people doing six. So most people do five years of urology residency, one year of fellowship, I did six and two. So I was definitely on the, you know, the slower track. And, you know, you sell yourself short. I mean, Jesse was like one of the star medical students at University of Iowa, we really felt lucky that we conned him or brainwashed him into becoming one of us. And he quickly left Iowa to go to greener pastures in Colorado and then did his fellowship down in Houston.

11:15And now, of course, he's a legend in LA. So I will tell you, it is so gratifying when And you see somebody that you interacted with early on in their career to watch them just flourish and, you know, become this monster of, you know, not just in urology, but just as a human being. So I really appreciate it. But, you know, I guess we're both captains of our mutual admiration society. So there you go. Very happy to be here. That's the way it should be. It's a wonderful community you're a part of. And again, that's one of the main motivations for doing this podcast, not because I don't have enough to do with my day job, but really because we get to let the world know, hey, what a great field we are and how happy urologists are if you get the privilege and onus of seeing one as a patient.

12:10But also, we love to talk and we love to, we love, we're very social creatures. And that's what we're going to do today.

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13:28You know Roald Dahl, the writer who thought up Willy Wonka, Matilda, and the BFG. But did you know he was also a spy? Was this before he wrote his stories? It must have been. Our new podcast series, The Secret World of Roald Dahl, is a wild journey through the hidden chapters of his extraordinary, controversial life. His job was literally to seduce the wives of powerful Americans. What? And he was really good at it. You probably won't believe it either. Okay, I don't think that's true. I'm telling you, the guy was a spy. Did you know Dahl got cozy with the Roosevelt's, played poker with Harry Truman, and had a long affair with a congresswoman?

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16:49You look at the top four number one seeds. What do you think UCLA is going to do? Break down that for me, my friend. I do think UCLA has a really good chance of getting back to the Final Four. Obviously, UConn is the overwhelming favorite in this tournament, but I'll be honest, I think people are kind of sleeping on Texas. Experts are suggesting that UCLA is the number one challenger to UConn and that right after that would be Texas. SEC is so deep and so thick in just about everything. It really is annoying. So it's UCLA, Texas, South Carolina, LSU. Only ones that could possibly upset UConn. On Flagrant and Funny, we're giving our unfiltered takes on the biggest moments, the conversations everyone's having.

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18:01One of the things I left out of your intro, because I got so excited, and obviously my mom sent you those index cards you just read off about, but I do want to say that you actually wrote the AUA guidelines, which are American Urologic Association guidelines on vasectomies. So I couldn't think of a better person, not to mention our own friendship and mentorship story, to talk to the average guy about a vasectomy. And so we're going to have sort of a couple of things that I'm going to ask you. And I think the best thing is let's start simply tell me who's a candidate for a vasectomy. What is it?

18:34Tell me that like, pretend I'm a 42 year old guy and I'm walking your office. I'm in a monogamous relationship. I have two beautiful young Dodger fans and sorry about the Brewers, by the way, you guys, what a scrap, what a scrappy team, but let me pull that knife out. Well, you said two young Dodgers fans like the their pre-production stops. Now we do not need any more of these Dodger fans in the world. there's enough already. And my wife is 41. She's still ovulating. And she said, look, we're done with kids. It's your turn. How does that console work in your practice? Walk me through if I'm in your office.

19:07You know, obviously most of the patients who come in, it's a little bit of a self-selection. They've already done at least enough research to know that a vasectomy is something they want to look into. I always tell patients that while we consider this a permanent form of male sterilization, we don't do anything to make it irreversible. And therefore, if life changes, we can undo it. It's just a much bigger deal. So I try to get guys to understand that this is by far the best birth control, but you should go into it thinking that this is it. You don't want to be going back and forth like the episode from The Office with snip, snap, snap, snap, snap.

19:52Yes. Good, good reference. And, and I'm sure you have more than one of those stories. And oh, yeah, too. So we'll, we'll, we'll definitely get it to that. So what what are the risks? I was gonna ask you how long it took, but I already had already threw shade upon you. So tell me really what, you know, what does it look like? So I say, okay, Dr. Sandlow, you look like the guy you wrote the you wrote the handbook, you've trained hundreds of residents and fellows to do this procedure. So I want you to do it. Tell me what happens next. Sure. So typically what I tell guys is it's about a 15 minute procedure.

20:27We're going to use local anesthesia to numb you up. I personally like to make two small holes, one on each side of the scrotum. Some people will do one right in the middle of the scrotum. Honestly, that's dealer's choice. My reasons for doing one on each side is that if you do one in the middle, then that second side has to come up to the exact same hole. And sometimes the vas doesn't want to move around the same from one side to the other. Also, I like to be able to look at the ends when I'm done at the end of the case. And if you've already done one side, you have to dunk it back down into the scrotum.

21:06So you can't really see if there's anything bleeding or oozing. But it's a very straightforward procedure. There's a little pulling, a little tugging. And I don't use any stitches because I am making such a small hole. So we just put a little plastic band-aid over each little hole and send you on your way. Yeah, I do too as well. And I think I trained that way even before I did a fellowship with with Dr. Lipschultz, but just I had a community urologist in Denver who did a very elegant vasectomy. My reasoning is, and I'm sure you've seen this, is that because you said in there too, you always, us reconstructive reproductive doctors do things, we're going to take things apart like we'd want to put them back together.

21:49Exactly. And so how many times have you gone in to do a reversal where you've got a high vasectomy site, which is very favorable on one side, and then a clip through the epididymis or as low as you possibly can on the other. And my argument is that, right, if you're swinging the same testicle up through the incision, you're never going to get it in that same high site so that if a guy ever wants to change his mind, that's it. But also a concern about hematoma. But I also like what you said, just so we're not throwing our one incision urology buddies under the bus, is that it is dealer's choice.

22:21The goal is to go some place where guys are, you know, that have done so many in a way that they're going to do it right for you. Yeah, I have seen several patients in my career, though, where because it was done through a midline, I won't even say the urologist, the vasectomist caught the same side twice. Yes, that's right. I've seen that as well. And then that's actually one of the questions I'm going to go to next was what could go wrong with a vasectomy? And actually, before I even ask you that, how successful is it? So if a guy from that same 42 year old guy say, great, you know, the wife is pulling the goalie, there's no more IUD, there's no more diaphragm.

23:01It's your work against, you know, 18 year college fund, what is the, you know, what, what is the success rate of this procedure? Yeah. So there's actually two different things you have to look at. There's an early failure rate where the two ends actually will heal back together in the first four to six weeks. That's called early recannulization. And that happens in about one in five to one in 600 vasectomies. So I'm very, you know, adamant with my patients. We don't even want to check your post vasectomy semen analysis until it's been at least eight weeks. Because there's really good evidence that after eight weeks, the likelihood of those two ends coming back together is less than one in 2000.

23:46And that number comes from the literature. I'll tell you, at least in my own practice, it's even lower than that. I have seen on occasion patients who have had what we call these late recannulizations years later. To be honest, I haven't seen any from my own patients, but I have seen it from people who did very good vasectomy. So I don't think anything was done wrong, but the body's natural reaction to any surgery is to try to heal. and we know when we do reversals, often when you find one end of the vas deferens, you can find the other end just by pulling up on that first end because there'll be a piece of scar tissue connecting the two ends and that scar tissue can have little micro channels running through it.

24:34That's how some of those late failures happen. I've seen that. Have you seen that? I've seen that in the OR. Yeah. I had a guy years ago who actually was coming to me for one of the other complications, which I'll get your opinion on in a sec called post vasectomy pain syndrome. And it was the strangest case because he had excruciating pain and he still had a positive semen analysis after his vasectomy. And so I went in, I did the right side. I still remember the laterality as most of us would do these in just world in my head, right side was fine. Just did a simple reversal. And on the left side, as I was getting ready to do it, I actually saw recannulation and it made sense that he was having persistent motel sperm but that my my theory i don't know you know i don't there's no way we can prove this but is that in some ways he was having kind of this obstructive pain because all this little sperm were trying to get through this and this little thready channel but so i had to cut through that re-channel and then sew together the pipe you know the main pipe in order to to reconstruct it but yeah that's that's real But I think you're saying basically that, you know, when you compare that to birth control pills or tubal ligation or condoms, you're still looking at something that's, you know, three or 400 times more successful.

25:49That's what I always remind guys. So I'll have some patients who'll say, God, what in 2000? That sounds like a high failure rate. And I'm like, well, I guarantee you whatever you're using for birth control now, this is a lot better. That's right. failure rates for tubal ligations, like one in 700. So as you pointed out, tubals are like a really big deal. General anesthesia, you're in a woman's belly and you still have a three to four time higher rate of failure than a vasectomy. Yeah, that's right. Yeah. I mean, I think it's as good a peace of mind as we can get when we get that negative semen analysis.

26:27And I like how you said that at eight weeks, which is also in the guidelines that you penned, there are some urologists, I don't know if you used to do this too, where they would say, you know, you should do about 10 to 12 to 15 ejaculations to clean the pipes. And I think that's kind of what's the Japanese and European guidelines that were, they don't even do post vasectomy sperm testing because it's so successful. The litigation society is a little bit less there. Is that, is that your thought too, or you're nodding your head and you're all sort of shaking your head? Well, there's a guy up in Canada, Michel Lebrecht, who is actually a GP.