Undoing the Snip: Inside Vasectomy Reversal Surgery

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3:50Dr. Jesse Mills:Let's talk about it. Let's talk about it, the mailroom. Welcome to the mailroom. Welcome back to the mailroom with Dr. Jesse Mills and Jordan Runtal, producer extraordinaire. It's such a delight to be back with you. Last episode, we had Dr. Jay Sandlow, chair of the Division of Urology at Medical College of Wisconsin. Is it a division or department, Jay? Department. It is a department. and I'm so sorry. That's a big distinction. Department. I wasn't going to correct you, but yeah. No, no, no, no, you please do. This is, it's, you know, we, we only do one take, whether it's good or bad. So that's, that's kind of called one take mills around here, but, but yeah, so the Department of Urology Medical Council of Wisconsin, and we'd had a great talk about vasectomies last time, which always goes right into the next conversation, which is whenever I talk with guys about vasectomy, I say it's the most definitive form of permanent birth control from a male until it isn't.

4:50Dr. Jesse Mills:And that's where reversal comes in. So welcome back to the mailroom, Jay. Jordan, thanks for joining us again. And glad you got your color back. We almost lost you from that last episode. And yeah, next time don't wear a red shirt because I can tell the difference between your face and the rest of you so that we know when we get in trouble. A little squeamish around blood, a little squeamish on blood. Well, okay, well, we didn't even talk. Okay, we said hematoma. That's it. Other than that, it was bodily fluids, not blood. when jesse and i do vasectomies there's no blood anyway so you don't have to worry exactly right i'm very empathetic you know just hearing about these kinds of surgeries it's just i i instinctually i clamp up i cringe i i run back you know what i mean it just sounds painful to me which i'm as you've said many times you said this in the last episode i'm sure we get more into this one is actually nowhere near as painful as i'm making it out to be as i assume it is i will and i don't know jay do you i started a couple few years ago using nitrous for my vasectomies do you have that or tell me what you know i wish um i've heard nothing but good things but you know i work out of a hospital-based office right which means that um i would have to have anesthesia privileges yes yeah we so i don't talk offline but there i did actually get a it took me eight or nine months of to get it all the way through the uc region so that we now have a way to do it because it's not technically anesthesia, it's analgesia, but not for the listeners to listen to and bore ourselves with hospital policies.

6:19Dr. Jesse Mills:But bottom line is that, yeah, with nitrous, it's even a little bit less painful than in the old days. But anyway, that's a vasectomy. That's past news. Now, I'm that same 42-year-old Dodger fan that has changed my mind. And we decided, in fact, after we won the World Series again, that the world does need more Dodger fans. So talk to me about... I'm sorry. He's shaking his head. And again, the Brewers, such a scrappy team. And the Blue Jays, too. You know, low payroll baseball is probably where we should be at. But on the other hand, gosh, it's so good to watch those guys win. Enough baseball.

6:56Dr. Jesse Mills:Talk to me about a reversal. So I've changed my mind. Walk me through what that looks like. And is that the only way that I can get pregnant after a vasectomy? And then what's your average patient? I mean, tell me some patient stories about what you've seen over the years. So when patients come to me to talk about reversals, you know, there's a couple of things that I think are really important to understand. First of all, is this the same relationship or is a new relationship? How many kids did you conceive before your vasectomy? Because we do see a fair number of guys who never had kids had a vasectomy.

7:36now they've met someone and they want to have kids. And how old is their partner? Because that obviously is going to really impact the actual success of the reversal. You can do the best reversal technically. And if you've got a partner who's premenopausal, she's not going to get pregnant. Doesn't matter how good of a job you do. I do let couples know that besides the reversal, There is an option to get sperm either from the testicle or the epididymis, but that sperm has to be used with in vitro fertilization that comes with its own set of costs and risks and whatnot. But assuming that this is a couple, and let's go with the couple you were just talking about.

8:23So they've got, you know, they've got two kids and the wife is, you made her 41, let's make her 38. Done. And you did his vasectomy three years ago, and she's not ready to just be done. And, you know, he's like most guys, he wants to keep his wife happy. And, you know, he's got a good job, so he can afford to raise a third kid. But reversal is a really good option in a guy like that. and then and so what I do is after I go through all that I sort of explain the two different types of reversals that there are and how we really can't determine which type they're going to get until we get in there and do the procedure so when I counsel them I always say you know I'm going to give you sort of worst case scenarios and then if you still want to proceed great.

9:19So what I do is I have a big poster in my office that shows the male reproductive system, and I show them how sperm are made in the testicles, go through the epididymis into the vas deferens, and then after a vasectomy, the sperm don't have anywhere to go, so your body breaks them down, reabsorbs them. But over time, you get a buildup of the breakdown products from those sperm and they back up into the epididymis. The epididymis can swell somewhat to sort of accommodate that. But if you are making sperm faster than your body can break them down, it is possible that with the backup of that fluid, with all those sperm parts that you can rupture the epididymis and cause a second blockage.

10:06The longer the time since the vasectomy, the greater the chance of that happening, but there's no absolute cut point. So I've had guys who are 25 years out from their vasectomy that did not have that second blockage, and I've had guys who were one or two years out that have. And so what we do is at the time of the reversal, we find the two ends of the vas, we open up the end attached to the testicle, and we look at the fluid coming out. And if that fluid is clear fluid or kind of cloudy fluid, and it's got, we look at the fluid under a microscope. If we see sperm, they can be dead sperm, live sperm.

10:46They can be parts of sperm because sperm only live about four to six months within our body before our body breaks them down. Then we know that things are open all the way back to the testicle, we can hook the two ends of the vas deferens back together. That's called a vasovasostomy. On the other hand, if when you open up that end, you just get a bunch of crud that comes out and there's just, when you look under a microscope, you just see a bunch of white blood cells. You don't really see any sperm. That means there's probably another blockage closer to the testicle in the epididymis. Then you have to do what's called a vasoepididymostomy, where you're taking one end of the vas and plugging it into the epididymis.

11:30The analogy that I use is a vasovasostomy is like coupling two fire hoses together. They match up pretty well, and the success rate is really pretty high. But a vasoepididymostomy is actually like plugging a garden hose into a fire hose. There's a big size mismatch. So it's a harder procedure to do, and it doesn't work quite as well, although it definitely works better than if you did that first procedure, the vasovasostomy, when there was already a blockage in the epidermis. Those almost never work.

12:06Dr. Jesse Mills:I'm so glad you didn't say rupture again for Jordan's sake. Yes. Secondary blockage. I like that. Right. And that's why it's important to go to someone who is a trained microsurgeon because a lot of people can put the vas deferens back together in the office, even just using magnifying glasses. But if you can't put the vas deferens into the epididymis, then you're pretty much going to just get one type of reversal that may or may not even work. Yeah, I think that's critical. And you touched on a couple of things there, which was my next question for you is how do you measure success? And one of the things that I think we, and I'd almost call this a myth based on what you just said, but it is in the literature, which is time from vasectomy.

12:54Dr. Jesse Mills:And so I think a lot of our reproductive endocrine colleagues read that paper from 91 or 93. 1991. There you go, 91. And it stratified success by age. But you just said it, you know, 25 years out. Same, I've done a VV, or I'm sorry, vasovasostomy, I got 30 years out. I think they sent him to me to fail. And he had modal sperm and his vast deference 30 years afterwards, which made me look like a hero, but I'm not. It just, you know, I was able to put two pieces of fire hose together instead of a garden hose to a fire hose, as you said, with your analogy. So it's not only time. So what else, how else will you cancel a couple when they come to your office?

13:34Dr. Jesse Mills:Do you say, well, look, you guys, you should just go right to IVF and sperm extraction. You said age of the partner makes sense. But what else? Is there anything else that you say, look, I don't think we should try this. You know, one question you have to ask is how easy was it for you to get pregnant first time around? Because I've had some guys who actually had fertility issues that male factor fertility issues that then got a vasectomy. Now they're coming back for a reversal. And I'm like, whoa, you were having issues before you even had the vasectomy. You may have even bigger issues after.

14:09Also, I will ask couples, how many kids do you want? You know, if you want to be one and done, maybe you do want to do IVF so that you don't have to then go through another vasectomy after your reversal. That's the snip, snap, snip, snap from the office. Right. And then I take some things into consideration like insurance coverage. There are some people who have coverage for IVF but don't have coverage for reversals or other way around. Who wants to go through what? But a reversal is at least the way that I like to do it. It's a general anesthetic. It's not a major surgery, but it's certainly a bigger deal than the vasectomy.

14:52And honestly, a lot of it, I always tell couples, there's no wrong answer. It's really your choice. Yeah.

15:00Dr. Jesse Mills:I'm glad what you didn't do there. And I think this is because of your wisdom and experience. And one of the things we find in early career urologists and reproductive specialists is quoting percentages. And it is dangerous because if you want to just put it out in the literature and say, look, chance of a vasovasostomy pregnancy is 70%. Chance of IVF working is 70%. Those numbers are published somewhere multiple times. But it really doesn't give anybody any good decision-making capacity. I mean, this is what happens if you put in to chat GPT, should I get a reversal or go to IVF? That's probably what they're going to quote.

15:39Dr. Jesse Mills:But there's so many other factors that are nuanced that really does become that dialogue with the procedure list, as well as somebody like you or I that is very plugged into the reproductive endocrine community, too. So we can help steward them through. Because one of the things you said earlier, and I'd love for you to unpack a little bit more, not unpack really, they just explain is when you do a testicular or an epididymal sperm extraction, whether it's after vasectomy or whether it's for other reasons, you said you can only do IVF with that sample. So walk me through what are the assist, this is just going to be sort of a sidebar, but it helps because I get this a lot where why can't you just do IUI with an epididymal aspiration?

16:23Dr. Jesse Mills:So first of all, I'll teach us the alphabet soup that I just threw at you. And second, what that looks like to a patient in terms of making those decisions. Yeah. So, and that's actually one of the more common questions I get. Well, can't you just stick a needle in the testicle and pull sperm out and then just put it up inside my wife? Well, artificial insemination, intrauterine insemination, same thing. Basically, all that is taking sperm, spinning it down, and then putting it up inside the uterus. So you're bypassing the vagina and the cervix, the two biggest barriers to pregnancy. The problem is you need lots of highly moving sperm because those sperm aren't just floating around in the uterus.

17:05They've got to swim up the tubes. They've got to find the egg and then fertilize the egg. So if you've got a bunch of sperm that are just kind of shaking and not really moving anywhere, they're never going to find the egg. So we can't get enough sperm from the testicle or even from the epididymis that are moving well enough that they're going to be able to get up and find the egg. So in vitro fertilization, you only need one sperm for each egg. So now the sperm don't even have to be moving. So that's why you can, we only use testicular sperm, but there are some labs that require epididymal sperm because the epididymal sperm move better.

17:44We've just found that the testicular sperm work just as well, and they're a lot easier to get. I can do that in the office under local, but you have to do in vitro fertilization or IVF where you're actually taking one sperm, injecting it into the egg. That's called ICSI, yet more alphabet soup, intracytoplasmic sperm injection. And then a certain percentage of those eggs will fertilize, and then you can put one or two of the fertilized eggs back inside. So it's a much more extensive procedure. And again, we see a select group of patients where they're coming to see us for a reversal. They've probably, not all, but probably have done at least some homework and have said, you know what, we want to go down the reversal route.

18:31But I do have some couples who were never aware that there are options. Similarly, because I work very closely with my reproductive endocrinology partners, they will get couples who will come in having been told by their local gynecologist, oh, you've had a vasectomy, you have to do IVF. And my REIs will say to the couple, have you thought about a reversal? And often send them to me and then, you know, So with the way our system works, there's no huge incentive for one of us to do one thing or the other. So we just want to do what's best for the couple. So I've had patients who came to see them that I end up doing a reversal.

19:18I've had some of my patients that I send to them to do IVF. It's really whatever works best for them.

19:25Dr. Jesse Mills:You made a ton of really good points in there about keeping the patient centered and being in a system that, you know, the incentivization is there to how you best get a successfully end with a pregnancy. And I think one of the things that I caution patients if they come to me is if they're reading adverts for I'm going to the world's greatest vasectomy reversalist ever. And, you know, they're out there. There's so much that goes into this. And you and I both know that, you know, at least I know personally that I've had one or two vasoepithetomomies over my 20 odd years that didn't work. And I've also had couples where there's no reason I should ever do reversal because of maternal age, because of prior fertility issues in the first place where a guy had oligospermia.

20:12Dr. Jesse Mills:So there's so many things that go into it that it isn't just, you know, a chest thumping match about, you know, if you see any guy that or any physician that wants to, do your reversal and they spend more time bragging about how awesome they are, you probably should turn around and find a new physician because, you know, humility is what should drive all of us to do better by our patients. And if you lose that humility, then you're probably not operating enough. So that's great. And I think it's awesome that you're part of that system and that you have reproductive endocrinologists that are willing to refer you patients for reversal, which has also happened in my career over the years, but not as much.

20:46Dr. Jesse Mills:I also will say that the demographic is important. Here in Milwaukee, the difference between my practice in Colorado, I did a lot more reversals in Colorado than I do in Los Angeles. Part of it is socioeconomic. There's a little more affluence here with the price tag of IVF, which we haven't really talked about, but it's about three times more expensive to do a cycle of IVF than a reversal. But also the maternal age tends to be creeping up a little bit on the west side of LA. So that seems to match you're saying as well. Yeah.

21:47Dr. Jesse Mills:patient health can still be a challenge. LabCorp brings clarity. Our cardiometabolic testing solutions support early risk assessment and empower more informed decision-making so you can focus on what matters most, your patients. Visit labcorp.com to partner with LabCorp and simplify complex patient profiles. Support for the show comes from Public, the investing platform for those who take it seriously. On Public, you can build a multi-asset portfolio of stocks, bonds, options, crypto, and now generated assets, which allow you to turn any idea into an investable index with AI. It all starts with your prompt from renewable energy companies with high free cash flow to semiconductor suppliers, growing revenue over 20 % year over year.

22:28Dr. Jesse Mills:You can literally type any prompt and put the AI to work. It screens thousands of stocks, builds a one of a kind index and lets you back test it against the S and P 500. Then you can invest in a few clicks. Generated assets are like ETFs with infinite possibilities, completely customizable and based on your thesis, not someone else's. Go to public.com slash podcast and earn an uncapped 1 % bonus when you transfer your portfolio. That's public.com slash podcast. Paid for by public investing. Brokered services by open to the public investing, Inc. Member FINRA and SIPC. Advisory services by public advisors, LLC, SEC registered advisor.

22:59Dr. Jesse Mills:Generated assets is an interactive analysis tool. Output is for informational purposes only and is not an investment recommendation or advice. Complete disclosures available at public.com slash disclosures. When people turn to telehealth or weight loss, they're looking for real support. That's why more people are choosing orderlymeds.com. Orderly Meds connects you with real doctors and access to proven GLP-1 medications like semaglutide and terzeptatide. No guessing, just a more supportive experience. And all shipped directly to your door in discreet packaging. Do your research, ask questions, then visit orderlymeds.com slash podcast for an exclusive offer.

23:29That's orderlymeds.com slash podcast. Individual results may vary. Now medical advice eligibility required. See site for details.

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25:20Dr. Jesse Mills:so tell me i have a story for you but but i'll see if you can if you can up me and i'll have you go first is there been sometimes guys don't always tell the truth right and they're in your office yep and yes you're already thinking of a story yeah and they're saying you know duck i I don't know why I can't get somebody pregnant and I'm there with my partner. What can you do to fix me? And they refuse that they've ever had a vasectomy. Is that a, okay. So tell me, tell me what are your best stories about that without, you know, remaining HIPAA compliant. Yeah. So, so I'll never forget. I probably hadn't been in Milwaukee more than about five years.