My vasectomy reversal schpeel

In essence, vasectomies can be reversed by re-routing the pipes. Basically, I find the site where the vasectomy was performed, remove the damaged tissues, and re-connect the 2 ends. Sounds easy, right?
Actually, vasectomy reversals are challenging, even in the best of hands.
Whether or not a vasectomy reversal will be straightforward or complex depends upon intra-operative findings. In a straightforward vasectomy reversal, the length of missing segment will be short and there will be sperm in the vasal fluid. In this instance, a vaso-vaso—or V-V—can be performed with success rates in the 90% range, or higher. When I detect no sperm in the vasal fluid during intra-operative inspection, you will have a condition known as “blow-out.” Blow-out, in medical terms, is caused by an obstruction at the level of the epididymis. The presence of blow-out requires that I perform an epididymo-vasostomy—or E-V—in order to ensure the highest chances of success for you.
Very few surgeons have the training or expertise to successfully perform an E-V. E-Vs require that the surgeon operate at high magnification and use sutures too small to see with the naked eye. The sutures must be placed perfectly or the procedure will simply not work. While in most operations, “good enough” is sufficient, an E-V requires perfection; nothing less.
The vasectomy reversal is best performed under the aid of a high power, operating microscope. The use of “loupes”, which are low cost magnifying glasses, is not sufficient. Only operating microscopes that have high power magnification, electronic motion, focus, and zoom controls, and vibration dampening are sufficient for vasectomy reversals. I use one that costs in excess of $100,000 and has truly amazing optics.
Finally, many surgeons will do vasectomy reversals under “local” anesthetic. Whether or not this is ok depends upon the patient and the surgeon. Personally, I believe that the patient ought to be asleep and under the care of a board certified anesthesiologist. That way, the patient is comfortable and safe and I can concentrate on the task at hand. I think that outcomes simply are better this way.
The cost of vasectomy reversal will vary depending upon several factors: surgeon cost, facility fee, anesthesia fee, and any additional procedures such as sperm banking and lab fees. Our fees are in the $6500 total cost range. This fee includes my surgical fee, the facility fee, and the anesthesiologist fee. While less than some others, I feel the fee provides me with adequate compensation as the surgeon and is still reasonable for the patient. Others charge more, but a mentor of mine once said to me, “bulls make money and bears make money, but pigs get slaughtered.” I chose not to be a pig. Plus, I enjoy doing the procedures.
The only other option for couples that wish to have a baby after vasectomy is in-vitro fertilization, or IVF. In order for the woman to undergo the IVF, the man must still have a procedure to extract sperm directly from the testicle and the woman must undergo multiple hormone medication injections and an egg retrieval procedure. The IVF process is both emotionally and physically taxing. In addition, it is very expensive; often in the $12,000 to $20,000 range, per attempt. Each attempt, in the best of conditions, in the best of centers, with best doctors and the best embryologists, has only a 30% chance of success, meaning an ongoing pregnancy. Therefore, should you choose IVF rather than a vasectomy reversal, be prepared to pay $50,000.
Success for a vasectomy reversal is defined as sperm returning to the ejaculate. Ideally, enough sperm returns so that you can get your wife pregnant naturally. If you to not impregnate your wife naturally, but sperm returns to the ejaculate, IUI--artificial insemination--is the next option. IUI is inexpensive. If all else fails, you can still proceed with IVF, secure in the knowledge that you did the logical, prudent, safe, and inexpensive treatment first.
Any other questions?

SPERM MORPHOLOGY: DO WANT STRICT OR STANDARD, AND WHAT’S THE DIFFERENCE?

Strict morphology is
not designed to be a screening test for male infertility. It is far too sensitive for that
indication. In fact, using strict
morphology, only 5% of men will have normal sperm and thus be considered
fertile. Rather than use strict
morphology, W.H.O 3^rd edition morphologies are designed for
screening populations of men for infertility.
Under this classification system, up to 50% of m en will have normal
sperm.

In the 1950’s, McLeod, an andrologist, began to examine the
shape of sperm in men of proven fertility and sterility. His research led to a classification
system. Under McLeod’s classification
system, only the shape of the sperm head mattered and 50% of men had normal
sperm morphology.

Things sure have changed.

Now most labs use Strict Morphology—also known as Kruger
Morphology—or the World Health Organization standard, the W.H.O 4^th
edition. These methods take sperm head,
midpiece, and tail features into consideration.
In the early 1990s, when these categorization schemas were developed, 20
to 50% of men had abnormal sperm morphologic features. Now, only about 5% of men will have “normal”
sperm when these strict criteria are applied.
Why is that?

Well, no one knows for sure, but one can infer that part of
the problem lies in the way that sperm morphology information is used. Strict morphology is used to decide on when
to send a couple for ICSI rather than standard IVF. Couples with less than 5% normal forms have
better fertilization rates with ICSI compared to IVF. Used In this way, morphology assessments can
only determine which treatment option to pursue.

Strict morphology is not designed to be a screening test for
male infertility. Iit is far too
sensitive for that indication. In fact,
using strict morphology, only 5% of men will have normal sperm. Rather than use strict morphology, W.H.O 3^rd
edition morphologies are designed for screening populations of men for
infertility. Under this classification
system, up to 50% of men will have normal sperm.

Ask if your lab can do both Strict and
W.H.O 3^rd and report them simultaneously. That way doctors can get the information they
need and patients can avoid unnecessary worry.

Thanks,

Richard A Schoor MD FACS

Urodynamic Studies: Who, when, & why.

The bladder does 2 things; it fills and it empties. All urinary problems can be grouped into problems of bladder filling or bladder emptying. For example incontinence--leakage of urine--can be due to inability to hold the urine in or due to inability to empty the bladder. Often, all that a urologist needs to diagnose and treat the problem is a good history and physical examination. However, on occasionally, the patient's symptoms and signs point in different directions and this makes it difficult for the urologist to come to an accurate diagnosis and hence treatment plan for the patient. In these cases, urodynamic studies may be helpful.

Urodynamic studies test the bladder as a functional unit. The test has 5 parts:

• CMG--the CystoMetroGram tests the bladder ability to fill. It measures the bladder compliance and the bladder pressures. The doctor can also get an assessment of bladder sensory capacity, ie pain with filling, ability to sense fluid presence and temperature, etc.
• The pressure flow: this tests the bladder ability to generate pressure during voiding and can give an assessment of whether a functional obstruction is present, such as the case in BPH or bladder neck obstruction.
• The EMG: this records sphincteric activity and measures whether or not a patient can appropriately contract and relax their pelvic musculature. For example, when voiding, EMG activity should decrease and it should increase while coughing. People with chronic pelvic pain conditions often have abnormal EMG patterns.
  
• The uroflow: this test records the velocity of the urine flow. People with blockages will typically have slow flow rates. This test is most informative when coupled with a pressure-flow assessment.
• The PVR: this determines how much urine is left behind after the person has completed the urination. Incontinence can be associated with both high and low PVRs. UTIs can be caused by high PVRs.
  

Urodynamic studies are useful in the diagnosis and treatment of patients with many urinary disorders. Such conditions include:

• bladder outlet obstruction/BPH
• urinary retention
• urinary incontinence
• urinary tract infections
• overactive bladder
• urinary frequency
• interstitial cystitis
• chronic pelvic & perineal pain syndrome

If you suffer from urinary problems and are not helped by empiric therapy, ask your urologist for a urodynamic study for a more accurate diagnostic evaluation.

Thanks

Dr S