Speaker 1: Let's talk about it. Let's talk about the Mayro. Let's
Speaker 1: talk about it.
Speaker 2: Let's talk about the may hero.
Speaker 3: Welcome to the Man, Welcome back to the mail room
Speaker 3: with doctor Jesse Mills and Jordan Runtal, producer extraordinaire.
Speaker 2: It's such a delight to be back with you.
Speaker 3: Last episode we had doctor j Sandlo, chair of the
Speaker 3: Division of Urology at Medical College of Wisconsin.
Speaker 2: Is it a division or department?
Speaker 4: Jay, department, It is a department.
Speaker 2: I'm so sorry. That's a big distinction. Department.
Speaker 4: I wasn't gonna correct you, but yeah.
Speaker 3: No, no, you please do it. This is it's you know,
Speaker 3: we we only do one take, whether it's good or bad.
Speaker 3: So that's that's kind of I'm called one take Mills
Speaker 3: around here. But but yeah, so the department.
Speaker 2: Eulogy of Medical consin Wisconsin.
Speaker 3: And we had a great talk about visseectims last time,
Speaker 3: which always goes right into the next conversation, which is
Speaker 3: whenever I talk with guys about vissectomy, I say it's
Speaker 3: the most definitive form of permanent birth control from a
Speaker 3: male until it isn't. And that's where reversal comes in.
Speaker 3: So welcome back to the mailor and Jay Geordan, thanks
Speaker 3: for joining us again, and glad you got your color back.
Speaker 3: We almost lost you from that last episode. And yeah,
Speaker 3: next time, don't wear a red shirt because I can
Speaker 3: tell the difference between your face and the rest of you,
Speaker 3: so that that we know when we get in trouble.
Speaker 2: A little squeamish around blood, litt scirmish on bood. Well okay,
Speaker 2: well we didn't even talk. Okay, we say to heemotoma.
Speaker 2: That's it. Other than that, it was bodily fluids, not blood.
Speaker 5: When Jesse and I do vasectomies, there's no blood anyway,
Speaker 5: so you don't have to worry exactly right.
Speaker 6: I'm very empathetic, you know, just hearing about these kinds
Speaker 6: of surgeries. It's just I instinctively I clamp up, I
Speaker 6: cringe back, you know what I mean. It just sounds
Speaker 6: painful to me, which I'm as you've said many times,
Speaker 6: you said this in the last episode. I'm sure we'll
Speaker 6: get more knowing this one is actually nowhere near as
Speaker 6: painful as I am making it out to be.
Speaker 2: Well, I will, and I don't know, Jay, do you.
Speaker 3: I started a couple of few years ago using nitrous
Speaker 3: for my sections.
Speaker 2: Do you have that or tell me what.
Speaker 5: You're no, I wish Yeah, I've heard nothing but good things.
Speaker 5: But you know I work out of a hospital based office, right,
Speaker 5: which means that I would have to have anesthesia privileges.
Speaker 3: Yes, yeah, we so when we talk offline. But there
Speaker 3: I did actually get up. It took me eight or
Speaker 3: nine months of to get it all the way through
Speaker 3: the UC regions, so that we now have a way
Speaker 3: to do it because it's not technically an anesthesia's analgeesus,
Speaker 3: but not for the listeners to listen to it and
Speaker 3: bore ourselves with hospital policies. But bottom line is that yeah,
Speaker 3: with nitrous it's even a little bit less painful than
Speaker 3: in the old days.
Speaker 2: But anyway, that's a physeectomy. That's past news.
Speaker 3: Now I'm that same forty two year old Dodger fan
Speaker 3: that has changed my mind, and we decided, in fact,
Speaker 3: after we won the World Series again that the world
Speaker 3: does need more Dodger fans, So talk to me about I'm.
Speaker 2: Sorry shing his head.
Speaker 3: And again the Brewer is such a scrappy team, and
Speaker 3: the Blue Jays too. You know, low payroll baseball is
Speaker 3: probably where we should be at But on the other hand, gosh,
Speaker 3: it's so good to watch those guys win.
Speaker 2: Yeah, enough baseball.
Speaker 3: Talk to me about a reversal, so so I've changed
Speaker 3: my mind. Walk me through what that looks like, and
Speaker 3: is that the only way that I can get pregnant
Speaker 3: after a vseectomy? And then what are your average what's
Speaker 3: your average patient? I mean, tell me your some patient
Speaker 3: stories about what you're seen over the years.
Speaker 5: So when patients come to me to talk about reversals,
Speaker 5: you know, there's a couple of things that I think
Speaker 5: are really important to understand. First of all, is this
Speaker 5: the same relationship or as a new relationship. How many
Speaker 5: kids did you conceive before your vasectomy, because we do
Speaker 5: see a fair number of guys who never had kids
Speaker 5: had a vasectomy. Now they've met someone and they want
Speaker 5: to have kids. And how old is their partner, because
Speaker 5: that obviously is going to really impact the actual success
Speaker 5: of the reversal. You can do the best reversal technically,
Speaker 5: and if you've got a partner who's pre menopausal, she's
Speaker 5: not going to get pregnant. Doesn't matter how good of
Speaker 5: a job you do. I do let couples know that
Speaker 5: besides the reversal. There is an option to get sperm,
Speaker 5: either from the tesco or the epidymus, but that sperm
Speaker 5: has to be used within vitro fertilization that comes with
Speaker 5: it with its own set of costs and risks and whatnot.
Speaker 5: But assuming that this is a couple, and let's go
Speaker 5: with the couple you were just talking about. So they've
Speaker 5: got you know, they've got two kids, and the wife
Speaker 5: is you made her forty one, let's make her thirty
Speaker 5: eight done, and you did his vasectomy three years ago,
Speaker 5: and she's not ready to just be done. And you know,
Speaker 5: he's most guys, he wants to keep his wife happy.
Speaker 5: And you know, he's got a good job, so he
Speaker 5: can he can afford to get air to raise a
Speaker 5: third kid. Reversal is a really good option in a
Speaker 5: guy like that. And so what I do is, after
Speaker 5: I go through all that, I sort of explain the
Speaker 5: two different types of reversals that there are, and how
Speaker 5: we really can't determine which type they're going to get
Speaker 5: until we get in there and do the procedure. So
Speaker 5: when I counsel them, I always say, you know, I'm
Speaker 5: going to give you sort of worst case scenarios and
Speaker 5: then if you still want.
Speaker 4: To proceed, great.
Speaker 5: So what I do is I have a big poster
Speaker 5: in my office that shows the mail reproductive system, and
Speaker 5: I show them how sperm are made in the testicles,
Speaker 5: go through the epidemus into the vaz deference, and then
Speaker 5: after a vasectomy, the sperm don't have anywhere to go,
Speaker 5: so your body breaks them down reabsorbs them. But over
Speaker 5: time you get a build up of the break down
Speaker 5: products from those sperm and they back up into the epididymus.
Speaker 5: The epididymus can swell somewhat to sort of accommodate that.
Speaker 5: But if you are making sperm faster than your body
Speaker 5: can break them down, it is possible that with the
Speaker 5: backup of that fluid with all those sperm parts, that
Speaker 5: you can rupture the epididymus and cause a second blockage.
Speaker 5: The longer the time since the vasectomy, the greater the
Speaker 5: chance of that happening. But there's no absolute cut point.
Speaker 5: So I've had guys who are twenty five years out
Speaker 5: from their vasectomy that did not have that second blockage,
Speaker 5: and I've had guys who were.
Speaker 4: One or two years out that have.
Speaker 5: And so what we do is at the time of
Speaker 5: the reversal, we find the two ends of the vas.
Speaker 5: We open up the end attached to the tescl and
Speaker 5: we look at the fluid coming out, and if that
Speaker 5: fluid is clear fluid or kind of cloudy fluid and
Speaker 5: it's got we look at the fluid under a microscope.
Speaker 5: If we see sperm, they can be dead sperm, live sperm,
Speaker 5: they can.
Speaker 4: Be parts of sperm.
Speaker 5: Because sperm only live about four to six months within
Speaker 5: our body before our body breaks them down. Then we
Speaker 5: know that things are open all the way back to
Speaker 5: the teskull. We can hook the two ends of the
Speaker 5: vas deference back together. That's called the vaso vasostomy. On
Speaker 5: the other hand, if when you open up that end
Speaker 5: you just get a bunch of crud that comes out,
Speaker 5: and there's just when you look under a microscope you
Speaker 5: just see a bunch of white blood cells. You don't
Speaker 5: really see any sperm. That means there's probably another blockage
Speaker 5: closer to the testicle in the epididymous. Then you have
Speaker 5: to do what's called a vaseo epididymoscomy, where you're taking
Speaker 5: one end of the vas and plugging it into the epididymus.
Speaker 5: The analogy that I use is a vasavaseosomi is like
Speaker 5: coupling two fire hoses together. They match up pretty well
Speaker 5: and the success rate is really pretty high. But a
Speaker 5: vasoepididymostomy is actually like plugging a garden hose into a
Speaker 5: fire hose. There's a big seize mismatch. So it's a
Speaker 5: harder procedure to do and it doesn't work quite as well,
Speaker 5: although it definitely works better than if you did that
Speaker 5: first procedure, the vasovasostomy, when there was already a blockage
Speaker 5: in the epidimus.
Speaker 4: Those almost never work.
Speaker 2: I'm so glad you didn't say rupture again for Jordan's sake.
Speaker 3: Yes, yeah, secondary blockage.
Speaker 5: I like that, right, And that's why it's important to
Speaker 5: go to someone who is a trained microsurgeon because a
Speaker 5: lot of people can put the VAZ deference back together
Speaker 5: in the office, even just using magnifying glasses. But if
Speaker 5: you can't put the VAZ deference into the epidiymus, then
Speaker 5: you're pretty much going to just get one type of
Speaker 5: reversal that may or may not even work.
Speaker 2: Yeah, I think that's critical.
Speaker 3: And you touched on a couple of things there, which
Speaker 3: was my next question for you is how do you
Speaker 3: measure success? And one of the things that I think
Speaker 3: we and I'd almost call this a myth based on
Speaker 3: what you just said, but it is in the literature,
Speaker 3: which is time from vasectomy. And so I think a
Speaker 3: lot of our reproductive endocrine colleagues read that paper from
Speaker 3: ninety one or ninety three. There you go, ninety one
Speaker 3: and it's stratified success by age. But you just said it,
Speaker 3: you know, twenty five years out. I'm say I've done
Speaker 3: a vv or I'm sorry vasavasast tom I got thirty
Speaker 3: years out.
Speaker 2: I think they sent him to me to fail and.
Speaker 3: He had modal sperm in his vast deference thirty years afterwards,
Speaker 3: which made me look like a hero.
Speaker 2: But I'm not.
Speaker 3: It just you know, I was able to put two
Speaker 3: pieces of fire hose together instead of a garden hose
Speaker 3: to a fire hose, as you said with your analogy.
Speaker 3: So it's not only time. So what else? How is
Speaker 3: will you cancel a couple when they come to your office?
Speaker 3: You say, well, look, you guys, you should just go
Speaker 3: right to IVF and sperm extraction. You said, age of
Speaker 3: the of the partner makes sense? What else is there
Speaker 3: anything else that you say? Look, I don't sure this.
Speaker 2: You know.
Speaker 5: One question you have to ask is how easy was
Speaker 5: it for you to get pregnant first time around? Because
Speaker 5: I've had some guys who actually had fertility issues that
Speaker 5: male factor fertility issues that then got to aseectomy. Now
Speaker 5: they're coming back for a reversal, and I'm like, whoa,
Speaker 5: you were having issues before you even had the vasectomy.
Speaker 5: You may have even bigger issues after. Also, I will
Speaker 5: ask couples, how many kids do you want? You know,
Speaker 5: if you want to be one and done, maybe maybe
Speaker 5: you do want to do IVF so that you don't
Speaker 5: have to then go through another vasectomy after your reversal.
Speaker 5: That's the snip snap, snip snap from the office, right.
Speaker 5: And then I take some things into consideration, like insurance coverage.
Speaker 5: There's some people who have coverage for IVF but don't
Speaker 5: have coverage for reversals, or other way around. Who wants
Speaker 5: to go through What a reversal is, at least the
Speaker 5: way that I like to do it. It's a general anesthetic.
Speaker 5: It's not a major surgery, but it's certainly a bigger
Speaker 5: deal than the vasectomy and honestly a lot of it.
Speaker 5: I always tell couples there's no wrong answer, it's really
Speaker 5: your choice.
Speaker 3: Yeah, I'm glad what you didn't do there, and I
Speaker 3: think this is because of your wisdom and experience. And
Speaker 3: one of the things we find an early career urologists
Speaker 3: and reproductive specialists.
Speaker 2: Is quoting percentages.
Speaker 3: And it is dangerous because if you want to just
Speaker 3: put it out in the literature and say, look, chance
Speaker 3: of vase of asostromy pregnancy is seventy percent, chance of
Speaker 3: IVF working is seventy percent, those numbers are published somewhere
Speaker 3: multiple times, but it really doesn't give anybody any a
Speaker 3: good decision making capacity unless, I mean, this is what
Speaker 3: happens if you put in to chat GPT, should I
Speaker 3: get a reversal or go to IVF.
Speaker 2: That's probably what they're going to quote.
Speaker 3: But there's so many other factors that are newts that
Speaker 3: that really does become that dialogue with the procedure list
Speaker 3: as well as somebody like you or I that is
Speaker 3: very plugged into the reproductive endocream community too, so we
Speaker 3: can you know, we can help steward them through because
Speaker 3: one of the things you said earlier, and I'd love for.
Speaker 2: You to unpack a little bit more.
Speaker 3: Not unpack really, They just explain is when you do
Speaker 3: a testicular or an epidimal sperm extraction, whether it's after
Speaker 3: a paseectomy or whether it's for other reasons. You said
Speaker 3: you can only do I v F with that sample.
Speaker 3: So walk me through what are the This is just
Speaker 3: going to be sort of a sidebar, but it helps
Speaker 3: because I get this a lot.
Speaker 2: Where why can't you just do IU.
Speaker 3: I with with an epidentimal aspiration? So first of all,
Speaker 3: teach us the alphabet soup that I just threw at you,
Speaker 3: and then second what that looks like to a patient
Speaker 3: in terms of making those decisions.
Speaker 4: Yeah.
Speaker 5: So, and that's actually one of the more common questions
Speaker 5: I get. Well, can't you just pick a needle in
Speaker 5: the tesco and pull sperm out and then just put
Speaker 5: it up inside my wife? Well, artificial insemination, intrauterine insemination,
Speaker 5: same thing. Basically, all that is taking sperm, spinning it down,
Speaker 5: and then putting it up inside the uterus, So you're
Speaker 5: bypassing the vagina and the cervix, the two biggest barriers
Speaker 5: to pregnancy. The problem is you need lots of highly
Speaker 5: moving sperm. Because those sperm r'ches floating around in the uterus,
Speaker 5: they've got to swim up the tubes. They've got to
Speaker 5: find the egg and then fertilize the egg. So if
Speaker 5: you've got a bunch of sperm that are just kind
Speaker 5: of shaken and not really moving anywhere, they're never going
Speaker 5: to find the egg. So we can't get enough sperm
Speaker 5: from the testicle or even from the epidimus that are
Speaker 5: moving well enough that they're going.
Speaker 4: To be able to get up and find the egg.
Speaker 4: So in vitro fertilization.
Speaker 5: You only need one sperm for each egg, So now
Speaker 5: the sperm don't even have to be moving. So that's
Speaker 5: why you can we only use testicular sperm, but there
Speaker 5: are some labs that require epidimals sperm because the epidimal
Speaker 5: sperm move better. We've just found that the testicular sperm
Speaker 5: work just as well and they're a lot easier to get.
Speaker 5: I can do that in the office under local, but
Speaker 5: you have to do in vitro fertilization or IVF, where
Speaker 5: you're actually taking one sperm injecting it into the egg.
Speaker 5: That's called IXI. Yet more alphabet soup intraciteoplasmic sperm injection
Speaker 5: and then a certain percentage of those eggs will fertilize,
Speaker 5: and then you can put one or two of the
Speaker 5: fertilized eggs back inside. So it's a much more extensive procedure.
Speaker 5: And again we see a select group of patients where
Speaker 5: they're coming to see us.
Speaker 4: For a reversal.
Speaker 5: They've probably not all but probably have done at least
Speaker 5: some homework and have said, you know what, we want
Speaker 5: to go down the reversal route. But I do have
Speaker 5: some couples who were never aware that there are options. Similarly,
Speaker 5: because I work very closely with my reproductive endochronology parters,
Speaker 5: they will get couples who will come in having been
Speaker 5: told by their local guynecologists, oh, you've had of aseectomy,
Speaker 5: you have to do IVF, and my ariis will say
Speaker 5: to the couple, have you thought about a reversal, and
Speaker 5: often send them to me. And then you know, with
Speaker 5: the way our system works, there's no huge incentive for
Speaker 5: one of us to do one thing or the other,
Speaker 5: so we just want to do it's best for the couple.
Speaker 5: So I've had patients who came to see them that
Speaker 5: I end up doing a reversal. I've had some of
Speaker 5: my patients that I send to them to do IVF.
Speaker 5: It's really whatever works best for them.
Speaker 3: You've made a ton of really good points in there
Speaker 3: about keeping the patient centered and being in a system
Speaker 3: that you know the incentivization is there to how you
Speaker 3: best can to successfully end with the pregnancy. And I
Speaker 3: think one of the things that I cautioned patients if
Speaker 3: they come to me is if they're reading adverts for
Speaker 3: I'm going to the world's greatest visseectomy reversalist ever, and
Speaker 3: you know they're out there.
Speaker 2: There's so much that goes into this.
Speaker 3: And you and I both know that you know, at
Speaker 3: least I know personally that that I've had one or
Speaker 3: two basi of EMPAThiE domosome's over my twenty odd years
Speaker 3: that didn't work. And I've also had couples where there's
Speaker 3: no reason I should ever do reversal because of maternal age,
Speaker 3: because of prior fertility issues in the first place, where
Speaker 3: a guy at aligospermia. So there's so many things that
Speaker 3: go into it that it isn't just you know, a
Speaker 3: chest thumping match about you know, if you see any
Speaker 3: guy that or any any physician that wants to do
Speaker 3: your reversal and they spend more time bragging about how
Speaker 3: awesome they are, you probably should turn around and find
Speaker 3: a new physician, because you know, humility is what should
Speaker 3: drive all of us to do better by our patients.
Speaker 3: And if you lose that humility and then you're probably
Speaker 3: not operating enough. So that's that's great, and I think
Speaker 3: it's awesome that you're part of that system and that
Speaker 3: you have reproductive any chronologists that are willing to refer
Speaker 3: you aasians for reversal, which has also happened in my
Speaker 3: career over the years, but not as much. I also
Speaker 3: will say that the demographic is important. You're in Milwaukee.
Speaker 3: In the difference between my practice in Colorado where I
Speaker 3: was for I did a lot more reversals in Colorado
Speaker 3: than I do in Los Angeles. Part of it is socioeconomic.
Speaker 3: There's a little more affluence here where the price tag
Speaker 3: of IVF, which we haven't really talked about, but it's
Speaker 3: about three times more expensive to do a cycle of
Speaker 3: IVF than a reversal. But also the maternal age tends
Speaker 3: to be a creeping up a little bit on the
Speaker 3: West side of la. So that seems to match your
Speaker 3: what you're saying as well.
Speaker 2: So tell me. I have a story for you.
Speaker 3: But I'll see if you can, if you can up me,
Speaker 3: and I'll have you go first. Is there been Sometimes
Speaker 3: guys don't always tell the truth right, And they're in
Speaker 3: your office and yes, you're already thinking of a story,
Speaker 3: and they're saying, in a duck, I don't know why
Speaker 3: I can't get somebody pregnant.
Speaker 2: And I'm there with my partner, what can you to
Speaker 2: fix me? And they refuse that they've ever had of
Speaker 2: the sect me. Is that okay?
Speaker 3: So tell me, tell me what are your best stories
Speaker 3: about that? Without you know, remaining hippo compliant.
Speaker 4: Yeah, so I'll never forget. I probably hadn't been Milwaukee
Speaker 4: more than about five years.
Speaker 5: I had an older gentleman, he was about fifty nine,
Speaker 5: denied any previous surgeries, never had had any children. He
Speaker 5: was dating a very attractive thirty eight year old.
Speaker 4: She really wanted kids and.
Speaker 5: Got the history and then went ahead to do the
Speaker 5: exam and he's like, could you ask her to step out?
Speaker 5: And I'm like, okay, that's fine. I mean most of
Speaker 5: the time I do the exam the partners in the room.
Speaker 5: But yeah, so as I'm examining him and I'm feeling
Speaker 5: these two defects in his vass deference, he goes, hey, Doc,
Speaker 5: I had of a sectomy, but I haven't told her
Speaker 5: because she really wants kids and I don't want to
Speaker 5: mess up this relationship. And I said, honestly, you know,
Speaker 5: you should probably tell her. If it's real, she'll understand.
Speaker 5: We can talk about a reversal. And he's like, no, no,
Speaker 5: I just can't do it. I said, all right, Well,
Speaker 5: she came back in. We talked about a surgery that
Speaker 5: could potentially restore his fertility. We didn't talk at all
Speaker 5: about you know, I said, well, it's possibly you have
Speaker 5: a blockage on both sides.
Speaker 4: And you know, it was.
Speaker 5: Just very very careful about never using the term vasectomy
Speaker 5: or vasectomy reversal. And you know, ultimately they did get married,
Speaker 5: and ultimately I did do a reversal.
Speaker 4: Unfortunately, the reversal didn't work.
Speaker 5: He was pretty far out from his vasectomy, but we
Speaker 5: did get a sperm at the same time, and they
Speaker 5: ended up doing IVF made a beautiful little girl, and
Speaker 5: somewhere along the line he either came clean or she
Speaker 5: figured it out, but we had notes all over his
Speaker 5: chart to make sure that nobody would say anything to
Speaker 5: her about his reversal, that.
Speaker 4: It was his surgery. Yeah, but yeah, it was tough.
Speaker 2: It is tough.
Speaker 3: You know, it's an ethical dilemma for us, because of
Speaker 3: course we have to prospect patient autonomy, and he's your
Speaker 3: patient and she is and so you bring up that story,
Speaker 3: and that's very, very similar. Though my guy committed to
Speaker 3: the bit a little bit longer than your guy, and
Speaker 3: he and I have a few of these stories. But
Speaker 3: when I remember years and years ago, it's still in
Speaker 3: Colorado and he was working as a bouncer and was
Speaker 3: assaulted on the job where he had to go to
Speaker 3: the hospital, had to have some kind of surgery to
Speaker 3: fix the assault to the testicles.
Speaker 2: And that's what that was a story he went with,
Speaker 2: And that was a story that she knew.
Speaker 3: And I met and examined him, and same deal in
Speaker 3: exam canc of gosh, it feels exactly like you have clips,
Speaker 3: like you've had a vasectomy.
Speaker 2: And she was in the room said, no, Doc, I
Speaker 2: don't know.
Speaker 3: I mean, that's just that they had to do something
Speaker 3: to fix my balls after I got beaten up on
Speaker 3: both sides. I said, that's that's a very I've never
Speaker 3: heard of a urologist attacking somebody outside of a bar
Speaker 3: and doing a vasectomy as a form of assault, but
Speaker 3: this is exactly what happened.
Speaker 2: And so he committed to the point where I.
Speaker 3: Said, well, look, okay, then I think the best thing
Speaker 3: is to is to actually do a biaps of your
Speaker 3: tested to make sure you're producing sperm. Because you didn't
Speaker 3: have kids before, we don't really know. And he committed
Speaker 3: to it. He actually, we did.
Speaker 2: We he doubled down, this is it, this is it.
Speaker 3: So so I do the biop, say come out, she's
Speaker 3: in the waiter, and said, God's great news.
Speaker 2: Sperm everywhere.
Speaker 3: The guy still never admitted to me that he had
Speaker 3: had of hseectomy. So I said, I think there's a
Speaker 3: reconstructive procedure that I.
Speaker 2: Can do to help you guys. He said, oh, doctor,
Speaker 2: this is a miracle. This is fantastic.
Speaker 3: And so then on the day of the reconstructive procedure,
Speaker 3: in the pre opholding you, he said, Doc, I got
Speaker 3: a level with you.
Speaker 2: I said, oh, do tell all ears.
Speaker 3: He said, I had of a sective and I said
Speaker 3: well if you told her yet, she said, I'm gonna,
Speaker 3: but I want to make sure this works first. I said, well, okay,
Speaker 3: if you come clean, great, we'll we'll, but I mean
Speaker 3: you went through an unnecessary procedure because you lied to me.
Speaker 2: He realized this.
Speaker 3: Yes, yes, well I'm here now. And so I thought
Speaker 3: that guy was committed enough that that. You know, we
Speaker 3: all make mistakes, so we had all want to own
Speaker 3: up to what we've done before. So so yeah, it's
Speaker 3: it's truly amazing that of what I would say new relationships.
Speaker 3: So let's look at this positive and say, okay, this
Speaker 3: this person is finally they've met each other, and they
Speaker 3: went on to you know, to have kids.
Speaker 5: Well I have one that I am sure you see
Speaker 5: a lot of talk to. So got a guy mid forties,
Speaker 5: second marriage again, you know, younger, attractive wife comes in,
Speaker 5: wants a reversal. He's like seven eight years out, so
Speaker 5: not super long, not super short, And we get into
Speaker 5: the r and he's got no fluid coming out of
Speaker 5: the out of the testicular.
Speaker 4: End either side. Wow, Like all right.
Speaker 5: I mean, even with epidimal obstruction, you usually see something
Speaker 5: coming out some paced. A lot of times if you like,
Speaker 5: irrigate towards the testicle real gently, you can get a
Speaker 5: little bit of sperm to come out.
Speaker 4: Nothing.
Speaker 5: So call out to the wife and the waiting room.
Speaker 5: I'm like, hey, you know, he said he wasn't on
Speaker 5: any medication. Do you know is he on an testosterone
Speaker 5: or anything like that? And she's like no, said okay,
Speaker 5: so I BIOPSI um. I look under the microscope and
Speaker 5: he's got some sperm in his tissue, but not tons.
Speaker 5: I'm like, well, I'm just gonna hook him back together
Speaker 5: do avasovesostomy because I don't think he has epidemal obstruction.
Speaker 5: I think maybe he's just not making a lot of sperm.
Speaker 5: So through a VV on both sides, he goes back
Speaker 5: to recovery. I start my next case. After that case,
Speaker 5: I come back to see how he's doing. I walk in.
Speaker 5: She's like bawling her eyes out. He is just got
Speaker 5: this look on his face like I just messed up
Speaker 5: so badly. Turns out he'd been on testosterone. Oh boy,
Speaker 5: didn't tell anybody. He was at one of the local
Speaker 5: clinics getting you know, T replacement, and I had to
Speaker 5: talk both of them off a ledge. Ultimately, you know,
Speaker 5: we got them on hCG and clomate and ultimately ended
Speaker 5: up getting sperm and they got pregnant. Look at that,
Speaker 5: it was really like, you have to think as a guy,
Speaker 5: We have to think of everything that guys may or may.
Speaker 4: Not tell you.
Speaker 3: Right, you bring up an amazing point that actually I
Speaker 3: will add that Perrol because it's a really good one.
Speaker 3: But yeah, that some of the guys that they put
Speaker 3: on the jail because we had a whole podcast on
Speaker 3: how to do testostera and how it's a great form
Speaker 3: of male birth control, they don't think of it as
Speaker 3: a medica. It's not a pill, it's not an injection.
Speaker 3: It's just a little hand sanitizer. Ifter on still works
Speaker 3: is birth control. But one thing that I found in
Speaker 3: my guys on testosterone therapy is that I've always been
Speaker 3: able to do it a vv that there's something about
Speaker 3: and we've never done the clinical study. We've talked about
Speaker 3: it year after year of somebody that's long term post
Speaker 3: phpsectomy when we put them on testosterone, clear out all
Speaker 3: that past, all of those byproducts of a sperm degradation
Speaker 3: and see what happens. But but yeah, in some ways
Speaker 3: that's you know, had you known that ahead of time,
Speaker 3: you would have had a less stress You wouldn't have
Speaker 3: had to buy up see the guy.
Speaker 2: You would have had a much.
Speaker 3: Less stressful day in the order to figure it out.
Speaker 3: So so yeah, guys, be honest with your doctors. It's
Speaker 3: just you and us in the room, and we've heard
Speaker 3: it all. We've seen it all, so just make sure
Speaker 3: that we're on your side, because we are and that's
Speaker 3: what we're all about. So yeah, I mean, I will say,
Speaker 3: one of the most gratifying things, even after all these years,
Speaker 3: and it probably dates back to when I watched you
Speaker 3: do your the first reversal I ever saw in my
Speaker 3: life was the one that you were doing. And there's
Speaker 3: nothing more gratifying than seeing that guy just had it
Speaker 3: a few days ago, who was in I think in June,
Speaker 3: and we did it, had a unilateral VASOEPI and a
Speaker 3: VV on the other side for the same fluid characteristics.
Speaker 3: And you know, to see his first essay come Maxima
Speaker 3: and Alice come back and he had maybe three million,
Speaker 3: and he comes back a month later and it's five
Speaker 3: and then yesterday was normal just a few months later. Right,
Speaker 3: you can't fake that, like you're taking somebody that you
Speaker 3: have a lab test that shows zero and then you
Speaker 3: make it not zero. And as a surgeon, there's nothing
Speaker 3: more gratifying and knowing that then that's going to help
Speaker 3: somebody on their pregnancy goals. I mean, that's one of
Speaker 3: the coolest things we do, is microsurgeons.
Speaker 5: Yeah, it's funny because the cancer docs are always, oh,
Speaker 5: you know, we're saving lives, we're curing cancer, and I'm like,
Speaker 5: I'm saving more human lives than you are.
Speaker 4: I'm creating a whole new life. Seventy eighty years.
Speaker 5: You're given some seventy five year old guy an extra
Speaker 5: five years.
Speaker 2: That's right. I love this.
Speaker 3: This is the eurological pissing matches between divisional specialties.
Speaker 2: Is right?
Speaker 3: And then we're making a family tree for God's sakes.
Speaker 3: All right, Jordan, you managed to not pass out, so
Speaker 3: that's a good sign that we made it through. But
Speaker 3: but you're still conspicuously quiet for yourself. So, so what
Speaker 3: did we miss on the secondomy reversal? What is it
Speaker 3: that that you want to know that that you think
Speaker 3: we didn't we didn't cover in this this half hour.
Speaker 6: I mean, I'm just still in a state of shock.
Speaker 4: By some of the stories you've told me. I mean,
Speaker 4: these sounds sound like episodes of House to me.
Speaker 6: I mean, just be I mean, your view of human
Speaker 6: nature must take a knock, I imagine in a way that
Speaker 6: I did not expect.
Speaker 2: It's the opposite.
Speaker 3: No, I mean we because we're so forgiving, you know,
Speaker 3: we and uh and I don't judge.
Speaker 4: We don't judge judgment.
Speaker 3: One of the things you learn in residency and I
Speaker 3: don't you know, and when I was in residencey we
Speaker 3: we take care of of of prison. And one of
Speaker 3: the first things you're told is that you never asked
Speaker 3: what they did, because you never went to cloud your judgment.
Speaker 3: But I carry that through every patient encounter. And I
Speaker 3: see because a I don't think I would do things differently.
Speaker 3: I'm still going to give, you know, a convict the
Speaker 3: best procedure I can because it's the right thing to
Speaker 3: do as a human being. So yeah, it's actually the opposite.
Speaker 3: I think is that, you know, it just makes for
Speaker 3: good stories, Jordan. That's all it does, is it makes
Speaker 3: for how what did you see today? And that that's
Speaker 3: the fun part about what we do as physicians is
Speaker 3: we get to take care everybody.
Speaker 4: You're a good man, both you.
Speaker 2: I mean, I guess.
Speaker 6: Thinking about approaching this episode, I realized that so much
Speaker 6: of the focus has been on vaseectomies and myths about it.
Speaker 6: I realized that I knew very little actually about reversing vaseectamies.
Speaker 6: Are there myths about that that you would look to
Speaker 6: clear up about that? Things that maybe didn't naturally occur
Speaker 6: to me?
Speaker 4: What do you have a sperm an of bodies? Oh?
Speaker 2: Yeah, good?
Speaker 5: Oh we always talk about No, you don't want to
Speaker 5: rehearsal ble work because you're making anisperm antibodies.
Speaker 4: So wow.
Speaker 5: Our immune system does not recognize our sperm as ourselves
Speaker 5: because the sperm don't develop until we go through puberty,
Speaker 5: so our immune system has already formed. So the testicle
Speaker 5: has a way of walling off the sperm from the
Speaker 5: blood streams so that your immune system never sees your sperm.
Speaker 5: Any kind of injury, including of a sectomy, will now
Speaker 5: expose sperm to the immune system, and you will make
Speaker 5: antibodies against your sperm. So there's this myth that reversals
Speaker 5: won't work because these anisperm antibodies will attack and kill
Speaker 5: all your sperm, and so they're never going to It
Speaker 5: just isn't going to work. And I mean, I don't
Speaker 5: know about you, Jesse, but it is rare, like probably
Speaker 5: less than ten percent of guys who I see who
Speaker 5: have successful reversals but can't get pregnant because they're so
Speaker 5: much clumping of the sperm from the antibodies that they don't.
Speaker 3: Move right right now, that's one of the things you
Speaker 3: look for under the microscope for sure.
Speaker 2: Yeah.
Speaker 3: Yeah, but again we have a fix for that anyhow,
Speaker 3: So you put them on a little pregnant zone if
Speaker 3: they need it, and their right is rerain. So now
Speaker 3: that's a great myth, yeah, because I think that does
Speaker 3: turn a lot of people away, especially when they hear
Speaker 3: it from another physician, like, oh, well, this doctor's telling
Speaker 3: me this, so obviously Sandlo doesn't know what he's talking about.
Speaker 3: So I guess I'm going to do IVF instead.
Speaker 2: Yeah, makes sense. Well, I think you've done it again.
Speaker 3: You've wasted another thirty to forty minutes with a bunch
Speaker 3: of urologists talking about about vaz as it was sick
Speaker 3: to be reversals. Bit boy, I he sture had a
Speaker 3: lot of fun with you, Jay. As always, I can't
Speaker 3: wait to hang out with you at the next meeting.
Speaker 5: I agree, Yes, it's first of all, like I said,
Speaker 5: I'm so proud of everything you have accomplished. And you know,
Speaker 5: this is why we do what we do, right, And
Speaker 5: I mean you do the same thing. You you turn
Speaker 5: out residents and fellows and then you watch them go
Speaker 5: on to do bigger and better things, and I just
Speaker 5: you are incredible.
Speaker 4: You know.
Speaker 5: I don't first of all, I'm going to start listening
Speaker 5: to this podcast because I haven't feeling i'd really like it.
Speaker 5: But you know, Jordan, I don't know if you know,
Speaker 5: Jesse runs one of the most successful fellowships like this
Speaker 5: for infertility. And it's great that we finally got you
Speaker 5: to come on board with the match, which was a
Speaker 5: really big deal.
Speaker 3: Yes, well, yes, it's uh yes, I think you forced
Speaker 3: forced me at gunpoint to eating my young So yes,
Speaker 3: I said, okay much. No, I mean, this is this
Speaker 3: is great And I will tell you what you said
Speaker 3: I had. I got texted from one of my fellows
Speaker 3: that just graduated last year. On our second day in
Speaker 3: the office. She did seventeen visectomies yesterday. So keep this,
Speaker 3: oh corone, I said, geez, Nancy, that's more than I've
Speaker 3: done in a week.
Speaker 2: That's uh, and I thought I didn't.
Speaker 3: Yeah, she's yeah, they set them up, set them up
Speaker 3: and knock them down in that practice.
Speaker 2: But yeah, good for her exactly. So. So No, this
Speaker 2: is great. This is why we do what we do.
Speaker 3: I appreciate your time away from your family and from
Speaker 3: the gym. You might be able to let me catch
Speaker 3: up to your bench press if I keep you on
Speaker 3: any longer, which.
Speaker 2: Would be nice.
Speaker 3: And yes, we'll let the cool stratocaster guitar stylings of
Speaker 3: Long Transit take us out.
Speaker 2: Jordan, thanks again for another episode.
Speaker 3: You can't wait for everybody to tune back in and
Speaker 3: see what we got coming out next.
Speaker 1: Let's talk about it. Let's talk about the Maro, Let's
Speaker 1: talk about it. Let's talk about the man Hero, Let's
Speaker 1: talk about it.
Speaker 2: Let's talk about.
Speaker 6: The Mailroom with Doctor Jesse Mills was a production of iHeartRadio.
Speaker 6: It was executive produced by Jordan Runtag. It was edited, mixed,
Speaker 6: and mastered by Beheid Fraser, and the theme was provided
Speaker 6: by Long Transit. If you liked what you heard, please
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