WEBVTT - Undoing the Snip: Inside Vasectomy Reversal Surgery 0:00:00.600 --> 0:00:09.080 Let's talk about it. Let's talk about the Mayro. Let's 0:00:09.119 --> 0:00:09.960 talk about it. 0:00:11.920 --> 0:00:13.920 Let's talk about the may hero. 0:00:17.000 --> 0:00:20.800 Welcome to the Man, Welcome back to the mail room 0:00:20.800 --> 0:00:24.040 with doctor Jesse Mills and Jordan Runtal, producer extraordinaire. 0:00:24.320 --> 0:00:26.520 It's such a delight to be back with you. 0:00:27.440 --> 0:00:30.920 Last episode we had doctor j Sandlo, chair of the 0:00:31.080 --> 0:00:34.440 Division of Urology at Medical College of Wisconsin. 0:00:34.520 --> 0:00:35.640 Is it a division or department? 0:00:35.720 --> 0:00:37.080 Jay, department, It is a department. 0:00:37.120 --> 0:00:39.199 I'm so sorry. That's a big distinction. Department. 0:00:39.479 --> 0:00:41.360 I wasn't gonna correct you, but yeah. 0:00:41.200 --> 0:00:43.640 No, no, you please do it. This is it's you know, 0:00:43.960 --> 0:00:46.160 we we only do one take, whether it's good or bad. 0:00:46.200 --> 0:00:48.880 So that's that's kind of I'm called one take Mills 0:00:48.920 --> 0:00:51.560 around here. But but yeah, so the department. 0:00:51.120 --> 0:00:52.720 Eulogy of Medical consin Wisconsin. 0:00:53.000 --> 0:00:55.440 And we had a great talk about visseectims last time, 0:00:55.480 --> 0:00:59.880 which always goes right into the next conversation, which is 0:01:00.000 --> 0:01:03.080 whenever I talk with guys about vissectomy, I say it's 0:01:03.080 --> 0:01:06.440 the most definitive form of permanent birth control from a 0:01:06.480 --> 0:01:10.560 male until it isn't. And that's where reversal comes in. 0:01:10.720 --> 0:01:13.360 So welcome back to the mailor and Jay Geordan, thanks 0:01:13.400 --> 0:01:16.200 for joining us again, and glad you got your color back. 0:01:16.200 --> 0:01:19.280 We almost lost you from that last episode. And yeah, 0:01:19.319 --> 0:01:21.280 next time, don't wear a red shirt because I can 0:01:21.280 --> 0:01:24.000 tell the difference between your face and the rest of you, 0:01:24.040 --> 0:01:26.200 so that that we know when we get in trouble. 0:01:26.240 --> 0:01:28.760 A little squeamish around blood, litt scirmish on bood. Well okay, 0:01:28.800 --> 0:01:31.440 well we didn't even talk. Okay, we say to heemotoma. 0:01:31.560 --> 0:01:34.800 That's it. Other than that, it was bodily fluids, not blood. 0:01:35.080 --> 0:01:37.880 When Jesse and I do vasectomies, there's no blood anyway, 0:01:37.920 --> 0:01:39.880 so you don't have to worry exactly right. 0:01:40.120 --> 0:01:43.080 I'm very empathetic, you know, just hearing about these kinds 0:01:43.080 --> 0:01:45.880 of surgeries. It's just I instinctively I clamp up, I 0:01:45.920 --> 0:01:48.440 cringe back, you know what I mean. It just sounds 0:01:48.480 --> 0:01:51.320 painful to me, which I'm as you've said many times, 0:01:51.360 --> 0:01:52.920 you said this in the last episode. I'm sure we'll 0:01:52.920 --> 0:01:54.960 get more knowing this one is actually nowhere near as 0:01:55.000 --> 0:01:56.520 painful as I am making it out to be. 0:01:56.840 --> 0:01:59.320 Well, I will, and I don't know, Jay, do you. 0:01:59.440 --> 0:02:02.360 I started a couple of few years ago using nitrous 0:02:02.360 --> 0:02:03.480 for my sections. 0:02:03.480 --> 0:02:04.720 Do you have that or tell me what. 0:02:04.720 --> 0:02:08.639 You're no, I wish Yeah, I've heard nothing but good things. 0:02:08.680 --> 0:02:13.079 But you know I work out of a hospital based office, right, 0:02:13.160 --> 0:02:17.200 which means that I would have to have anesthesia privileges. 0:02:17.680 --> 0:02:20.880 Yes, yeah, we so when we talk offline. But there 0:02:21.000 --> 0:02:23.959 I did actually get up. It took me eight or 0:02:24.040 --> 0:02:26.119 nine months of to get it all the way through 0:02:26.120 --> 0:02:29.120 the UC regions, so that we now have a way 0:02:29.160 --> 0:02:32.720 to do it because it's not technically an anesthesia's analgeesus, 0:02:32.720 --> 0:02:35.680 but not for the listeners to listen to it and 0:02:35.680 --> 0:02:39.239 bore ourselves with hospital policies. But bottom line is that yeah, 0:02:39.280 --> 0:02:42.880 with nitrous it's even a little bit less painful than 0:02:42.919 --> 0:02:43.640 in the old days. 0:02:43.680 --> 0:02:46.520 But anyway, that's a physeectomy. That's past news. 0:02:46.520 --> 0:02:48.679 Now I'm that same forty two year old Dodger fan 0:02:49.240 --> 0:02:52.280 that has changed my mind, and we decided, in fact, 0:02:52.320 --> 0:02:55.560 after we won the World Series again that the world 0:02:55.600 --> 0:02:59.560 does need more Dodger fans, So talk to me about I'm. 0:02:59.400 --> 0:03:00.560 Sorry shing his head. 0:03:00.600 --> 0:03:03.560 And again the Brewer is such a scrappy team, and 0:03:03.560 --> 0:03:08.280 the Blue Jays too. You know, low payroll baseball is 0:03:08.280 --> 0:03:10.440 probably where we should be at But on the other hand, gosh, 0:03:10.480 --> 0:03:11.680 it's so good to watch those guys win. 0:03:11.800 --> 0:03:13.880 Yeah, enough baseball. 0:03:14.000 --> 0:03:16.960 Talk to me about a reversal, so so I've changed 0:03:16.960 --> 0:03:19.400 my mind. Walk me through what that looks like, and 0:03:19.520 --> 0:03:22.280 is that the only way that I can get pregnant 0:03:22.280 --> 0:03:25.359 after a vseectomy? And then what are your average what's 0:03:25.360 --> 0:03:27.440 your average patient? I mean, tell me your some patient 0:03:27.520 --> 0:03:29.280 stories about what you're seen over the years. 0:03:29.800 --> 0:03:33.799 So when patients come to me to talk about reversals, 0:03:34.160 --> 0:03:36.320 you know, there's a couple of things that I think 0:03:36.360 --> 0:03:39.720 are really important to understand. First of all, is this 0:03:39.920 --> 0:03:44.240 the same relationship or as a new relationship. How many 0:03:44.320 --> 0:03:49.520 kids did you conceive before your vasectomy, because we do 0:03:49.600 --> 0:03:52.280 see a fair number of guys who never had kids 0:03:52.920 --> 0:03:56.000 had a vasectomy. Now they've met someone and they want 0:03:56.040 --> 0:03:59.960 to have kids. And how old is their partner, because 0:04:00.200 --> 0:04:04.640 that obviously is going to really impact the actual success 0:04:04.680 --> 0:04:08.880 of the reversal. You can do the best reversal technically, 0:04:09.520 --> 0:04:14.280 and if you've got a partner who's pre menopausal, she's 0:04:14.320 --> 0:04:16.479 not going to get pregnant. Doesn't matter how good of 0:04:16.520 --> 0:04:19.520 a job you do. I do let couples know that 0:04:20.360 --> 0:04:24.000 besides the reversal. There is an option to get sperm, 0:04:24.600 --> 0:04:27.599 either from the tesco or the epidymus, but that sperm 0:04:27.720 --> 0:04:31.400 has to be used within vitro fertilization that comes with 0:04:31.440 --> 0:04:35.840 it with its own set of costs and risks and whatnot. 0:04:36.279 --> 0:04:39.080 But assuming that this is a couple, and let's go 0:04:39.240 --> 0:04:41.200 with the couple you were just talking about. So they've 0:04:41.240 --> 0:04:46.200 got you know, they've got two kids, and the wife 0:04:46.240 --> 0:04:49.760 is you made her forty one, let's make her thirty 0:04:49.800 --> 0:04:53.440 eight done, and you did his vasectomy three years ago, 0:04:53.800 --> 0:04:58.800 and she's not ready to just be done. And you know, 0:04:59.000 --> 0:05:02.359 he's most guys, he wants to keep his wife happy. 0:05:02.520 --> 0:05:05.160 And you know, he's got a good job, so he 0:05:04.839 --> 0:05:07.520 can he can afford to get air to raise a 0:05:07.560 --> 0:05:10.279 third kid. Reversal is a really good option in a 0:05:10.320 --> 0:05:14.920 guy like that. And so what I do is, after 0:05:14.960 --> 0:05:18.279 I go through all that, I sort of explain the 0:05:18.360 --> 0:05:22.600 two different types of reversals that there are, and how 0:05:22.720 --> 0:05:26.440 we really can't determine which type they're going to get 0:05:26.520 --> 0:05:28.839 until we get in there and do the procedure. So 0:05:29.480 --> 0:05:32.120 when I counsel them, I always say, you know, I'm 0:05:32.120 --> 0:05:35.080 going to give you sort of worst case scenarios and 0:05:35.120 --> 0:05:36.120 then if you still want. 0:05:36.000 --> 0:05:36.919 To proceed, great. 0:05:37.640 --> 0:05:39.920 So what I do is I have a big poster 0:05:40.040 --> 0:05:43.640 in my office that shows the mail reproductive system, and 0:05:43.680 --> 0:05:46.120 I show them how sperm are made in the testicles, 0:05:46.560 --> 0:05:49.599 go through the epidemus into the vaz deference, and then 0:05:50.000 --> 0:05:53.480 after a vasectomy, the sperm don't have anywhere to go, 0:05:53.600 --> 0:05:57.120 so your body breaks them down reabsorbs them. But over 0:05:57.200 --> 0:06:00.360 time you get a build up of the break down 0:06:00.400 --> 0:06:03.520 products from those sperm and they back up into the epididymus. 0:06:04.400 --> 0:06:08.000 The epididymus can swell somewhat to sort of accommodate that. 0:06:08.480 --> 0:06:11.479 But if you are making sperm faster than your body 0:06:11.520 --> 0:06:15.520 can break them down, it is possible that with the 0:06:15.600 --> 0:06:19.720 backup of that fluid with all those sperm parts, that 0:06:19.800 --> 0:06:24.440 you can rupture the epididymus and cause a second blockage. 0:06:24.600 --> 0:06:27.640 The longer the time since the vasectomy, the greater the 0:06:27.720 --> 0:06:32.680 chance of that happening. But there's no absolute cut point. 0:06:32.839 --> 0:06:35.720 So I've had guys who are twenty five years out 0:06:35.760 --> 0:06:39.440 from their vasectomy that did not have that second blockage, 0:06:39.680 --> 0:06:41.359 and I've had guys who were. 0:06:41.560 --> 0:06:43.120 One or two years out that have. 0:06:44.080 --> 0:06:46.320 And so what we do is at the time of 0:06:46.320 --> 0:06:48.799 the reversal, we find the two ends of the vas. 0:06:49.279 --> 0:06:51.479 We open up the end attached to the tescl and 0:06:51.520 --> 0:06:54.120 we look at the fluid coming out, and if that 0:06:54.240 --> 0:06:57.919 fluid is clear fluid or kind of cloudy fluid and 0:06:58.000 --> 0:07:00.720 it's got we look at the fluid under a microscope. 0:07:00.760 --> 0:07:04.799 If we see sperm, they can be dead sperm, live sperm, 0:07:04.960 --> 0:07:05.240 they can. 0:07:05.240 --> 0:07:06.640 Be parts of sperm. 0:07:07.279 --> 0:07:10.600 Because sperm only live about four to six months within 0:07:10.640 --> 0:07:13.680 our body before our body breaks them down. Then we 0:07:13.760 --> 0:07:15.720 know that things are open all the way back to 0:07:15.760 --> 0:07:18.800 the teskull. We can hook the two ends of the 0:07:19.360 --> 0:07:24.320 vas deference back together. That's called the vaso vasostomy. On 0:07:24.360 --> 0:07:26.200 the other hand, if when you open up that end 0:07:26.240 --> 0:07:28.120 you just get a bunch of crud that comes out, 0:07:28.160 --> 0:07:30.960 and there's just when you look under a microscope you 0:07:31.040 --> 0:07:32.840 just see a bunch of white blood cells. You don't 0:07:32.880 --> 0:07:36.720 really see any sperm. That means there's probably another blockage 0:07:36.760 --> 0:07:40.880 closer to the testicle in the epididymous. Then you have 0:07:41.000 --> 0:07:44.880 to do what's called a vaseo epididymoscomy, where you're taking 0:07:45.360 --> 0:07:48.200 one end of the vas and plugging it into the epididymus. 0:07:49.080 --> 0:07:52.040 The analogy that I use is a vasavaseosomi is like 0:07:52.080 --> 0:07:55.880 coupling two fire hoses together. They match up pretty well 0:07:56.880 --> 0:08:00.440 and the success rate is really pretty high. But a 0:08:00.560 --> 0:08:04.920 vasoepididymostomy is actually like plugging a garden hose into a 0:08:04.920 --> 0:08:08.080 fire hose. There's a big seize mismatch. So it's a 0:08:08.120 --> 0:08:12.680 harder procedure to do and it doesn't work quite as well, 0:08:13.200 --> 0:08:16.720 although it definitely works better than if you did that 0:08:17.000 --> 0:08:21.960 first procedure, the vasovasostomy, when there was already a blockage 0:08:21.960 --> 0:08:22.760 in the epidimus. 0:08:22.800 --> 0:08:24.040 Those almost never work. 0:08:24.360 --> 0:08:26.880 I'm so glad you didn't say rupture again for Jordan's sake. 0:08:26.960 --> 0:08:29.920 Yes, yeah, secondary blockage. 0:08:29.960 --> 0:08:33.520 I like that, right, And that's why it's important to 0:08:33.559 --> 0:08:38.160 go to someone who is a trained microsurgeon because a 0:08:38.240 --> 0:08:40.880 lot of people can put the VAZ deference back together 0:08:40.960 --> 0:08:45.439 in the office, even just using magnifying glasses. But if 0:08:45.480 --> 0:08:48.960 you can't put the VAZ deference into the epidiymus, then 0:08:49.320 --> 0:08:52.679 you're pretty much going to just get one type of 0:08:52.800 --> 0:08:54.760 reversal that may or may not even work. 0:08:56.280 --> 0:08:57.680 Yeah, I think that's critical. 0:08:57.679 --> 0:09:00.400 And you touched on a couple of things there, which 0:09:00.480 --> 0:09:02.440 was my next question for you is how do you 0:09:02.440 --> 0:09:04.960 measure success? And one of the things that I think 0:09:05.200 --> 0:09:08.400 we and I'd almost call this a myth based on 0:09:08.440 --> 0:09:10.720 what you just said, but it is in the literature, 0:09:10.760 --> 0:09:13.320 which is time from vasectomy. And so I think a 0:09:13.320 --> 0:09:17.240 lot of our reproductive endocrine colleagues read that paper from 0:09:17.320 --> 0:09:21.080 ninety one or ninety three. There you go, ninety one 0:09:21.720 --> 0:09:25.800 and it's stratified success by age. But you just said it, 0:09:25.880 --> 0:09:28.120 you know, twenty five years out. I'm say I've done 0:09:28.120 --> 0:09:31.079 a vv or I'm sorry vasavasast tom I got thirty 0:09:31.160 --> 0:09:31.600 years out. 0:09:31.960 --> 0:09:34.000 I think they sent him to me to fail and. 0:09:33.960 --> 0:09:37.640 He had modal sperm in his vast deference thirty years afterwards, 0:09:37.640 --> 0:09:38.880 which made me look like a hero. 0:09:39.440 --> 0:09:39.960 But I'm not. 0:09:40.280 --> 0:09:41.959 It just you know, I was able to put two 0:09:41.960 --> 0:09:44.240 pieces of fire hose together instead of a garden hose 0:09:44.280 --> 0:09:46.319 to a fire hose, as you said with your analogy. 0:09:46.800 --> 0:09:49.240 So it's not only time. So what else? How is 0:09:49.280 --> 0:09:52.000 will you cancel a couple when they come to your office? 0:09:52.080 --> 0:09:54.520 You say, well, look, you guys, you should just go 0:09:54.640 --> 0:09:57.920 right to IVF and sperm extraction. You said, age of 0:09:57.440 --> 0:10:00.600 the of the partner makes sense? What else is there 0:10:00.600 --> 0:10:03.120 anything else that you say? Look, I don't sure this. 0:10:03.720 --> 0:10:03.960 You know. 0:10:04.080 --> 0:10:06.720 One question you have to ask is how easy was 0:10:06.760 --> 0:10:10.000 it for you to get pregnant first time around? Because 0:10:10.000 --> 0:10:13.640 I've had some guys who actually had fertility issues that 0:10:14.080 --> 0:10:17.800 male factor fertility issues that then got to aseectomy. Now 0:10:17.840 --> 0:10:20.120 they're coming back for a reversal, and I'm like, whoa, 0:10:20.640 --> 0:10:23.200 you were having issues before you even had the vasectomy. 0:10:23.880 --> 0:10:28.360 You may have even bigger issues after. Also, I will 0:10:28.400 --> 0:10:31.120 ask couples, how many kids do you want? You know, 0:10:31.360 --> 0:10:34.439 if you want to be one and done, maybe maybe 0:10:34.440 --> 0:10:37.480 you do want to do IVF so that you don't 0:10:37.480 --> 0:10:40.760 have to then go through another vasectomy after your reversal. 0:10:41.160 --> 0:10:44.400 That's the snip snap, snip snap from the office, right. 0:10:45.800 --> 0:10:49.240 And then I take some things into consideration, like insurance coverage. 0:10:49.280 --> 0:10:52.120 There's some people who have coverage for IVF but don't 0:10:52.120 --> 0:10:56.240 have coverage for reversals, or other way around. Who wants 0:10:56.280 --> 0:11:00.240 to go through What a reversal is, at least the 0:11:00.280 --> 0:11:02.839 way that I like to do it. It's a general anesthetic. 0:11:03.280 --> 0:11:07.079 It's not a major surgery, but it's certainly a bigger 0:11:07.080 --> 0:11:12.319 deal than the vasectomy and honestly a lot of it. 0:11:12.400 --> 0:11:16.319 I always tell couples there's no wrong answer, it's really 0:11:16.400 --> 0:11:17.120 your choice. 0:11:17.559 --> 0:11:20.439 Yeah, I'm glad what you didn't do there, and I 0:11:20.440 --> 0:11:23.680 think this is because of your wisdom and experience. And 0:11:23.720 --> 0:11:27.920 one of the things we find an early career urologists 0:11:27.920 --> 0:11:29.600 and reproductive specialists. 0:11:29.120 --> 0:11:30.760 Is quoting percentages. 0:11:31.000 --> 0:11:33.800 And it is dangerous because if you want to just 0:11:33.840 --> 0:11:35.920 put it out in the literature and say, look, chance 0:11:35.960 --> 0:11:39.520 of vase of asostromy pregnancy is seventy percent, chance of 0:11:39.880 --> 0:11:43.400 IVF working is seventy percent, those numbers are published somewhere 0:11:43.920 --> 0:11:47.680 multiple times, but it really doesn't give anybody any a 0:11:47.920 --> 0:11:50.440 good decision making capacity unless, I mean, this is what 0:11:50.480 --> 0:11:53.760 happens if you put in to chat GPT, should I 0:11:53.760 --> 0:11:55.400 get a reversal or go to IVF. 0:11:55.559 --> 0:11:57.360 That's probably what they're going to quote. 0:11:57.760 --> 0:12:01.040 But there's so many other factors that are newts that 0:12:01.040 --> 0:12:03.840 that really does become that dialogue with the procedure list 0:12:03.880 --> 0:12:06.839 as well as somebody like you or I that is 0:12:06.960 --> 0:12:09.800 very plugged into the reproductive endocream community too, so we 0:12:09.880 --> 0:12:11.840 can you know, we can help steward them through because 0:12:11.840 --> 0:12:13.240 one of the things you said earlier, and I'd love for. 0:12:13.200 --> 0:12:14.320 You to unpack a little bit more. 0:12:14.520 --> 0:12:19.040 Not unpack really, They just explain is when you do 0:12:19.720 --> 0:12:24.360 a testicular or an epidimal sperm extraction, whether it's after 0:12:24.360 --> 0:12:27.600 a paseectomy or whether it's for other reasons. You said 0:12:27.640 --> 0:12:30.720 you can only do I v F with that sample. 0:12:30.760 --> 0:12:34.080 So walk me through what are the This is just 0:12:34.080 --> 0:12:36.040 going to be sort of a sidebar, but it helps 0:12:36.040 --> 0:12:36.920 because I get this a lot. 0:12:36.960 --> 0:12:39.080 Where why can't you just do IU. 0:12:38.800 --> 0:12:42.880 I with with an epidentimal aspiration? So first of all, 0:12:43.000 --> 0:12:45.120 teach us the alphabet soup that I just threw at you, 0:12:45.640 --> 0:12:48.000 and then second what that looks like to a patient 0:12:48.040 --> 0:12:49.400 in terms of making those decisions. 0:12:49.640 --> 0:12:50.000 Yeah. 0:12:50.040 --> 0:12:52.240 So, and that's actually one of the more common questions 0:12:52.240 --> 0:12:54.480 I get. Well, can't you just pick a needle in 0:12:54.480 --> 0:12:56.960 the tesco and pull sperm out and then just put 0:12:56.960 --> 0:13:01.599 it up inside my wife? Well, artificial insemination, intrauterine insemination, 0:13:01.880 --> 0:13:07.120 same thing. Basically, all that is taking sperm, spinning it down, 0:13:07.200 --> 0:13:10.559 and then putting it up inside the uterus, So you're 0:13:10.600 --> 0:13:14.079 bypassing the vagina and the cervix, the two biggest barriers 0:13:14.080 --> 0:13:18.280 to pregnancy. The problem is you need lots of highly 0:13:18.360 --> 0:13:23.680 moving sperm. Because those sperm r'ches floating around in the uterus, 0:13:23.880 --> 0:13:25.880 they've got to swim up the tubes. They've got to 0:13:25.920 --> 0:13:28.600 find the egg and then fertilize the egg. So if 0:13:28.640 --> 0:13:31.120 you've got a bunch of sperm that are just kind 0:13:31.120 --> 0:13:34.080 of shaken and not really moving anywhere, they're never going 0:13:34.160 --> 0:13:38.840 to find the egg. So we can't get enough sperm 0:13:38.920 --> 0:13:41.959 from the testicle or even from the epidimus that are 0:13:42.040 --> 0:13:44.240 moving well enough that they're going. 0:13:44.240 --> 0:13:45.800 To be able to get up and find the egg. 0:13:45.880 --> 0:13:48.600 So in vitro fertilization. 0:13:48.000 --> 0:13:51.240 You only need one sperm for each egg, So now 0:13:51.320 --> 0:13:53.400 the sperm don't even have to be moving. So that's 0:13:53.400 --> 0:13:57.480 why you can we only use testicular sperm, but there 0:13:57.480 --> 0:14:01.320 are some labs that require epidimals sperm because the epidimal 0:14:01.360 --> 0:14:05.160 sperm move better. We've just found that the testicular sperm 0:14:05.480 --> 0:14:08.000 work just as well and they're a lot easier to get. 0:14:08.040 --> 0:14:10.720 I can do that in the office under local, but 0:14:11.160 --> 0:14:14.440 you have to do in vitro fertilization or IVF, where 0:14:14.480 --> 0:14:18.760 you're actually taking one sperm injecting it into the egg. 0:14:18.840 --> 0:14:24.040 That's called IXI. Yet more alphabet soup intraciteoplasmic sperm injection 0:14:24.760 --> 0:14:27.960 and then a certain percentage of those eggs will fertilize, 0:14:27.960 --> 0:14:30.000 and then you can put one or two of the 0:14:30.000 --> 0:14:34.800 fertilized eggs back inside. So it's a much more extensive procedure. 0:14:35.360 --> 0:14:39.440 And again we see a select group of patients where 0:14:39.840 --> 0:14:40.880 they're coming to see us. 0:14:40.760 --> 0:14:41.520 For a reversal. 0:14:41.560 --> 0:14:45.120 They've probably not all but probably have done at least 0:14:45.160 --> 0:14:48.160 some homework and have said, you know what, we want 0:14:48.200 --> 0:14:50.280 to go down the reversal route. But I do have 0:14:50.320 --> 0:14:55.480 some couples who were never aware that there are options. Similarly, 0:14:55.720 --> 0:15:00.400 because I work very closely with my reproductive endochronology parters, 0:15:01.320 --> 0:15:04.640 they will get couples who will come in having been 0:15:04.680 --> 0:15:09.560 told by their local guynecologists, oh, you've had of aseectomy, 0:15:09.920 --> 0:15:14.000 you have to do IVF, and my ariis will say 0:15:14.000 --> 0:15:17.560 to the couple, have you thought about a reversal, and 0:15:17.760 --> 0:15:21.520 often send them to me. And then you know, with 0:15:21.640 --> 0:15:26.040 the way our system works, there's no huge incentive for 0:15:26.160 --> 0:15:28.400 one of us to do one thing or the other, 0:15:28.560 --> 0:15:30.520 so we just want to do it's best for the couple. 0:15:31.320 --> 0:15:34.440 So I've had patients who came to see them that 0:15:34.520 --> 0:15:37.840 I end up doing a reversal. I've had some of 0:15:37.880 --> 0:15:40.440 my patients that I send to them to do IVF. 0:15:40.840 --> 0:15:43.040 It's really whatever works best for them. 0:15:43.280 --> 0:15:45.760 You've made a ton of really good points in there 0:15:45.760 --> 0:15:48.800 about keeping the patient centered and being in a system 0:15:48.800 --> 0:15:51.680 that you know the incentivization is there to how you 0:15:52.000 --> 0:15:54.480 best can to successfully end with the pregnancy. And I 0:15:54.480 --> 0:15:57.160 think one of the things that I cautioned patients if 0:15:57.160 --> 0:16:00.280 they come to me is if they're reading adverts for 0:16:01.040 --> 0:16:05.680 I'm going to the world's greatest visseectomy reversalist ever, and 0:16:05.960 --> 0:16:06.840 you know they're out there. 0:16:08.080 --> 0:16:09.520 There's so much that goes into this. 0:16:09.720 --> 0:16:13.160 And you and I both know that you know, at 0:16:13.280 --> 0:16:15.280 least I know personally that that I've had one or 0:16:15.320 --> 0:16:17.800 two basi of EMPAThiE domosome's over my twenty odd years 0:16:18.000 --> 0:16:21.000 that didn't work. And I've also had couples where there's 0:16:21.000 --> 0:16:24.720 no reason I should ever do reversal because of maternal age, 0:16:25.440 --> 0:16:28.800 because of prior fertility issues in the first place, where 0:16:28.800 --> 0:16:31.360 a guy at aligospermia. So there's so many things that 0:16:31.400 --> 0:16:33.640 go into it that it isn't just you know, a 0:16:33.720 --> 0:16:36.560 chest thumping match about you know, if you see any 0:16:36.560 --> 0:16:39.840 guy that or any any physician that wants to do 0:16:39.920 --> 0:16:42.040 your reversal and they spend more time bragging about how 0:16:42.040 --> 0:16:44.200 awesome they are, you probably should turn around and find 0:16:44.240 --> 0:16:47.920 a new physician, because you know, humility is what should 0:16:48.000 --> 0:16:50.400 drive all of us to do better by our patients. 0:16:50.400 --> 0:16:52.640 And if you lose that humility and then you're probably 0:16:52.680 --> 0:16:55.480 not operating enough. So that's that's great, and I think 0:16:55.480 --> 0:16:57.040 it's awesome that you're part of that system and that 0:16:57.120 --> 0:16:59.760 you have reproductive any chronologists that are willing to refer 0:16:59.840 --> 0:17:03.120 you aasians for reversal, which has also happened in my 0:17:03.240 --> 0:17:05.440 career over the years, but not as much. I also 0:17:05.480 --> 0:17:08.919 will say that the demographic is important. You're in Milwaukee. 0:17:09.320 --> 0:17:12.359 In the difference between my practice in Colorado where I 0:17:12.520 --> 0:17:15.200 was for I did a lot more reversals in Colorado 0:17:15.600 --> 0:17:18.159 than I do in Los Angeles. Part of it is socioeconomic. 0:17:18.240 --> 0:17:21.280 There's a little more affluence here where the price tag 0:17:21.320 --> 0:17:24.000 of IVF, which we haven't really talked about, but it's 0:17:24.040 --> 0:17:27.040 about three times more expensive to do a cycle of 0:17:27.080 --> 0:17:30.280 IVF than a reversal. But also the maternal age tends 0:17:30.280 --> 0:17:32.320 to be a creeping up a little bit on the 0:17:32.320 --> 0:17:35.520 West side of la. So that seems to match your 0:17:35.680 --> 0:17:36.760 what you're saying as well. 0:18:06.560 --> 0:18:08.560 So tell me. I have a story for you. 0:18:08.520 --> 0:18:10.480 But I'll see if you can, if you can up me, 0:18:10.520 --> 0:18:13.520 and I'll have you go first. Is there been Sometimes 0:18:13.560 --> 0:18:15.639 guys don't always tell the truth right, And they're in 0:18:15.680 --> 0:18:19.760 your office and yes, you're already thinking of a story, 0:18:20.000 --> 0:18:22.880 and they're saying, in a duck, I don't know why 0:18:23.440 --> 0:18:25.120 I can't get somebody pregnant. 0:18:25.760 --> 0:18:28.679 And I'm there with my partner, what can you to 0:18:28.760 --> 0:18:30.800 fix me? And they refuse that they've ever had of 0:18:30.840 --> 0:18:32.280 the sect me. Is that okay? 0:18:32.280 --> 0:18:34.640 So tell me, tell me what are your best stories 0:18:34.680 --> 0:18:36.879 about that? Without you know, remaining hippo compliant. 0:18:37.119 --> 0:18:41.160 Yeah, so I'll never forget. I probably hadn't been Milwaukee 0:18:41.359 --> 0:18:42.719 more than about five years. 0:18:43.440 --> 0:18:46.800 I had an older gentleman, he was about fifty nine, 0:18:47.320 --> 0:18:52.560 denied any previous surgeries, never had had any children. He 0:18:52.640 --> 0:18:57.119 was dating a very attractive thirty eight year old. 0:18:57.920 --> 0:18:59.919 She really wanted kids and. 0:19:02.160 --> 0:19:05.159 Got the history and then went ahead to do the 0:19:05.240 --> 0:19:07.879 exam and he's like, could you ask her to step out? 0:19:08.000 --> 0:19:10.560 And I'm like, okay, that's fine. I mean most of 0:19:10.560 --> 0:19:12.720 the time I do the exam the partners in the room. 0:19:12.760 --> 0:19:18.320 But yeah, so as I'm examining him and I'm feeling 0:19:18.720 --> 0:19:22.520 these two defects in his vass deference, he goes, hey, Doc, 0:19:22.600 --> 0:19:24.720 I had of a sectomy, but I haven't told her 0:19:25.240 --> 0:19:28.119 because she really wants kids and I don't want to 0:19:28.160 --> 0:19:34.399 mess up this relationship. And I said, honestly, you know, 0:19:35.640 --> 0:19:39.720 you should probably tell her. If it's real, she'll understand. 0:19:39.800 --> 0:19:43.600 We can talk about a reversal. And he's like, no, no, 0:19:43.720 --> 0:19:46.879 I just can't do it. I said, all right, Well, 0:19:47.080 --> 0:19:49.879 she came back in. We talked about a surgery that 0:19:49.920 --> 0:19:55.480 could potentially restore his fertility. We didn't talk at all 0:19:55.520 --> 0:19:57.199 about you know, I said, well, it's possibly you have 0:19:57.200 --> 0:19:58.640 a blockage on both sides. 0:19:58.720 --> 0:20:00.680 And you know, it was. 0:20:00.640 --> 0:20:04.000 Just very very careful about never using the term vasectomy 0:20:04.119 --> 0:20:11.320 or vasectomy reversal. And you know, ultimately they did get married, 0:20:11.359 --> 0:20:13.359 and ultimately I did do a reversal. 0:20:14.000 --> 0:20:15.879 Unfortunately, the reversal didn't work. 0:20:15.960 --> 0:20:20.040 He was pretty far out from his vasectomy, but we 0:20:20.080 --> 0:20:22.639 did get a sperm at the same time, and they 0:20:22.720 --> 0:20:25.959 ended up doing IVF made a beautiful little girl, and 0:20:26.040 --> 0:20:29.159 somewhere along the line he either came clean or she 0:20:29.280 --> 0:20:32.280 figured it out, but we had notes all over his 0:20:32.440 --> 0:20:36.159 chart to make sure that nobody would say anything to 0:20:36.280 --> 0:20:39.720 her about his reversal, that. 0:20:39.680 --> 0:20:43.320 It was his surgery. Yeah, but yeah, it was tough. 0:20:43.800 --> 0:20:44.440 It is tough. 0:20:44.480 --> 0:20:47.399 You know, it's an ethical dilemma for us, because of 0:20:47.440 --> 0:20:49.680 course we have to prospect patient autonomy, and he's your 0:20:49.680 --> 0:20:52.560 patient and she is and so you bring up that story, 0:20:52.600 --> 0:20:56.040 and that's very, very similar. Though my guy committed to 0:20:56.080 --> 0:20:58.879 the bit a little bit longer than your guy, and 0:20:58.960 --> 0:21:01.320 he and I have a few of these stories. But 0:21:01.400 --> 0:21:03.480 when I remember years and years ago, it's still in 0:21:03.880 --> 0:21:07.639 Colorado and he was working as a bouncer and was 0:21:07.680 --> 0:21:10.720 assaulted on the job where he had to go to 0:21:10.720 --> 0:21:13.760 the hospital, had to have some kind of surgery to 0:21:14.320 --> 0:21:16.160