How To Choose A Vasectomy Reversal Doctor

 

For couples who want to maximize their chances of having a baby after a vasectomy, the single most important factor is choosing a surgeon who offers the latest, most effective microsurgical techniques.  The process of choosing the right surgeon can be more difficult than one would think, as many doctors who advertise on the internet intentionally use vague descriptions or deceptive marketing to disguise their true medical background and training.  However, by investing a little time and effort, it is actually quite a simple process to determine if a doctor is a true microsurgical expert.  The goal of this section is to provide couples with the tools to accomplish this task, because it is so important to optimizing a couple’s chances of fertility success.

 

While the older, outdated vasectomy reversal procedures were accessible to the skill levels of most general urologists, mastering current microsurgical techniques now requires urologists to dedicate themselves to an extra 1-2 years of intensive male infertility fellowship training.  The good news is that most regions in the country have at least one fellowship-trained specialist who has been adequately trained in the latest vasectomy reversal techniques.  The bad news is that the majority of doctors in the United States who perform vasectomy reversals have not invested the additional training time to learn these new, sophisticated microsurgical reversal procedures.  Instead, they continue to use the old, outdated reversal techniques of decades past which are associated with significantly lower success rates.  Unfortunately, many of these doctors do not inform their patients that more up-to-date and effective vasectomy reversal techniques are available.  Even worse are the doctors who aggressively advertise on the internet and market themselves as “reversal experts” despite having minimal actual training in urologic microsurgery.

 

Five Questions You Should Ask Any Reversal Surgeon

 

Research studies have shown that the first attempt at a vasectomy reversal clearly offers the best chance of success.  If you really want to maximize your chances of successfully starting or expanding your family, here are a few very important questions that you should ask any prospective reversal surgeon you are considering working with:

 

1) Is the doctor a urologist?  If yes, then at minimum you are assured that the surgeon has had 5-6 years of training in scrotal surgery, and can offer you as safe a procedure as possible.  You would not seek out a urologist to treat a fractured arm, so why would you travel to another state to have an orthopedic surgeon perform complex urologic microsurgery?

 

2) Will the surgery last at least 2.5 hours of actual operating time?  This does not include how long you will be at the office or surgery center or in the recovery area, but how long the surgeon will take actually doing the procedure itself.  Some doctor’s websites claim that their procedures last 2-3 hours, but they are including the pre-procedure and recovery times to the total “procedure” length.  The latest, most successful microsurgical vasectomy reversal techniques take most fellowship-trained experts at least 2.5 to 3 hours of actual surgery time to perform (with a total of about 5-6 hours spent at the surgery center).  If your procedure is only going to last about an hour, then it is highly unlikely that the most optimal surgical techniques are being used.  Precision and attention to detail are vital to the success of a vasectomy reversal, which is why no fellowship-trained experts perform quick reversals under local anesthesia.  It just does not make logical sense that a surgeon with less training can perform this precise of surgery in less than half the time an expert could and expect anywhere close to the same outcomes.

 

3) Does the surgeon ever perform more than one reversal procedure per day?   The latest microsurgical reversal procedures are very technically demanding, and 2.5-3 hours of intense concentration under an operating microscope can cause mental fatigue.  I always want to feel “fresh” going into a reversal procedure in order to be able to give my best effort.  I therefore limit my surgeries to no more than one reversal case a day.  Reversal doctors who perform more than one reversal a day are either: a) Superhuman b) Using suboptimal, less technically demanding techniques, or c) Don't mind operating on patients when fatigued and not at their “best”.  Some surgeons may claim to be in the “superhuman” category, but the safer bet is to find a specialist who limits himself/herself to no more than one reversal per day.

 

4) Does your surgeon know how to perform an expert vas-to-epididymis connection if “unfavorable” fluid is found at the time of the reversal?  “Unfavorable” fluid can be found at any length of time since a vasectomy was performed.  If “unfavorable” fluid is found at the time of a reversal and the surgeon does not know how to perform a vas-to-epididymis connection, then the reversal will almost invariably be unsuccessful on that side.  It is therefore extremely important that a reversal doctor know how to properly perform a vas-to-epididymis connection if it is needed.  A word of caution: some reversal doctors describe the vas-to-epididymis connection on their website, thereby implying that they perform it, when actually they only really offer the vas-to-vas connection.  Others may “theoretically” know how to perform a vas-to-epididymis, having observed it during training or maybe even performed it a handful of times.  It is therefore very important to ask a prospective reversal doctor if they regularly perform vas-to-epididymis connections.  For example, my average patient is about 10-12 years out from their vasectomy and I do plenty of re-do reversals (for patients who had failed reversal attempts elsewhere), so I end up needing to perform a vas-to-epididymis connection on couples about a 1/3rd of the time.  On average I perform at least one vas-to-epididymis connection a week.

 

5) Has the urologist completed a 1-2 year fellowship in male infertility and microsurgery?  If you only ask one question, this should be the one, because if you are working with a fellowship-trained microsurgical specialist, the answer to the four questions listed above will almost invariably be "Yes". Having completed a full 1-2 year fellowship in fertility microsurgery is the only sure sign that the surgeon with whom you are working has devoted the time and energy to receive the intensive training that is needed to become a true microsurgical reversal expert. 

 

Why It Is So Important To Know How To Perform A Vas-to-Epididymis Connection

There are two ways to reconnect the vas deferens during a reversal procedure.  The first is the vas-to-vas connection (“vasovasostomy”) in which the 2 ends of the vas deferens are reconnected after taking the scar tissue out between them.  The second is the vas-to-epididymis connection (“vasoepididymostomy”), in which the vas deferens is attached to the epididymis, the structure on the side of the testicle where the sperm spend time maturing.  The epididymal tubules are much smaller than the vas deferens, so it takes less scar tissue formation during the healing process to block them off. A vas-to-vas connection has a higher chance of success, so it would always be the preferred procedure if possible.  However, until the time of a reversal operation, it is not known what type of connection will be needed.  So how does the surgeon know which procedure to use?  At the start of the reversal, the end of the vas deferens leading towards the testicle is opened up and the fluid that comes out is examined microscopically.  “Favorable” fluid is defined as fluid containing sperm or sperm parts.  If the man is <10 years out from his vasectomy, then copious clear fluid (with or without sperm) is also considered “favorable”.  If “favorable” fluid is found, then the vas deferens is open all the way back to the testicle and a vas-to-vas connection can be performed.  “Unfavorable” fluid is defined as either thick/creamy or scant clear fluid without sperm or sperm parts.  When “unfavorable” fluid is seen, it means that a blockage has formed within the epididymis blocking off everything beyond it.  Therefore, if “unfavorable” fluid is seen then a vas-to-vas connection is not going to be successful on that side, since the segment of the vas deferens you would be hooking up to is blocked. Instead, you need to go above the area of blockage on the epididymis (as indicated by finding sperm in those epididymal tubules) and connect the vas deferens here with a vas-to-epididymis connection.  

The more time that has passed since the vasectomy, the higher the chance is of having an epididymal blockage and needing a vas-to-epididymis connection.  For example, at 2 years after a vasectomy, the chances of needing a vas-to-epididymis connection is about 10%.  This number gradually increases to 35% at 10 years, 50% at 15 years, and 70% at 22 years.  These are only statistical odds, though, and all men have a chance of needing a vas-to-epididymis connection no matter how many years have passed since their vasectomy.  I personally have had men as little as one year out from their vasectomy that needed a vas-to-epididymis connection when their vasal fluid was examined.  It is therefore extremely important that a vasectomy reversal doctor know how to perform a vas-to-epididymis connection, because any reversal patient may potentially need one.  If the vasal fluid is “unfavorable” and your doctor only knows how to perform a vas-to-vas connection, the reversal is basically guaranteed to fail on that side.

 

What Do Modern Medical Research Studies Say?

 

Some high volume reversal doctors who have not had the training to learn how to properly perform a vas-to-epididymis (VE) connection present confusing information by claiming that the medical literature does not support the use of vas-to-epididymis connections for most first-time reversals.  However, in order to find published papers to support this view, these doctors have to go back several decades, quoting studies such as the Belker “Vasovasostomy Study Group” paper published in 1991, and which relied on data predominately from surgeries performed approximately 30 years ago.  Based on 30 year old surgical techniques and technology, the Belker study concluded that vas-to-epididymis connections were not indicated in men less than 9 years out from their vasectomy and only in “certain circumstances” in men greater than 9 years out.  This was arguably a valid claim in that era when vas-to-epididymis techniques had much lower success rates and were rarely performed.

So let’s fast-forward to more recent times and see what the current urologic literature says on this topic.  Dr. Jarvi, a leading reversal expert in Toronto summed up the contemporary viewpoint of experts nicely in a 2004 paper published in the Journal of Urology which stated: “We recommend that all surgeons offering vasectomy reversals be able to offer VE if required based on intraoperative findings to serve the patient adequately as well as his partner and their future fertility” (Chawla A. J Urol 2004).  One of the main reasons behind this dramatic change in practice is that 2 decades of microsurgical innovations had transformed the vas-to-epididymis technique into the highly successful procedure that it is today.  The current “gold standard” is the longitudinal intussusception vasoepididymostomy (LIVE) procedure, first described in 2003 and whose high success rates have been validated in multiple studies to date (Grober ED. Urology 2014) (Peng J. Hum Reprod 2014).  

The vital importance of needing to be able to perform an expert vas-to-epididymis connection has been nicely illustrated in several papers from the modern era.  One study looking at 1229 vasectomy reversal cases found that vas-to-epididymis connections were needed in up to 20% of men who were 6 years or less from their vasectomy, and in 35% of men up to 10 years out from their vasectomy (Mui P. Andrology 2013).  Other studies looked at re-do vasectomy reversals by a fellowship-trained expert in men who had previously undergone a failed reversal attempt by a doctor who did not know how to perform a vas-to-epididymis connection.  These studies found that in 47-74% of these men, the cause of the failed initial reversal was due to an epididymal obstruction that was either unrecognized or ignored (since the initial doctor did not how to perform the procedure that the patient really needed) (Chawla A. J Urol 2004).  While some doctors rely on decades-old medical literature to try and support the reversal techniques that they use, the modern literature clearly shows that offering vas-to-epididymis connections is an absolutely integral part of maximizing success in all couples undergoing a vasectomy reversal.


The 3 Types of Vasectomy Reversals

It is understandable that some people without a medical background may think that all vasectomy reversal techniques are essentially the same.  The reality could hardly be further from the truth.  A large variety of reversal techniques exist, and with them a wide range of associated chances of fertility success rates.

Broadly speaking, all vasectomy reversal techniques fall into 3 basic categories:

 

1) Quick Re-alignment.

The “Quick Re-alignment” is a short procedure (usually takes about an hour) that is easy to learn.  No urologic training is needed to master the basics of this relatively straightforward procedure, and doctors from almost any specialty can usually pick it up in a one-week course.  It is generally quite easy to identify a website offering a Quick Re-alignment procedure, as they always have a low price of around $3000 or less and are generally performed under local anesthesia (though some have an option for light IV sedation as well).

-Advantages: The primary advantage of the Quick Re-alignment is that mastering this procedure does not involve learning any advanced microsurgical skills. Really, any doctor willing to invest a little time in a week-long course can learn the procedure, set up a website and claim that they are now a “microsurgical expert”.  The other advantage is that these procedures take such little time that they can be performed under local anesthesia in the doctor’s office.  Without the costs of anesthesia and the surgery center, the price for the procedure is extremely low, making them an attractive option for unsuspecting couples who think that they are getting a state-of-the-art surgery for an amazing price.

-Disadvantages: Like many things in life, you get what you pay for.  The Quick Re-alignment procedures have relatively low success rates, although you would never know that from the websites of the doctors who offer them.  You are also going to get a vas-to-vas connection no matter what the quality of the vasal fluid shows.  So if unfavorable fluid is found and a vas-to-epididymis connection is needed, the couple is out of luck and will not get the surgery that they need.  Of course, all doctors who offer Quick Re-alignment procedures will claim that they perform advanced microsurgery.  However, a quick one-hour procedure that you can learn in a one week course offers a fraction of the precision and attention to detail that the complex 2.5 to 3 hour reversals performed by true microsurgical specialists offer.

 

2) Urologic Reversal

The Urologic Reversal is the procedure that is performed by general urologists. (Definition: a general urologist is a urologist who has not chosen to pursue advanced fellowship training in fertility microsurgery).  The Urologic Reversal procedures usually take about 2.5-3 hours and are typically performed under general anesthesia in a surgery center or hospital setting as an outpatient.

-Advantages: One of the main advantages of the Urologic Reversal over the Quick Re-alignment is that the procedure is being performed by a physician who has spent 5-6 years learning how to safely operate in the scrotum.  Success rates are generally better than those of the Quick Re-alignment reversals.

-Disadvantages: General urologists regularly perform a variety of scrotal surgeries, but general urology residency training programs do not provide intensive training in the most updated and successful vasectomy reversal techniques (which are generally only taught in an advanced fellowship training program).  Most general urologists also do not know how to effectively perform a vas-to-epididymis connection if needed in the event of finding unfavorable fluid during a reversal.

 

3) Fellowship-Trained Reversal

The Fellowship-Trained Reversal represents the most successful reversal techniques that have been developed over decades of microsurgical innovation.  These techniques are learned only by true specialists who have undergone not only 5-6 years of urologic training, but also another 1-2 years of advanced male fertility microsurgical fellowship training.

-Advantages: Reversals performed by fellowship-trained experts have the highest rates of surgical success.  These high rates of success are well studied and documented in respected peer-reviewed medical journals.

-Disadvantages: It generally takes 2.5-3 hours to perform a reversal using the latest, most successful microsurgical techniques.  When working under the operating microscope, any movement by the patient looks like an earthquake (which is certainly not conducive to precision microsurgery).  It is simply not reasonable to ask someone who is awake or under “twilight” sedation to hold perfectly still for several hours.  For this reason, outpatient general anesthesia in a surgery center or hospital is required.

 

Medical Training Overview

The medical community is well aware that a vasectomy reversal performed by a fellowship-trained specialist represents the “gold standard” with the highest success rates.  Fortunately for the doctors who offer Quick Re-alignment reversals, the majority of the general public remains unaware of the differences in success rates between the 3 different types of vasectomy reversals and the training of the doctors who perform them.  The physicians who offer Quick Re-alignments know this and often work hard to make sure that their websites blur the distinction between general medical training and the skills needed to be a true fertility microsurgical expert.  In this endeavor, they are aided by the fact that most non-medical couples understandably do not have a good grasp of the structure of medical education in the United States.  This confusion can be taken advantage of by some less specialized doctors who make vague statements about their medical training and imply that they are microsurgical experts despite minimal actual training in this area. 

To help couples see through some of the “smoke and mirrors” of websites whose doctors claim be “microsurgical experts” but really offer only Quick Re-alignment and General Urology reversals, what follows is a brief explanation of how physician training works in the United States:

 

Step 1- Medical School (mandatory for all physicians)

After college, students enter an accredited medical school which generally lasts 4 years.  Traditionally, the first 2 years are spent doing intensive classroom study.  The second 2 years are spent rotating through different medical areas (e.g family practice, general surgery, neurology, etc.) to help them decide what area they would like to specialize in.  Very little “hands-on” training is actually performed during surgery rotations as a medical student.

 

Step 2- Residency (mandatory to get state licensure to practice)

Residency is where physicians actually learn how to practice in their chosen specialty.  The length of residency varies depending on the specialty.  For example, internal medicine training is generally 3 years long, whereas surgical specialties like Urology usually take 5-6 years.  Most doctors complete their training at the end of residency and start their medical practice in their chosen field, but some choose to do additional advanced fellowship training.

 

Step 3- Fellowship (optional)

Doctors who wish to become super-specialized elect to perform fellowship training.  During this time they get the opportunity to focus in on a very narrow area of interest and learn the most optimal and up-to-date techniques from the leaders in their field.  Male infertility microsurgical fellowships are only offered to physicians who have proven that they can safely and effectively operate within the scrotum by completing a 5-6 year Urology residency.

So (to summarize), true fellowship-trained fertility microsurgical experts have completed (after medical school):

    - 5 to 6 years of urologic surgery training

    - 1 to 2 years of advanced fellowship training in fertility microsurgical techniques

 

In comparison, doctors who offer only Quick Re-alignment reversals have done no formal urologic training. The websites of some such doctors describe learning their microsurgical skills at a one week long course.  Others claim that their training involved shadowing another Quick Re-alignment doctor who themselves had little-to-no microsurgical training.  This is in comparison to the 6 to 8 years of intensive training by true fellowship-trained experts.  The difference in professional preparation for performing these intricate and demanding microsurgeries is not even close.

 

So let’s look in more detail at the 3 types of reversal procedures and the doctors who perform them: 

 

Quick Re-alignments

I am happy to say that I do not know of any board-certified urologist who offers these quick “bargain” procedures.  A careful examination of the websites of doctors who offer Quick Re-alignments shows that they have backgrounds in unrelated fields of medicine (such as general and thoracic surgery, orthopedics, and even family practice) in which there is no formal training in safe and effective scrotal surgery 

When evaluating these Quick Re-alignment websites, some openly state the medical field in which their doctor did their residency training.  However, other websites are very vague when describing the specifics of their doctor’s medical training.  As a general rule, if a website does not explicity state that the doctor completed a 5 to 6 year Urology residency, then you are almost certainly looking at the website of a doctor who has had no formal training operating anywhere near the vas deferens.  An example of this would be a website that states something like: “I did residency training in St. Louis and then spent time at Johns Hopkins where I developed my skills to perform vasectomy reversals.”  This is not going to be from the website of a urologist, as all urologists want prospective couples to know that they have devoted many years to learning how to operate effectively within the scrotum, and will clearly state that they trained in “Urology” for 5+ years.

To be clear, general, thoracic, and orthopedic surgeons do not learn how to operate in the scrotum despite being surgeons (just as urologists do not learn how to remove gallbladders and lung masses, or to treat hip fractures).  Some doctors who performed microsurgery in other fields (like orthopedics) claim that this has prepared them for performing vasectomy reversals, implying that all microsurgery is the same.  This is completely false.  Despite all of my advanced fertility microsurgical training, I would not feel even remotely qualified to perform advanced orthopedic microsurgery (and a few week-long mini-courses would not at all change this fact).  

 

Debunking the Claims of the “Bargain Doctors”

Let’s examine some of the supposed benefits of the “Quick Re-alignment” procedure and marketing tricks used to attract prospective couples:

#1) The benefits of local anesthesia

First of all, let’s be clear about one thing: almost all Quick Re-alignment doctors do not “choose” to perform vasectomy reversals under local anesthesia.  They HAVE to perform them under local anesthesia (or sometimes light IV sedation).  In order to give general anesthesia (in which the patient is asleep while being monitored by a member of the anesthesia team), a procedure needs to be performed in a surgery center or hospital.  As we discussed above, the doctors who offer Quick Re-alignments are not urologists.  No accredited surgery center/hospital concerned about their liability risk would ever allow a non-urologist to perform urologic procedures at their facility.  In the service of patient protection, all accredited surgery centers and hospitals have strict credentialing policies which carefully scrutinize a surgeon's training to make sure that they have undertaken the basic training in the surgical field for which they want to perform procedures at that facility.  For example, if a surgeon wants to perform orthopedic procedures at a surgery center, they have to first provide documentation that they have successfully completed a formal orthopedic residency training program and are board-eligible or board certified by the national orthopedic credentialing organization.  In this way, patients know that if they choose to have a procedure at a certain facility, they have a level of comfort in knowing that the surgeons who work there have at least had basic training in that particular field.  The only possible exception to this would be if the doctor was the owner or part-owner of a surgery center and used that leverage to get them to “relax” their credentialing criteria.  However, for most independent surgery centers in the United States, it would be difficult (if not impossible) for a urologist to get privileges to repair fractured bones, and likewise these same surgery centers would not allow an orthopedic surgeon to perform a vasectomy reversal within their facility. 

Unfortunately, no such regulations for patient protection exist when practicing medicine in your own private office.  If a procedure can be performed under local anesthesia and a doctor has a valid medical license in any field of practice, that doctor can go ahead and offer that procedure in their office without any oversight.  Therefore, the Quick Re-alignment doctor who claims to have made the gracious decision to offer vasectomy reversals under local anesthesia to save their patients money typically has no other choice.  Some Quick Re-alignment doctors even imply that they are taking on a more challenging procedure under local anesthesia for the benefit of their patients, since doing reversals under general anesthesia is so much “easier”.  However, it defies logic that a quick one-hour procedure that can be learned in a week-long course is more difficult than the demands of an advanced 2.5 to 3 hour microsurgical procedure that takes 6 to 8 years to master.

 

#2) The safety and comfort of local anesthesia

Many man have understandable reservations about undergoing another scrotal procedure under local anesthesia.  Most of these men had their initial vasectomy procedure performed under local anesthesia.  Even though vasectomies are generally quite straightforward procedures that take only about 20 minutes to perform, many men have had an unpleasant enough experience to wonder whether another scrotal procedure that is going to take 3 times longer while they are wide awake is a good idea.

The Quick Re-alignment websites are therefore typically full of assurances that their reversals under local anesthesia are wonderfully painless procedures.  Most have testimonials from non-traumatized men who seem relieved to have emerged from the procedure without excrutiating pain. I am sure that a certain percentage of men have a tolerable experience with their hour-long reversal under local anesthesia, just as I am sure that the men who have less-than-wonderful experiences are not going to see their comments successfully make it onto the testimonial pages of these websites. 

There are 3 points that I would ask couples to consider when thinking about using local anesthesia (or just light IV sedation) for their reversal. The first is that the most successful microsurgical techniques generally take around 2.5 to 3 hours- local anesthesia or light sedation is not going to be effective for a procedure this long.  As mentioned earlier, it is not reasonable to ask someone who is awake or under “twilight” sedation to remain absolutely motionless for that period of time, and complete stillness is critical when performing extremely delicate microsurgery.  

The second point is that when I first started my male fertility practice, I performed all of my testicular sperm extractions under local anesthesia (which is a reasonable option for that type of procedure).  Most men were quite comfortable using local anesthetic for these brief extraction procedures which usually lasted about 25 minutes.  However, some men were clearly more sensitive to pain stimuli in this region, or the local anesthetic medications were just not as effective with their body chemistry.  The result was that in about 10% of men, the extraction procedure was extremely uncomfortable.  In other words, for most of the men the local anesthesia worked fine- but for some men the experience was really bad. I now perform all of my sperm extractions with the patient asleep, and my patients are almost uniformly happy with this approach.

The third comment I would make is that I have done quite a few re-do reversals on men who had their first reversal performed with a Quick Re-alignment under local anesthesia.  Almost invariably when I talk with these men after their procedure, they say that they greatly preferred not being awake for the reversal.

As for safety concerns, modern general anesthesia (when administered by trained anesthesia providers) is extremely safe, especially in the young healthy population that is generally undergoing vasectomy reversals.  In my 10 years of routinely performing vasectomy reversals, none of my patients have ever experienced a severe or life-threatening anesthetic complication.

 

#3) Success Rates

A doctor’s stated vasectomy reversal success rates should be a valuable tool in helping a patient to decide who would be a qualified surgeon to perform his procedure.  Some couples feel like they have “done their research” by looking up a doctor’s listed success rates on their website, or by directly asking doctors what their success rates are.  Unfortunately, when it comes to vasectomy reversals, all quoted success rates must be taken with a healthy dose of skepticism (my own included).  There are a few medical specialties (such as in-vitro fertilization doctors) who are mandated to keep verifiable pregnancy success rates and publish them on a central website.  Unfortunately, the field of vasectomy reversals has no such requirements.  Physicians offering vasectomy reversals can literally make up whatever success rates they want, either in terms of sperm returning back to the ejaculate (called “patency” rates) or successful pregnancies. Due to patient privacy rules, no one can ever go and review a doctor’s charts to see if what they claim their success rates to be are really true.  And many of the quoted success rates from Quick Re-alignment websites do seem truly unbelievable, matching (or sometimes even surpassing) the success rates of the most advanced reversal techniques, which take 3 times longer and are performed by specialists with far more microsurgical training. In my own practice, I routinely do phone consults (and re-do reversals) on men who have had failed Quick Re-alignment reversals, and wonder how this can possibly match up with their published success rates.  For an illustration of what I would call “hard to believe” success rates, some Quick Re-alignment doctors list patency rates of 70% or more for men who are 15 years or farther out from the time of their vasectomy.  Recent studies have shown that men 15 years out from their vasectomy have about a 50% chance of needing a vas-to-epididymis connection (Mui P. Andrology 2013), and this is what I see in my practice as well. Since Quick Re-alignment doctors do not learn how to perform an effective vas-to-epididymis connection, then fully ½ of these men 15+ years out are inappropriately getting a vas-to-vas connection when unfavorable vasal fluid is found (an approach which has little to no chance of success).  Even if every single other reversal in this group was successful (which never happens), the patency rate for this group of men would be at most 50%.  Things just do not add up with these numbers- but then again, they do not have to since no one is checking to verify them.

 

Some Marketing Options if a Doctor’s Success Rates Are Not so Great

Quick Re-alignment doctors often face a fairly large credibility gap with many couples who are intuitively skeptical about deals that seem too good to be true (i.e. the same quality product for a fraction of the price).  Wonderful success rates published on their websites are a must for Quick Re-alignment doctors who need to create a sense of legitimacy.  But what if a doctor knows that his success rates are not that good?  Never fear, there are a number of tools that can be readily employed to solve this bothersome marketing problem.

#1) “Cook the Books”- no one is verifying any doctor’s reversal results, so really anyone is able to publish whatever numbers they want.  Tip: the more detailed the published results, the more scientific and legitimate they appear to be.

#2) Do not clearly define what “patency” success rates means

Besides outright fabrication of numbers, a few other methods can be used to “modify” a doctor’s published reversal success rates.  One of these is the definition which this doctor chooses to define “successful” patency following a reversal.  Does patency mean “live sperm present”, a definition which could include 1-2 barely twitching sperm (which is not going to get anyone even close to pregnant)?  Of note, sperm counts of less than 5 million/cc usually require the use of IVF (in vitro fertilization) to achieve a pregnancy.  I personally consider a reversal to be a failure if the numbers and quality of the sperm are not high enough to allow a decent chance at natural conception, but this is not the definition most Quick Re-alignment websites use to calculate their success rates.

#3) Calculate pregnancy rates, but do not specify how the couples achieved these pregnancies

High published pregnancy rates may look impressive, but how are they defined?  Do they include just natural pregnancies following the Quick Re-alignment reversal?  Or do the questionnaires sent to patients simply ask if there was “a pregnancy”?  This broad definition could include: 1) those in which IVF was needed due to low sperm counts in the ejaculate, 2) men who had no sperm after the reversal and needed a sperm extraction and IVF, 3) donor sperm combined with inseminations, or even 4) pregnancy after a successful re-do reversal by another doctor.  If the website does not clearly define its definition of pregnancy, its calculations could be including a lot of couples whose reversal actually failed.

 

Any combination of these techniques can help turn even the most mediocre of success rates into world-class reversal outcomes. Essentially, any licensed physician of any subspecialty can make a nice website and claim whatever reversal success rate that they want with absolutely no control or oversight.  However, there does exist good published data in national peer-reviewed medical journals on the excellent outcomes of microscopic vasectomy reversals when performed by fellowship-trained urologists.  Some examples include: 1) Boorjian S. J Urol 2004, 2) Sandlow JL. J Urol 2005, 3) Grober ED. Urology 2014, and 4) Ostrowski KA. J Urol 2015.  For these published studies, follow-up semen analysis results were reviewed and success rate results calculated under the patient privacy guidelines of what is called an IRB (Institutional Review Board), which allow accurate reversal success data to be obtained while patient privacy is protected.  If you choose a urologist who is fellowship trained in microsurgery, you at minimum know that he or she has had extensive training in techniques with these proven excellent results.

The techniques of the low-cost non-urologists (to my knowledge) have no published data and their only “proof” is that they ask you to trust that their short surgical procedures under local anesthesia somehow have the same outcomes as the meticulous 2.5-3 hour procedures of fellowship-trained experts.  

 

#4) Testimonials

Quick Re-alignment doctors often expend quite a bit of effort in trying to convince couples that their “bargain” reversals are just as good as the sophisticated microsurgical techniques of fellowship-trained specialists.  Since the Quick Re-alignment doctors know that they do not have the background and training to back up these claims, they often invest a great deal of time in marketing and “spin” to attempt to sell their product.  And nothing sells like a good story.  Or even better: lots of good stories.

Though all reversal websites generally have their share of testimonials and/or baby pictures, the Quick Re-alignment sites are often drowning in them.  The obvious goal is to provide couples with the impression that the Quick Re-alignment procedure must be extremely comfortable as well as exceedingly successful- just look at all of these wonderful success stories on the website.  But once again, appearances can be deceiving.  Let’s look at some clever marketing techniques that can be employed to generate lots of testimonials even with surgeries that have mediocre success rates.

A) Huge numbers of testimonials and baby pictures

It must be remembered that most Quick Re-alignment practices are high volume businesses- basically an assembly line model for surgery.  When a procedure takes only an hour to perform, it is easy to squeeze 2-3 or more reversals into a day.  And it must be remembered that even the most out-dated reversal techniques have some degree of success.  In fact, a 1948 survey by the American Urologic Association found a patency rate of 38% among urologists using truly antiquated non-microscopic reversal techniques 70 years ago (review by Dickey RM. Curr Urol Rep 2015).  Even a doctor using 1948 reversal techniques would be able to generate a website full of testimonials by performing a huge number of reversals each year.  In fact, a doctor doing 3 reversals a day would only need a 33% success rate to generate a new testimonial and baby picture every surgery day, despite their extremely low overall success rate.  All that is needed is a full-time marketing person at the doctor’s office to actively encourage the couples who had success to send in a testimonial. The sheer volume of success stories on the websites of high volume Quick Re-alignment doctors may look impressive at first, but a closer look at the numbers shows that it in no way necessarily correlates with a couple’s chances of reversal success with them.

B) Independent Website Reviews

What about “independent” websites where patients review their doctors?  As opposed to the testimonials section of their own websites, doctors theoretically do not have control over these independent reviews.  You will find that the websites of some Quick Re-alignment doctors provide links to these (supposedly) independent reviews as “proof” of their talents and the comfort of their procedures under local anesthesia.  But how independent and “spontaneous” are these reviews really?  One deceptive method you will sometimes see used to make published reviews look extremely favorable is to use a website that looks like an independent review, but is really a paid site for patient feedback.  An example of this is “Best Local Reviews”, in which a doctor can pay $100 a month to have this site reach out to all of their patients and ask them to rate their experience from 1 to 5 stars (with 5 stars being the best).  The site then identifies the patients who gave “5 out of 5 stars” and asks them to write a review/testimonial, even giving tips on specific topics they should mention and providing examples for them to imitate.  These reviews/testimonials (from only the “5 out of 5 stars” patients) are then published on the internet and social media sites.  However, anyone who reports less than 5 stars is not asked to write a review, but instead is only asked to send their feedback to the doctor’s office.  These potentially negative comments are kept private and never published on the internet.  The result is that all published reviews show “5 out of 5 stars”, giving the impression of a uniformly good experience by all patients (though in reality they were only from hand-picked couples identified by the paid web service).  Truly independent doctor review websites (where the doctor is not paying to screen out less favorable reviews) are more difficult to manipulate, but this is still possible.  One strategy is to have a staff member call all patients a week or two after the procedure to see how their experience was and ask if their recovery is going well.  The patients who report to the staff member that they had a “wonderful” experience are then encouraged to post a testimonial on a specific independent doctor review website and given detailed instructions on how to access this site. For the patients who had a less pleasant experience, the review website would conveniently not be mentioned.  Using these types of patient feedback manipulation techniques (combined with a high volume Quick Re-alignment practice performing multiple reversals a day), it is quite easy to generate a few hundred good reviews in a relatively short period of time, irrespective of the average experience of each individual couple.

 

#5) The Business Model of Quick Re-alignments

The “bargain” doctors who offer Quick Re-alignments often talk about their intense desire to offer couples an affordable vasectomy reversal option.  Some even offer discounted rates for a “re-do” reversal if the first one fails.  Couples see such an offer and may think that they can get 2 chances for a successful reversal for less than the price of a single reversal elsewhere.  The problem with this logic is that it is well-documented that a man’s first attempt at a reversal is by far his best chance.  The build-up of scar tissue associated with re-do reversals always leads to a higher chance of needing a vas-to-epididymis connection and lower chances of success.  If a Quick Re-alignment does not work the first time, then chances that a re-do reversal using the exact same technique actually being successful is extremely low.  However, the offer of a discounted re-do is an excellent strategy for increasing the “bargain” doctor’s case load.

So let’s look at the overall business model of the Quick Re-alignment reversals.  The cost of traditional vasectomy reversals consists of 3 parts: the doctor’s fee, the anesthesia fee, and the surgery center fee.  Quick Re-alignment doctors charge such a low price because they cut out the anesthesia and surgery center fees (as mentioned before, they generally have no choice in this matter as most surgery centers and hospitals would never allow a non-urologist to perform urologic surgery within their facility due to the legal liability risk).  So Quick Re-alignment doctors are usually charging a doctors fee of about $2000-$3000 for a one hour procedure.  When you subtract out the anesthesia and surgery center fees of a Fellowship-trained specialist, the doctors fee usually comes out to about $2000-$3000 as well- but for a 2.5 to 3 hour procedure.  So on a per-hour basis, the Quick Re-alignment doctors are actually charging two to three times the surgical fee rates as compared to the fellowship-trained specialists, and for this their patients get an out-dated procedure by someone with a fraction of the microsurgical training.

 

How I Could Triple My Income Overnight

If my priorities were those of a businessman first (and physician a distant second), I could experience a “calling” to start my own “fertility ministry”.  Conveniently forgetting the advanced surgical principles that I learned through my 7 years of intensive training, I could offer Quick Re-alignments under local anesthesia.  Naturally, I could say that this would be purely for the benefit of my patients to help save them money.  I could keep my own doctor’s fee unchanged, but would now have the opportunity to perform several reversals a day (instead of the one long meticulous reversal a day that I currently perform).  Since Quick Re-alignments only take about an hour, I could easily perform 3 reversals a day and work the exact same number of hours that I do now.  Since my doctor’s fee is unchanged, my income would triple overnight by doing the exact same amount of work.  Of course my success rates would fall like a rock, but I could easily hire a full-time marketing person in my office to “massage” the data and publish wonderful (if not entirely truthful) success rates on my website- nobody would know the difference.  From a purely business standpoint, any financial advisor would tell me that I would be crazy not to make these changes to my practice.

Fortunately, (for my patients, and my ability to go to sleep guilt-free every night) I am a physician first and foremost, and I know that optimal reversal outcomes require the longer (2.5-3 hour) meticulous techniques under general anesthesia.  In addition to being a physician, I am also a father, and my two children are truly the joys of my life.  After experiencing the amazing journey of parenthood firsthand, there is no way that I could offer anything but the best available techniques that I am able to perform for couples who so profoundly wish to welcome a new baby into their family

The simple truth is that the most successful microsurgical techniques take 2.5-3 hours of operating time, and surgeries of this length almost invariably need to be performed under general anesthesia in a surgery center or outpatient hospital setting.  No matter how much “spin” a nice-looking website tries to play on the topic, a quick 1 hour procedure under local anesthesia is not going to offer couples nearly as high rates of success as the latest techniques performed by fellowship-trained experts. Your first attempt at a vasectomy reversal represents your best chance of success.  You only get one first best chance at a reversal- make it count by doing it right the first time.

 

Urologic Reversals

Urologic Reversals are vasectomy reversals performed by general urologists.  A general urologist is a doctor who has completed 5-6 years of general urology training, but not any advanced fellowship training in male fertility microsurgery.  General urologists have completed the training needed to be proficient at managing problems such as kidney stones, bladder cancer, and prostate problems.  General urologists also learn the skills necessary to be able to safely operate within the scrotum, and are generally very skilled at vasectomies.  However, the teaching of advanced microsurgical is extremely limited during a general urology residency and does not include the intensive, focused training needed to learn the most advanced reversal techniques. In addition, the ability to perform an effective vas-to-epididymis connection is only learned during infertility microsurgical fellowship training.  So almost all general urologists are only able to perform a vas-to-vas connection even if unfavorable vasal fluid is found at the time of a reversal, which as we discussed earlier, can significantly decrease a couple’s chances of that reversal being successful.  Really, the experience that urology residents get with vasectomy reversals during their residency training is not designed to master these techniques, but instead to expose them to the field of fertility microsurgery to see if they might have a special interest in pursuing advanced fellowship microsurgical training once they have completed their basic urologic residency.

The big marketing advantage that general urologists have is that most couples do not realize that general urologists do not undergo the training needed to learn the most critical microsurgical reversal techniques.  Therefore, many men who want a reversal just make an appointment with their local general urology group or go back to the urologist who performed their original vasectomy.  Luckily, the majority of general urologists are ethical people and realize that their skills do not offer couples the best chance of success, and instead refer them to one of their fellowship trained colleagues.

However, some general urologists pride themselves on being “jacks-of-all-trades” and offer any patient who walks in their door any urology procedure out there, including reversals.  Other general urologists go further and market themselves as “microsurgical specialists” despite not having any advanced fellowship microsurgical training.  There are a few such general urologists who advertise heavily on the internet and whose practices focus exclusively on vasectomy reversals, despite not having any more specialized training in this field than their other general urology colleagues. Unfortunately, doing lots of vasectomy reversals over the course of many years does not make you an “expert” if you are using outdated techniques learned only during general urology training.

If a website for a urologist does not explicitly state that they completed a full 1-2 year fertility microsurgical fellowship (also sometimes called “Andrology”), then that doctor is almost certainly a general urologist.  Some general urologists employ some clever “diversions” on their websites when describing their training to distract readers from the fact that they did not undergo specialized microsurgical fellowship training.  These include:

#1) Claiming to have had advanced microsurgical training during their residency training.  As described above, however, urology residency training teaches doctors how to be general urologists, not fertility microsurgical specialists.  The latest microsurgical reversal techniques, including mastering how to perform a vas-to-epididymis connection can only be learned during intensive fellowship training.

#2) Claiming on their website to be fellowship-trained, but not specifying what sub-specialty of urology this training was in.  Upon completing their residency, there are a number of fellowships that urologists can choose to pursue if they wish, including endourology, oncology, female urology, and pediatrics among others.  If a true vasectomy reversal specialist is taking the time to put together a website, he is going to be sure to explicitly state that his fellowship training was in male fertility microsurgery or andrology.  If a urologist just states that he completed “fellowship training” in an unspecified area on their vasectomy reversal website, it most likely was not in fertility microsurgery.  Be sure to ask.

#3) “Micro-fellowships” or “Visiting” fellowships.  These are generally short several week-long courses that at most offer only a fraction of the in-depth training compared to a 1-2 year full fertility microsurgery fellowship.

 

Fellowship-Trained Reversals

Reversals performed by urologists who have been legitimately and fully fellowship-trained are the most advanced and effective microsurgical vasectomy reversal procedures available.  They are performed by board-certified urologists who have completed further advanced fellowship training in the latest and most effective microsurgical vasectomy reversal techniques.  Less than 1-2% of urologists choose to complete a full 1-2 year fellowship training program in microsurgery, which means that there are few such legitimate specialists in practice.  They are worth taking the time to find. 

What is the difference between one vs. two years of fellowship?  The answer: research.  Two year fellowship programs are more geared towards fertility specialists who want to go into teaching and academics, and at least one of the two fellowship years is devoted to doing lab research on topics like low sperm counts. Either way, a full year is typically devoted to learning the critical microsurgical skills in both one and two year fellowship programs. 

 

Summary

If a couple is truly interested in optimizing their chances of post-vasectomy fertility success, it is definitely in their best interest to work with a true fellowship-trained fertility specialist.  It can be a frustrating and confusing process to sort through the multitudes of reversal doctors on the internet who all claim to be microsurgical experts despite a huge variation in the quality of services that they offer.  The goal of this section is to give couples the knowledge and tools to see through the “smoke and mirrors” of the vague claims and unverifiable success rates to accurately determine which doctors actually have the background and training to give them their best chance of fertility success.

Devoting a little effort to researching and asking a few direct questions to your doctors (and expecting a direct answer) can go a long way towards realizing your fertility dreams.  At minimum, you should make sure that any reversal doctor you are considering using is a board-certified urologist who has completed a full 1-2 year fellowship in male infertility microsurgery.

Something that many couples do not realize is that to optimize outcomes, a reversal doctor’s care should not be finished once the procedure has been completed.  The performing of the reversal should really just mark the start of your partnership with your reversal doctor.  True reversal specialists know that close follow-up during the healing process and optimization of sperm production is needed to maximize reversal success rates.  The high volume, assembly-line model of Quick Re-alignment doctors is based on cranking out fast cheap surgeries, not individualized care and close follow-up after your procedure.  Though they may have their staff call to see how your recovery is going, and ask you to send them the results of semen analysis results after the procedure, Quick Re-alignment doctors and general urologists generally do not have the clinical skills to help maximize a couple’s overall fertility potential. In contrast, fellowship-trained specialists are also experts in helping men to improve sperm production and quality, and these interventions can often make the difference in successfully achieving a post-reversal pregnancy.  

Dr. Russell is not the only well-qualified fellowship-trained specialist in the Midwest, and we strongly encourage all post-vasectomy couples to do their research and call around to see which fellowship-trained expert they feel most comfortable with.  Find a doctor who is willing to take the time to talk with you on multiple occasions and answer all of your questions in detail.  Responsiveness and accessibility before the reversal is usually indicative of how they are going to provide couples with support after the procedure.  We feel strongly that every couple deserves their very best chance of successfully growing their family.  This is why Dr. Russell is the only fellowship-trained microsurgical specialist in the Midwest whose practice is 100% devoted to male infertility/microsurgery.  Our passion and sole focus is helping couples to achieve their fertility goals.