How To Choose Your Vasectomy Reversal Doctor

 

For couples who want the absolutely best chance of fertility success following a vasectomy reversal, the single most important factor is choosing a surgeon who offers the latest, most effective microsurgical techniques, focuses on just one meticulous vasectomy reversal each day, and performs the entire reversal procedure themselves. This section of the website is designed to help you to identify which doctors are true microsurgical specialists as well as those who focus on the quality of each and every reversal instead of trying to maximize the number of cases that they do each week.

When couples are looking to fulfill their fertility goals by pursing a vasectomy reversal, there are 3 main variables that they generally consider:

1) Who they want to perform their reversal

2) How far they are willing to travel to have the procedure performed

3) The total cost of the reversal (procedure + any travel/hotel-related expenses)

These are all important factors to consider, and some (such as cost and how far someone is willing to travel) are going to differ from couple to couple. The one variable that is generally constant among all couples considering a reversal, though, is that the overriding goal is the desire to try and maximize the chances that the procedure is going to be successful. That is the whole reason that they are pursuing a vasectomy reversal procedure in the first place!

With all of the choices of doctors offering vasectomy reversals locally and on the internet, some couples feel overwhelmed and do not know where to start the selection process. My recommendation is to begin by first identifying which doctors are actually true microscopic reversal specialists. As you will read later in the section, there is an extremely large variation in the types and quality of reversal procedures that are currently being performed in the United States today. Who you entrust to perform your reversal procedure is the #1 factor in determining your chances of fertility success. Step 1 in the process is therefore to identify which of the doctors you are considering actually has the training and expertise to offer the most technically advanced and successful reversal techniques. Once you have narrowed down your list to these expert doctors, you can then move on to Step 2 in which you can then factor in the other important variables (such as cost, location, etc.) to narrow down your final decision.

Let’s take a closer look at Step 1:


Step 1: How To Identify a True Vasectomy Reversal Specialist


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.

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 devoted the extra time to learning the latest vasectomy reversal techniques. The bad news is that a survey published recently in a medical journal found that the majority of vasectomy reversals currently being performed in the United States are actually being done by doctors who have not taken the time to learn the newest and most sophisticated reversal techniques. What this means is that despite years of significant technical innovation by leaders in the field, most patients currently undergoing vasectomy reversals today are actually having their procedures done using old, outdated reversal techniques which are associated with significantly lower success rates. Invariably, the doctors performing these outdated procedures are not volunteering to their patients that there are better trained specialists out there who offer much more up-to-date and effective vasectomy reversal techniques. 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. For couples who want to optimize their chances of having a successful reversal, it is up to them to do their research themselves and find out the truth about each doctor’s true training and expertise. The good news is that if you know the right questions to ask, then it is actually fairly simple to find out this information.


The 3 Types of Vasectomy Reversals

Broadly speaking, all vasectomy reversal techniques fall into 3 basic categories. Understanding the basics of each of these types of reversals will help you to identify which one any particular doctor offers. Sometimes you can tell by just the descriptions on their website, but in some circumstances you will need to ask a few extra questions of the doctor or their staff.

The following is a description of the 3 types of reversals that you will find:

1) QUICK RE-ALIGNMENT

What I like to call 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. The importance of being able to perform a vas-to-epididymis connection if needed will be discussed in more detail later in this section. Of course, all doctors who offer Quick Re-alignment procedures will claim that they perform state-of-the-art 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.

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 at least 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 (but certainly lower than those of fellowship-trained specialists).

-Disadvantages: General urologists regularly perform a variety of scrotal surgeries so the procedure is likely going to at least be performed with a relatively low risk of significant complications. However, general urology residency training programs do not provide intensive training in the most updated and successful vasectomy reversal techniques (which are truly only taught in an advanced fellowship training program). Without this advanced training, general urologists also do not know how to effectively perform a state-of-the-art 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 basic urologic teaching, 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. The vast majority of fellowship-trained specialists therefore recommend that reversal be performed with the patient asleep under anesthesia. While most men certainly would not want to be awake for a 3 hour procedure on such a sensitive part of the body, doing the procedure with the patient asleep under the constant monitoring of an anesthesia professional does add some to the cost. In the opinion of most fellowship-trained experts, though, this is a worthwhile investment in terms of both patient comfort as well as the ability to perform the delicate microsurgery more precisely when the man is asleep and absolutely motionless throughout the procedure.

MEDICAL TRAINING OVERVIEW

Many members of the medical community (but certainly not all), are 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 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. This is where future surgeons first get exposed to the basics of performing surgery. In essence, medical school lays a solid foundation for future doctor in important areas such as anatomy and physiology, and starts the process of teaching basic surgical technique that can be built upon by later more specialized training during their residency if they choose to pursue residency training in a surgical field.

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, while general surgery (where doctors learn how to remove gall bladders, perform appendectomies, etc.) are generally 4-5 years in length. Surgical sub-specialites, like Urology, usually take 5-6 years to complete. Urologists are the only surgeons who learn how to become experts in the field of scrotal surgeries. 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 of these 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.


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 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 on their websites 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 were much less sophisticated, had significantly 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.


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 1 hour “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 surgery 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 explicitly 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 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 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

The majority of men who have undergone a vasectomy had their procedures performed while they were awake under local anesthesia. Even though vasectomies are generally quite straightforward procedures that take only about 20 minutes to perform, many of these men have had an unpleasant enough experience to wonder whether another scrotal procedure is a good idea to have while they are awake, especially since a reversal is much more involved than a simple vasectomy and takes many times longer to complete.

The websites of doctors who perform reversals with patients awake under local anesthesia are therefore typically full of assurances that their procedures are wonderfully painless experiences. Most have testimonials from non-traumatized men who seem relieved to have emerged from the procedure without excruciating pain. I am sure that a certain percentage of men have a tolerable experience with their “Bargain” 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.

A few of my fellowship trained colleagues have also recently started offering vasectomy reversals under local anesthesia. This switch to local anesthesia (often with light oral sedation) is made for one simple reason. If the fees of the anesthesia team can be eliminated, then the overall cost of the procedure can be dropped. Offering a lower price is marketed as being done solely for the benefit of couples- what they fail to mention is that it also sets up a very lucrative business model for the doctor as well. Lower prices attract more patients, and more patients means that more reversals can be performed each day. Since the surgeon’s fee has not changed (just the anesthesia cost eliminated), the increase in surgical volume translates into significantly more income for the doctor. There is no downside for the doctor in this situation (attract more patients, do more cases, make more money). Unfortunately, the negative trade-offs all fall on the patient’s side, in terms of comfort and a potential negative impact on success rates as we will discuss in more detail later in this section.

The doctors who eliminate the anesthesia-provider’s fee to lower their prices will all strongly insist that doing reversals on patients who are awake in no way negatively impacts their ability to perform their delicate microsurgery with the highest degree of precision. But then again, what surgeon would actually admit to potentially cutting some corners to improve their ability to market their practice by offering lower prices? There are 3 points that I would ask couples to consider when thinking about using local anesthesia (or just light sedation) for their reversal. The first is that the most successful microsurgical techniques generally take around 2.5 to 3 hours. With microsurgery, it is extremely important that the man remain completely motionless for the entirety of the procedure, as any movement under the operating microscope looks like an earthquake to the surgeon. Under just straight local anesthesia, asking a nervous man (yes, most men are at least somewhat nervous on the day of their procedure) to lie absolutely motionless on a surgical table for up to 3 hours is generally not a reasonable (or remotely comfortable) request. If you add oral sedation to the mix, the man is certainly more relaxed, but also more likely to wiggle around when his back starts to ache after a few hours, his nose has an itch, etc. Having a patient moving during his reversal procedure is certainly not conducive to performing precision 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 particular 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 for this short procedure- but for some men the experience was really bad. Without having an anesthesia team present, the only two options for these patients were to continue on with significant discomfort or to cancel the case. Because of this early experience, 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 under local anesthesia. Almost invariably when I talk with these men after their procedure, they say that they greatly preferred not being awake during 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 15 years of routinely performing vasectomy reversals, none of my patients have ever experienced a severe or life-threatening anesthetic complication. The websites of doctors who do reversals under just local anesthesia always state that doing the procedure while the man is awake “avoids the risks” of general anesthesia or IV sedation, but the bottom line is that these risks are incredibly small with these minimally invasive surgeries in otherwise healthy men. I would even argue that for less-healthy men, the stress and discomfort of having a scrotal procedure while he is awake may arguably place more strain on the heart than being asleep under anesthesia (which also has the added benefit of having an anesthesia expert continuously monitoring his vital signs throughout the case).

Is it possible for a reversal to be performed under local anesthesia? The answer is yes, but with some potentially important negative trade-offs. Certainly the quick and non-complex 1 hour reversals can be completed under just local anesthesia, though many of my redo reversal patients who had their initial reversal attempt performed while awake (by another physician) report that it was not a very pleasant experience. As for the latest 2.5-3 hour reversal techniques, there is one published study showing that these can technically be accomplished with the patient awake under local anesthesia as well. However, this study reported some important limitations with this approach. An example is that in men who are awake for their reversal, it is necessary to minimize manipulation of the abdominal ends of their vas deferens (the ends of the vas above the vasectomy site that travel up from the scrotum towards the abdomen) as this can contribute to significant abdominal and flank pain that the local anesthetic cannot block. What if a man’s vasectomy was performed quite high on one or both sides requiring more extensive abdominal vasal mobilization (which is a not-uncommon scenario)? In these situations, the surgeon performing a procedure while the patient is awake would be put into the position of having to decide whether to sacrifice either patient comfort or optimal surgical technique. Maybe this is why the success rates in the one published study of reversal reversals performed with the patient awake were significantly lower than what you would normally expect, despite being performed by a urologist with fellowship training in microsurgery [Alom M, et al. Translational Andrology and Urology 2017, 6: 761-772]. On follow-up semen analysis testing, only 74% of the reversal patients in this study had any sperm return to their ejaculate following their reversal under local anesthesia, and only 61% had total sperm counts that rose to at minimum 1 million sperm (note: normal sperm counts are 15 million sperm/cc or higher, and men with counts of <5 million/cc usually need the assistance of in-vitro fertilization/IVF to conceive). These are not particularly good rates of success for a fellowship-trained specialist, especially since <6% of the reversals in this series required the less successful vas-to-epididymis connection on both sides. Using the latest reversal techniques with the patient asleep, the percent of men with normal sperm counts (at least 15 million/cc) should be closer to 90% or more if the majority were able to have a vas-to-vas connection on one or both sides.

When patients are asleep during their reversal, the doctor does not need to potentially sacrifice optimal technique to keep the patient comfortable, but instead can just take the necessary steps needed to maximize the chances of success without having to worry about causing significant pain as a result. There is a reason why the vast majority of fellowship-trained reversal specialists perform their reversals under outpatient general anesthesia, and this is because it allows more precise surgical technique in all patients and optimizes overall comfort.

#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. 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. Another point to consider is that sperm motility needs to evaluated as well, since the sperm need to swim up the fallopian tube to establish a pregnancy. What if a doctor defines “success” as 5 million sperm/cc or above. If that patient’s count is above 5 million/cc but his motility is 0% then there is no way a pregnancy is going to be established- is this really a “success”? I personally consider a reversal to be a failure if the numbers and motility of the sperm are not high enough to allow a decent chance at natural conception, but this is not the definition most websites use to calculate their success rates. My goal is to get the semen parameters up to what the latest 5th edition WHO guidelines state are the normal value cut-offs for fertility in men: a sperm count of at least 15 million sperm/cc and a motility (the % of sperm that are swimming) of 40% or higher.

#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 outdated 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.

Despite the potential for manipulation, online reviews can sometimes be useful by giving a general impression of a doctor and the quality of care that they provide. If a doctor has a large number of negative reviews, reading the comments can potentially reveal problems with aspects like effective communication or commitment to long-term follow-up with patients, both of which are very important for optimizing the chances of success after a reversal. Conversely, if all of the reviews are uniformly positive, this may be a sign that the online reviews are being manipulated by the medical practice (using techniques as described above). Almost all fertility doctors (who are not manipulating their online review sites) inevitably have some negative reviews, as even the most advanced fertility treatments available today do not have 100% success rates. Even when top quality care is provided, the understandable disappointment which couples can experience when a procedure is not successful can translate into a negative online review which serves as an easy (and if desired, anonymous) way to vent one’s frustration. One aspect to keep in mind is that if a negative online review contains incorrect or misleading information, there is no effective way for a medical practice to respond to this. Due to medical confidentiality (HIPAA) laws, medical providers are not allowed to respond to online reviews by patients since doing so provides public confirmation that this person has a specific medical problem (i.e. gives medical information on patients without their express consent). Consequently, if an online review states that a reversal was not a success, does this mean that it truly did not work (i.e. no sperm present on semen analysis testing at a year out), or has that couple just not yet established a pregnancy but have only had 1 initial analysis and no further testing for the past year? This type of online feedback can prompt the doctor to contact that particular patient to encourage them to get their recommended updated semen analysis testing and get them back on track, but there is no way to clarify this on the online review site. Contrast this with the Better Business Bureau website, where consumers can post complaints that the business is able to publicly respond to. This is good for both consumers and businesses, as it can lead to potentially helpful and informative discussions that may genuinely help future consumers make informed choices. Unfortunately, in medicine the HIPAA privacy rules preclude this type of productive back-and-forth communication online.

In summary, reading online reviews can potentially provide some useful information when looking at doctors, but it is most productive to look at overall trends in responses by patients. Individual reviews may not reflect an accurate picture of a doctor and the services that they provide, and be wary of uniformly good reviews as these often represent a manipulation of the online review system, such as paying for positive reviews with a site like “Best Local Reviews”.

#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 post-medical school 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.

Another option would be to hire a PA (physician assistant) and teach them how to perform parts of the reversal. It would then be possible to have multiple reversal cases going on at the same time and therefore easily perform 2 to 3 reversals a day. I could then lower my prices (which would look GREAT for my internet advertising) and still make significantly more money. We will discuss this high-volume business model that some reversal doctors utilize more in the next section of the website.

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. I also know that focusing on only one vasectomy reversal per day and doing 100% of each reversal myself provides a much better procedure than delegating significant parts of each case for a PA to perform. 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.

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 (so long as these experts are doing the entire procedure themselves). 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 advanced 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” fellowships), 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 seem 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. However, asking two simple questions (and expecting a direct answer) of every reversal doctor you are evaluating can quickly identify whether or not they are a true reversal specialist:

1) Is the doctor a board-certified urologist?

2) Has that doctor completed a 1-2 year fellowship in male infertility/microsurgery?

If the answer is not an unqualified “Yes” to both of those questions, then that doctor has not devoted the time and effort to acquire the skills and training needed to provided the latest most successful reversal techniques.

Now that you have identified which doctors are true fellowship-trained specialists, you can move on to Step 2 and look at the other important factors that can help narrow down your decision-making process.