My favorite drawing of the epididymovasostomy procedure (Courtesy: Netters Images)

You had your wings clipped and now you want more children. What’s a guy to do? Well that depends on who you ask.  Your choices include vasectomy reversal or sperm retrieval and assisted reproduction (IVF – ICSI).

Doctors who perform IVF – ICSI might say that vasectomy reversals don’t work. Doctors who do vasectomy reversals say that they do. Other doctors fall in somewhere in the middle and say that “younger” vasectomies are reversible but “older” ones are not. Again, what’s a guy to do?

Facts about Fatherhood after Vasectomy

To get a handle on this, let’s start with the irrefutable facts of the case:

• Where does conception occur? Vasectomy reversal allows for conception in the bedroom, whereas it occurs in a fluorescent-lit laboratory test tube with IVF – ICSI.
• Who pays? If insurance does not cover either approach, then vasectomy reversal is always cheaper than IVF – ICSI.
• Who gets procedures? Reversal involves surgery on the man but not the woman. IVF – ICSI involves procedures on both partners. Good to know if you like sharing such things.
• How quickly can we get pregnant? Time to conception is generally faster with IVF – ICSI than vasectomy reversal.
• What is the risk of twins? The chance of having twins or higher multiples is 1% with vasectomy reversal (i.e. sex) and 40% with IVF – ICSI.
• What is the risk of birth defects? The chance of having a child with birth defects is twice as high (10% vs. 5%) with IVF – ICSI compared to sex.

The Problem of the Older Vasectomy

As I apprise patients of these facts in my daily practice, it recently occurred to me that the issue of the “older” this or that surfaces a lot. I have published research that speaks to relative performance of vasectomy reversal and IVF-ICSI with female partners who are less than 38 years old. I can also address the success of either approach in cases of older men. But there is much less information about the true reversibility of “older” (more than 15 year old) vasectomies.  Is there any truth behind the statement that older vasectomies aren’t worth reversing? I really needed to answer this question and so I put my research hat on to do it.

Probably the biggest issue with the “older” vasectomy is that, just like a tire that is continually being filled, a physiological “blow out” of the system is more likely to be observed at reversal. It’s not dangerous or anything, but it does mean that a more “involved” procedure, termed epididymovasostomy, is needed at reversal to restore connectivity and fertility. And, by the way, the epididymovasostomy is one of the hardest microsurgical procedures to perform well on this good earth. So, knowing more about how often “blow outs” happen as vasectomies age could be very informative for doctors and patients alike.

For 25 years the prevailing thought among surgeons is that the rate of “blow outs” increases linearly as vasectomies age. Published algorithms and nomograms confirm the thinking that, given enough time, every vasectomy will “blow out” and need an epididymovasostomy instead of a vasovasostomy to restore sperm counts and fertility. And, as epididymovasostomy success rates are not as good as simpler procedures at reversal, this means that vasectomy reversal success rates should indeed fall with vasectomy age.

But what if it’s not true? What if the occurrence of “blow outs” does not rise along with vasectomy age? If true, then older vasectomies would be much more reversible than previously thought. And the return of sperm counts should be higher in older vasectomies than one would think. Voila, this is precisely what our new research shows and will be presented at our annual international urology meeting in Atlanta tomorrow. I guess that I agree with Don Miguel Ruiz when he said: “It is always better to ask then to make an assumption.” Stay tuned for the findings!

Related posts:

1. Insider’s Guide to Vasectomy Reversal
2. Rise of the Instant Family
3. Assisted Reproduction: A Two-Edged Sword
4. A Year Without Answers II
5. A Year Without Answers

Try doing this with suture much smaller than the finest human hair…

A recent study on hungover surgeons suggests that they are slower and sloppier after a night on the town. Get them toasted, let them sleep it off and they can’t perform surgery on par the next day. Not surprising findings, given the physical and mental demands of many surgeries. But quite alarming for patients who will quickly forgive a heart surgeon for having a terrible personality, but expect and demand that a surgeon be at the top of their game when operating.

Study of Sloshed Surgeons

Eight experienced surgeons and a bunch of medical students were treated to dinner in a restaurant and were instructed to drink until they felt intoxicated.  They were then driven home and picked up again the next morning. Brought to a laboratory, they performed virtual reality (fake) surgeries at 9am, 1pm and 4pm. At 1pm, their skills were the worst, but at all three time points, they performed simulated surgeries below baseline, even though they were technically sober at the time of testing. So, surgeons are people too. The problem is that they wield scalpels.

As a microsurgeon, I shuttered when I read this study. It violates the mantra of centeredness that many of us adhere to religiously in practicing such a high art. And although any surgery can be challenging and take years to master, microsurgery places a unique demand on the surgeon: to fix things that are utterly invisible to the naked eye.

The Microcosm of Microsurgery

How demanding is microsurgery? Demanding enough that you would certainly not want your microsurgeon to rave all night before your procedure. In vasectomy reversal surgery, we routinely reconnect tubes that are less than 1/10th of a millimeter in size, slightly bigger than the absolute limit of human hand-eye coordination. For perspective, here are a variety of other dimensions in this subatomic universe:

• Thickness, credit card                                 0.76 mm
• Diameter, human egg                                  0.12 mm
• Diameter, average human hair                     0.1   mm
• Diameter, human vas deferens opening    0.1   mm
• Average thickness, plain sheet of paper       0.09 mm
• Length, human sperm cell tail                     0.04 mm
• Limit of human motion                             0.03 mm
• Wavelength of light emitted by a carbon dioxide laser     0.0011 mm

What’s the Surgeon’s Secret?

The secret of expert surgeons is the same as that of any Olympic-caliber athlete. Natural skill and experience are assumed. If your outstretched hand has a visible tremor, you should probably avoid microsurgery. More importantly, however, are consistency and discipline, which are the true hobgoblins of great surgeons. With this Tao in mind, drinking binges are unacceptable for a master surgeon. Regarding coffee, its allowed, but just drink the same amount every day. Stay consistent. Play sports and keep fit but don’t expect to be Picasso if you’ve thrown a shoulder, your back or sprained a finger-playing ball. Pain diverts critical mental and neuromuscular energy away from the task at hand. Best to heed the words of Aristotle on this: “We are what we repeatedly do. Excellence… is not an act, but a habit.”

But should we define recommendations for alcohol use by surgeons before procedures as the study authors suggest? Fine with me. But what about pilots, school bus drivers and cabbies, to name a few other professions, who also take other’s lives in their hands?

Related posts:

1. The Low Down on Being Knocked Up
2. Adding Hope to Health
3. One Child China
4. The Man in the Mirror
5. The Condom Cha Cha

It doesn't get any better than this!

Legend has it that surfing began in the Hawaiian Islands hundreds of years ago. In the late 1800’s, it was introduced to the U.S. mainland by way of southern California. Duke Kahanamoku, an Olympic star in swimming from Hawaii, helped popularize the sport by traveling internationally and demonstrating his surfing style. He is credited with surfing the longest wave ever in 1917, at a break called Outside Castles in Waikiki. The 1000 meter long wave that he surfed is a record that has yet to be broken.

Surfing became known in the Santa Cruz area, at the northern edge of Monterey Bay, began in the early 1930’s, 30 years before the epic surfing movie “Endless Summer” was released. Even today, Santa Cruz is known throughout the world as a mecca for peeling point breaks, and is certainly one of the best surf spots in California.

I love surfing Santa Cruz waters. To me, it is really the pinnacle of pristine California coastal beaches, a place where you can still hear the driving surf guitar of Dick Dale and feel the relaxed atmosphere of surf living. Pelicans, sea otters and often dolphins join you as you play in the water. Just magic.

I surfed Pleasure Point this weekend with an old friend on two windless days. Warm, waist- to head-high surf launched from a southern swell beginning in New Zealand and entering Monterey bay in perfectly peeling corduroy sets. Poetry.

In my other life as a surgeon, a craft like many others, I have learned to appreciate and enjoy the smallest details in life. For details matter in surgery, let this be clear. But they are not the ends, only the means, to a much larger whole that they constitute. Witness the healing and restoration of patients after complex microsurgery.

Surfing is also rich with details. The size, pitch and break of the swell, the aura of the murmuring ocean and breaking tide. The contour, rail, and rocker of the hand shaped board, and the trim of the body on board as it silently cuts through water.  Like surgery, surfing reaches an almost spiritual realm not only through the sensations conveyed by innumerable associated details, but also through the sublime and intoxicating feeling that, at least for a moment, one is in control of life.

No related posts.

Dr. Paul Turek

Dr. Paul Turek graduated from Yale College with highest honors (summa cum laude), Phi Beta Kappa, and then attended medical school at Stanford University, where he also took top research honors.

He completed his residency in urology at the Hospital of the University of Pennsylvania, the nation’s first medical school, founded by Benjamin Franklin.

After completing a fellowship in male reproductive medicine and microsurgery at Baylor College of Medicine, he was recruited to the faculty of the University of California San Francisco (UCSF), one of the nation’s top ten hospitals.

While at UCSF, Dr. Turek served with distinction, performing incisive and widely praised research, publishing hundreds of papers and lecturing around the world. In time, he was awarded membership in the prestigious Academy of Medical Educators and became a full professor, with an Endowed Chair in Urology.

Yet despite the international acclaim and the chance to mentor the next generation of physicians, Dr. Turek realized that what he most enjoyed was being a physician and caring for patients with reproductive health problems.

I’ve always believed in scientific research because it generates medical knowledge, but what matters most to me is how that translates into good, old-fashioned wisdom for patient care.

That simple but deeply felt insight gave birth to The Turek Clinic.

No related posts.