Step 2: Determining Which Fellowship-Trained Specialist to Work With
How to Choose Your Vasectomy Reversal Doctor
The previous section (“How to Identify a True Microsurgical Specialist”) described in detail how to distinguish true fellowship-trained microsurgical experts from general urologists and the “Bargain” doctors who have had minimal-to-no training in urologic surgery but still claim to be “reversal experts”. Taking the time to identify which doctors have actually undertaken the intensive training to offer the most advanced reversal techniques is extremely important to increasing your chances of the procedures being a success.
Once you have established which doctors are true specialists, how do you then choose which one you want to work with? There are several factors to take into consideration at this point:
1) Location
2) How much of their practice currently focuses on male infertility and microsurgery?
3) Does the surgeon perform the entire procedure himself/herself?
4) Cost of the procedure
We will now look at each of these important factors individually in more detail.
Location
How far would you like to travel to have your procedure performed? Ideally, your hometown or the area within a hundred miles or so would be optimal in terms of travel time and logistics. However, sometimes it makes sense to have the flexibility of being willing to travel a little farther to work with someone who is a true specialist in the field. If you can find a qualified doctor within driving distance, this is the best scenario. Modern air travel is often a hassle with increased TSA screening, frequent flight delays, and often long walks down large terminals (which can be not very comfortable after scrotal surgery). I have plenty of patients who come in by airplane and most do just fine, but if a couple can drive then it is usually a more relaxed and comfortable experience. There is no rush to get to an airport by a specified time for men who might not be moving at the quickest pace, no bags to be lugged around an airport, or long walks (from parking garages, car rental booths, or between gates). I regularly have couples drive 8-10 hours to come for their surgeries and they do just fine on the drive home. Besides, who wants to shuffle around a busy airport with large bulky ice packs shoved in their underwear if there is a better alternative?
How much of their practice focuses on male infertility and microsurgery?
Just because a urologist has completed a fellowship in male fertility does not mean that this is necessarily the primary focus of their practice. You can actually make quite a bit more money doing general urology as opposed to just male infertility, so most fellowship-trained urologists actually spend 50% or more of their time doing general urology (e.g. treating kidney stones, prostate cancer, etc.). In my practice, I have personally chosen to devote 100% of my time exclusively to male infertility. I feel that this provides me with the benefit of being completely focused on optimizing the fertility outcomes of my couples instead of having to spend time keeping up with the latest research and treatments for problems like erectile dysfunction and Peyronies disease. It is not necessarily a problem for a surgeon to do both general urology and male infertility as long as they are honest and open about the nature of their practice. Some doctors who offer reversals try and give the impression that vasectomy reversals are the only procedure that they offer by making websites that do not mention any other part of their practice. It is fairly easy to find this out, though, by just Googling their name and state where they practice and seeing what comes up. You are sometimes surprised by what you find- like a supposed reversal specialist whose Orthopedic surgery practice website comes up when you just enter in his name and state, though nowhere on his reversal website does it mention that he is actually an orthopedic surgeon. For urologists who are in academics, their websites also often list their research publications. Looking over their more recently published articles can also sometimes give you an idea of what the true focus of their clinical practice might be.
Does the Surgeon Perform the Entire Procedure himself/herself?
This may sound like a silly question to ask any prospective surgeon, but it is actually extremely important. As described previously, the latest vasectomy reversal techniques are some of the most demanding microsurgical procedures in medicine today, and only a physician who has devoted 6-8 years of (post-medical school) formal surgical training acquires the skills to perform them with the highest degree of precision. Certainly if a couple makes the effort to travel to see an expert with this degree of training, then this surgeon will be the actual person performing the entire surgery, right? In truth, you may be surprised to hear that some reversal doctors actually delegate fairly large parts of the procedure for someone else to do. That someone else is usually their physicians assistant (PA) or nurse practitioner (NP) who works with them. Why would they do this? Answer: to save time and increase the number of surgical cases that they can do each day.
The model for a doctor and their PA or NP doing different parts of a surgical case does work well in some common non-Urology surgical cases. A classic example of this are cardiac surgeons performing heart bypass surgery. While the cardiac surgeon prepares the heart for the bypass of the blocked coronary arteries, his PA/NP is simultaneously harvesting a vein from the patient’s leg. While the cardiac surgeon uses this vein to do the delicate bypass procedure, the PA/NP closes up the incision on the patient’s leg. This model works well because harvesting a superficial leg in the vein is a short and easy surgery to learn. The cardiac surgeon is performing all of the vital and difficult parts of the case and the PA/NP does the easy-to-learn removal of the leg vein.
In contrast, vasectomy reversals do not have “difficult” and “easy” parts like cardiac bypass surgery. Harvesting the relatively large superficial veins from a patient’s leg takes nowhere near the technical skills that are demanded for the precision microsurgery of modern vasectomy reversal techniques. The doctors that choose to delegate parts of their reversal procedure to a PA/NP will invariably attempt to argue that they perform all of the “critical” parts of the reversal procedure, and that their assistant only does the “routine, non-technical” parts. To see why this is not at all accurate, let’s look at the reversal procedure in more detail which can be broken down into 4 parts:
1) Initial incision
2) Preparation of the vasal ends and/or epididymis for anastomosis
3) Performing the anastomosis (i.e. placing of the microsutures)
4) Incision closure
Steps 1 and 4 are extremely easy and take about 5 minutes each. Most people think that the placement of the extremely fine microsutures for the anastomosis is the most difficult (and only really critical) part of the reversal procedure. This is completely inaccurate. If done correctly, the preparation steps are just as critically important to the success of the whole procedure. To quote Dr. Marc Goldstein of Cornell University, who is one of the most experienced fertility microsurgeons in the world and helped to develop many of the modern techniques that we use today: “The preparing of the ends of the vas deferens is as demanding and important a step to ensuring success as the actual placement of the microsutures themselves.” Steps 2 and 3 take up about 95% of the actual reversal procedure. If any part of the reversal procedure is being delegated to a PA/NP (other than closure of the incisions at the end), then you are placing your chances of having a successful pregnancy into the hands of someone with 2 years of post-college school (and no formal advanced microsurgical training). You want to make sure that your fellowship-trained surgeon (who has 11-12 years of post-college education) is going to be performing your entire procedure. As you will read in the next section, most reversal surgeons who utilize a PA/NP to perform significant parts of the procedure do this so that they can run a low cost/high volume business model. These high-volume surgeons who have their PA/NP perform parts of their surgeries are not going to volunteer this information to their patients. If asked, they (or their staff) may vaguely state that the PA/NP only “assists” them in their procedures. The only way to know for sure is to ask whether that doctor “personally performs 100% of the reversal procedure themselves.” This is critical information that you need to know before working with any reversal doctor.
Vasectomy Reversal Cost
The average cost of vasectomy reversal in the United States is currently about $10,000. Most of the variation in overall cost is due to the facility fee of the surgeon. As I mentioned earlier, even most fellowship-trained fertility specialists also do general urology procedures as a major part (if not the majority) of their practice. They therefore add any reversals on at the surgery center or hospital where they are doing their other general urology surgeries (such as prostate and kidney stone cases). The handful of fellowship-trained specialists in the country who focus exclusively on reversals are often able to negotiate lower facility prices by choosing surgery centers that offer reasonable prices for cash-pay cases, without having to factor in how this may impact their ability to perform other general urology cases there.
So how can some doctors offer vasectomy reversals for $3000 or less? As described in the previous section, most of these that you find on the internet are the “Bargain” one-hour reversals performed by doctors who are not even urologists. But what about the fellowship-trained urologists who offer 2.5-3 hour reversals for $3000 or less? How do they do this since the economics don’t seem to add up for the time investment made by the physician? Well, there are 2 primary ways that a doctor can reduce the cost of a reversal while actually increasing the overall amount of money that they make: these include eliminating the fee of the anesthesia provider and employing a “high throughput” business model that tries to maximize the number of reversals that they perform each week.
Performing Vasectomy Reversals While the Patient is Awake
Part of the answer of how reversal doctors can cut overall costs (while keeping their procedure fees the same) is to perform the procedures under local anesthesia, thereby cutting out the fee of the anesthesiologist. The previous section (“How to Identify a True Microsurgical Specialist”) reviewed why this might not be a good idea in terms of both patient comfort as well as being able to provide optimal surgical outcomes. As described, there is one published study looking at vasectomy reversals performed with the patient awake under local anesthesia by a fellowship-trained urologist, and the outcomes showed only a low (61%) chance of sperm returning to even very low levels (1 million sperm or higher) in the ejaculate [Alom M, et al. Translational Andrology and Urology 2017, 6: 761-772]. This is in comparison to the multitude of published studies over the last several decades showing that reversals performed by similarly trained specialists but with the patient asleep have success rates of 90% or higher in a comparable patient population. These differences in outcomes are not surprising since having the patient asleep offers multiple significant advantages, including:
1) Allowing the surgeon to perform their delicate microsurgery on a completely motionless surgical field
2) Being able to perform necessary steps during the surgery that might be very uncomfortable to a man who is awake (such as work on the upper ends of the vas deferens which are not possible to fully numb with local anesthetics)
3) The ability to focus their full concentration on optimizing their surgical technique without the distractions of having to simultaneously manage pain control in an awake and anxious patient
Almost all fellowship-trained experts perform their reversals with the patient asleep because they choose to optimize both patient comfort and surgical technique over the potential to maximize their online marketing advantage.
Maximizing Surgical Volume- Prioritizing Quantity over Quality
The primary way that doctors can offer extremely low prices for their reversals is by utilizing a “high throughput” model for their surgical practice. These surgeons have adopted a business model in which they trade off lower prices (to entice patients to travel to their facility) for much higher surgical volumes. In essence, they are using the “Costco” approach to buying in bulk to offer lower prices. Unfortunately, microsurgery is not like purchasing boxes of cereal or rolls of paper towels. The latest vasectomy reversal procedures are very technically demanding, and 2.5-3 hours of intense concentration under an operating microscope can cause mental fatigue. I personally always want to feel “fresh” going into a reversal procedure and devote my entire attention each day to just one reversal so as to truly optimize each couple’s chances of fertility success.
The “high throughput” model focuses on maximizing surgical volume and involves performing several reversals each day (and often other non-reversal surgeries on top of that). After focusing exclusively on just reversal and sperm extraction procedures for the past 15 years, in my opinion, reversal doctors who perform more than one reversal a day (and do the ENTIRE procedure themselves) 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”.
In reality, fellowship trained surgeons utilizing the “high throughput” model are not superhuman, nor do they spend 6-9 hours performing the 2-3 vasectomy reversals that they might have on the schedule that day. They actually are just performing parts of each vasectomy reversal, and relying on their PA to do a significant part of each case as described above. Using this strategy, the surgeon’s time is freed up to either do other procedures (like surgeries for Peyronies disease) or do phone/office consultations while large parts of “their” reversal procedure are being performed in another room by their PA. This dramatically increases the number of reversals that the surgeon can perform each week, which more than offsets the lower prices that they charge. It is a win-win for them- charge less for a reversal, get more patients to come, make more overall money. The only catch is that someone (their PA) with 2 years of post-college training is tasked with completing very important parts of the surgery. The question is whether you want your chosen microsurgeon to perform 100% of your case, or if you are OK with paying a lower price for a PA to perform a substantial portion of your case in an “assembly line” model.
Some practices claim with pride that they perform more reversals than any other practice in the region. I would argue that this is only a good thing up to a point. You certainly want a microsurgeon whose primary focus is on male infertility and vasectomy reversals and does at least 3-5 of these procedures per week. However, practices whose business model is to entice couples with very low prices and make up for this by maximizing volume inevitably need to cut corners somewhere. As for all deals that seem too good to be true (i.e. the same product for a vastly cheaper price), there are always negative trade-offs upon closer inspection. In the case of the low cost/high volume business model of vasectomy reversals, these negative trade-offs again all fall upon the patient (just like performing reversals with the man awake under local anesthesia as described in the previous section). The doctor (and his PA) make significantly more money with this high volume model, while the patient is forced to have important parts of his surgery performed by someone without advanced microsurgical training and who is not even a licensed surgeon.
I strongly recommend asking any prospective fellowship-trained surgeon if they are going to be performing 100% of your surgical case and if they only ever perform just one vasectomy reversal case per day. If you want to truly optimize your chances of fertility success, then the answer to BOTH of these questions needs to be “Yes”. If a practice claims that a PA only does “non-technical” parts of the case, then ask specifically which parts these non-physician providers perform. An “I’m not really sure” answer to this question by a staff member needs further clarification. If the eventual answer is anything more than just closing the skin at the end of the case (which takes about 5-10 minutes), then what the PA is doing is actually an important element of the reversal procedure despite what they try and tell you. Your fellowship-trained surgeon devoted up to 12 years of specialized training in urology and microsurgery to acquire the skills needed to provide the highest level of vasectomy reversal success. It just does not make sense to delegate significant parts of one of the most difficult microsurgeries to a PA who has had none of the advanced fellowship training of the surgeon themselves.
Vasectomy Reversal Money Back Guarantees
Some reversal doctors offer money-back guarantees as part of their marketing strategy, since on first glance this seems like a potentially good deal for couples. However, on closer inspection the caveats and inevitable trade-offs involved with reversals that come with a “guarantee” typically turn out to make choosing this option not nearly as good as it might initially appear.
First of all, the concept that a “guarantee” necessarily represents an assurance of a quality procedure is not really true, since guarantees are usually offered by doctors employing a low cost/high volume model of business. The doctors offering the guarantees will claim that their primary motivation is to be “fair” to patients whose reversals are not successful. However, the prominence with which the guarantees are promoted on their website show that the true motivation of these offers is to serve as a very effective marketing tool to drive more cases into their high volume surgical schedule. The economy of scale allowed by these assembly line high volume practices generates income that more than compensates for the losses that are refunded to even a relatively high number of patients. Numbers always trump quality in the low cost/high volume model, and the primary role of the “guarantee” is to help maximize numbers.
The specific details of what definition of “failure” qualifies a couple for a refund also needs to be closely examined. Most “guarantee” doctors use a cut-off that only evaluates the number of sperm in the ejaculate (sperm density). However, in defining a “successful” reversal, the sperm motility (percentage of sperm swimming) is just as important as the sperm density. In fact, men who have a high grade partial obstruction following a reversal (where scar tissue is blocking most, but not all of the vasal lumen) often have normal sperm densities (15 million sperm/cc or above) but very low sperm motilities. No matter how many sperm are present, if they cannot swim up the fallopian tubes then a pregnancy is not going to take place. A high grade obstruction following a vasectomy reversal is not what I would consider a successful reversal, but by most “guarantee” doctor’s criteria, a couple in this situation would not qualify for a refund. Any definition of reversal failure needs to include sperm motility in the assessment if it is to have any meaningful relevance as to whether the reversal was actually as success or not.
The other problem with the money back guarantee is that it can lead some couples to choose to just “give the cheap reversal a try” despite misgivings that they are not receiving the absolutely best microsurgery possible. The thinking goes that even if they do not get a refund after a failed reversal (e.g. good sperm counts but very poor motility), they could still have 2 “cheap” reversal attempts for the same price as one from a specialist who might charge more but performs only 1 meticulous reversal per day (and does the entire reversal themselves). The problem with this thinking is that the scientific literature clearly shows that a man’s first attempt at a vasectomy reversal represents his very best chance of success. Redo reversals can be performed, but numerous studies have documented that they always have significantly higher failure rates. This is because there is always much more scar tissue in the scrotum from the prior reversal attempt, and the chance of needing the less successful vas-to-epididymis connection rises significantly for redo reversals in comparison to a first-time procedure.
All men with vasectomies who would like to have more children get a single first attempt at a reversal in which their chances of success are optimal. In couples for whom maximizing their chances of having a reversal baby is the #1 priority, the money back guarantees should not distract them from focusing on finding the specialist who offers them their absolutely best chances with their first attempt. Couples who are pursuing a vasectomy reversal want to have a baby, not a refund. Besides, what man wants to go through more than one surgery on their scrotum if it can be otherwise avoided?
SUMMARY- optimizing chances of vasectomy reversal success
If a post-vasectomy couple is truly interested in optimizing their chances of successfully having a baby together, it is definitely in their best interest to work with a true fellowship-trained fertility specialist who does 100% of each and every reversal case. The first attempt at a vasectomy reversal always represents the best opportunity for success, as redo reversals are always associated with higher failure rates- you only get one first, best chance at a reversal. Devoting a little effort to researching and asking a few direct questions to your doctors (and expecting direct answers in response) can go a long way towards realizing your fertility goals. Again, 3 simple questions can generally narrow down identifying the true microsurgical specialists who are devoted to providing optimal surgical technique on every single case:
1) Are they a urologist who has completed fellowship training in male fertility microsurgery?
2) Do they perform 100% of the vasectomy reversal themselves, or does a PA perform part of the case?
3) Do they perform only one microscopic vasectomy reversal each day, focusing on quality over quantity?
One other factor that couples sometimes 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 some reversal doctors is based on cranking out fast cheap surgeries, not individualized care and close follow-up after your procedure. Fellowship trained specialists who focus on only one meticulous reversal each day generally have both the time and expertise to help men improve their 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. I am always surprised by reversal websites that have an option to schedule a surgery date without ever even having talked with surgeon beforehand. Based on a website alone, is this enough information to convince people to travel across the country to see someone who they have not even spoken with before? Personally talking with a doctor (either by phone or in-person) always provides insights into that person’s character and ability to effectively communicate- both of these are very important aspects to know about someone into who’s hands you are placing your dreams of a future family.
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.