Re-Opening Closed Chapter
This case history is now quite a few years old. A young couple had consult me. The man and the wife were both young, in their early thirties. They were well dressed, articulate and seemed highly educated. Yet, something about them was curiously unusual. There was a distinct aura of gloom and melancholia surrounding them.
This, in itself, is not uncommon in my practice. The gloom, I mean. Couples struggling with infertility and erectile dysfunction are often depressed, and their relationships too, are precariously balanced, if not altogether jeopardized. But this couple’s sadness seemed to belong in the vas deferens between men and women category. They seemed so fragile that it was hard for me to speak. I was afraid that I might say the wrong thing and trigger off something inadvertently. My empathy was instantaneous.
The couple’s inter-personal relationship didn’t seem one bit estranged though. The looks they exchanged were that of deep love and understanding. It was almost as if they were together in their grief, with an even stronger bonding than in fun times. There was definitely some other issue at play here, an issue on which I was not able to put my finger immediately. Sensitivity and delicacy were the need of the hour, my antennae warned me.
‘Yes, please,’ I finally began because they didn’t, ‘what can I do for you?’
He men oh pause. By now, his wife was choking on stifled sobs. Just the trigger I was afraid I might accidentally pull, I thought to myself. To her credit , however, she recovered quickly and regained her composure
I knew what was coming next. I have been through case histories like this is a couple of times in the past. However, the correct thing for me to do was to wait until they told me. If I was wrong, it would have been even more calamitous, so I waited for them to tell me. I could feel their pain as they relived their traumatic experience all over again, but could do nothing but wait and let them take their time to finish. After a brief while, they regained their composure somewhat.
‘Six months ago,’ the husband continued, ‘we lost out only child in a tragic accident. We didn’t imagine in our wildest dreams that such a tragedy could befall us when I went in for a vasectomy. How we take simple things for granted! Nothing is in our too hot to handle, actually. Our lives have turned completely upside down after that, doctor. Nothing, nothing in lie hereafter can ever compensate us for this irreparable loss.’
I waited for them to settle down after the hardest part. I took a deep breath too. I admired their fortitude. Such a young couple, and all this just when their lives seemed picture perfect. It didn’t take long for them to recover. This time, the wife spoke, finally.
‘We are slowly coming to terms with what has happened to us, doctor, but the void in our lives is simply too much to bear. We are now very keen to have another child. I have spoken to my gynecologist about this, and she has suggested an In Vitro Fertilisations (IVF)/Intra Cytoplasmic Sperm Injections (ICSI) procedure as the best solution to our predicament. She said that they would retrieve sperms from my husband’s testes using a needle or a biopsy procedure, and then inject the sperm directly into my egg at the time of ovulation. But my husband gain one organ lose another , who has surfed the internet extensively on the subject and has also read many of your columns in the past, seems to be convinced that we have a better chance of success with a microsurgical vasectomy reversal operation. That’s why we are here, doc. We don’t know what to do.’
‘You are placing an unfair responsibility on me,’ I told them. ‘I can only explain to you the various available options, and tell you what the success rates, costs, hospital stay duration, and other logistics are. The final decision will have to be made by you.’
‘We’re okay with that doctor. I know you will tell us the facts right.’
I pointed them to many articles from leading international textbooks and journals, including one from the then current issue of the revered journal, Fertility & Sterility, which clearly mentioned that the results of a micro surgically performed vasectomy reversal operation are superior to those obtained with IVF techniques if the reversal is performed at centers of the excellence. The results are even better if the vasectomy reversal is performed within five years of the vasectomy. The patency rates can exceed ninety percent and the pregnancy rates, seventy percent. Besides, the whole exercise is cheaper than one cycle of IVF and is a one-time day care surgery. The patient spends only a few hours in the hospital.
On the other had, I pointed out, even the cumulative success rates a of IVF/ICSI after several cycles cannot match these figures at most centers. Besides, each cycle entails visits for the woman to the IVF centre of several days, many medicines and injections, serial ultrasound scans, and an ovum pick up. At the end of all this, the success rates are only a modest fifteen to twenty per cent per cycle even at the best centers. The procedure will have to equal that obtained with a microsurgical vasectomy reversal operation. And there is a high cost involved each time too.
Another great thing about a microsurgical vasectomy reversal, I told them, is that when it works, enduring results can be expected, and one can even have many children in the future. By contrast, IVF/ICSI procedures have to be repeated each time, and each attempt costs more than a microsurgical vasectomy reversal operation.
‘Thanks for the reassurance, doc. This is exactly what I showed my wife on the internet. I took her to the sites of the best infertility microsurgery centers in the world, but her doctor didn’t agree with those figures.’
‘There may be a reason for that,’ I told them. ‘Not all infertility surgeons are trained to perform microsurgery. Many will just use optical loupes (magnifying spectacles) and loosely call it microsurgery. The two are totally different, and so are the results. Your doctor must be speaking from experience with such surgery and its poor results. But all reversal operations are not alike; microsurgery is different. It employs magnifications of up to forty times and allows for great precision. By contrast, most loupes offer only modest magnifications of three to four times. This is definitely not good enough for the very minute was deferens, and this is promptly reflected in the poor results. That is probably what your doctor is talking about.’
After two days, the couple came back tome and announced that they have decided to opt for the microsurgical operation. The patient was admitted in the morning, operated upon, and discharged the same evening. Six months after operation, the patient’s sperm counts were respectable. They improved steadily, and after a year and a half, the wife conceived again.
Take Home Message:
Vasectomy can be reversed. When performed micro surgically at centers of excellence, the results are excellent. It is a day care operation, which is performed under local or regional anesthesia. The results of this reversal operation are usually much superior to the results of IVF/ICSI , if performed at centre's of excellence. For these reasons, vasectomy is the sterilization operation of choice.