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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?’
‘Ours is a somewhat  unfortunate  case, doctor,’ the husband replied.  ‘My wife and I are both highly  qualified working professional.  We got married  about six years ago.  Our was  a dream marriage of sorts, with everything  falling into place, like a fairy tale.   We met at the workplace, fell in love, and after a few months’ brief whirlwind courtship, got married with our parents’ whose sex after a heart attack approval.  Both our families are affluent  and there was nothing missing in our lives.  Within a year and a half of our marriage, we were  blessed with a bonny  son.  Our joy  knew no bounds.  Then, when our son was two years old, we  decided that with both of us being so career-minded, we didn’t want  another child.  My wife and I discussed  it pretty much in detail, and I underwent a vasectomy.’

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.’
Most doctors would  have been flattered with such trust from a patient.  I always  get a bit  apprehensive instead.  I am notorious for warning patients about all the gory morbid details  of every procedure.  I don’t tell them that a particular procedure carries  a seventy-five  percent success rate.  I tell them instead that it carries a twenty-five  percent failure rate.  When they  ask if it’ll  hurt, I say, ‘Yes! It certainly will.’  In the  beginning of my practice, I was warned, and  therefore worried, that I might lose patients because  I am so blunt.  However, to my pleasant surprise, I found  that my patients not only appreciated my honesty and thanked me for it, they also  coped with their  post-operative  situation much better.  For instance, most patients experience less pain than they had been told to expect,  and this improves  their convalescence quite  considerably.  Therefore, to cut  a long story short, this couple couldn’t  have been more right when they said  that I would  tell them  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.
They plan to name the baby Amar.

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.