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Interviewer: Here to speak with us about vasectomy reversal is Dr. James Hotaling, a urologist and the director of the men's health program here at University of Utah Health. Now, Dr. Hotaling, when it comes to a procedure like this, what are some of the reasons a patient might be looking for a reversal?

Dr. Hotaling: About 6% of people who have a vasectomy will ultimately want it reversed. The most common reason is that they have gotten divorced and have a different partner and want kids with that new partner. Although we do see couples who have had kids, had a vasectomy and then decided they want more kids. So those are usually the most common reasons people want it reversed.

Interviewer: I've been seeing some rates that say, "Hey, you know, a reversal is only 30% to 90% effective." How effective is a procedure like this?

Dr. Hotaling: Yeah. It works about a 90% to 95% of the time.

Interviewer: Oh, wow.

Dr. Hotaling: So it's pretty effective. It depends a little bit on how far out you are from your vasectomy. If you're like 20 years out, it has a lower chance of success. Although it, you know, that chances of success still may be like 80%, 85% than if you're two years out, just because there's more scar tissue.

Interviewer: And we're determining success by being the ability to get pregnant.

Dr. Hotaling: Yeah. That's exactly right. You're determining success by having swimming sperm in the ejaculate.

Interviewer: And so what other factors besides just length of time since you've had the procedure?

Dr. Hotaling: Yeah. A little bit it can be exactly how the procedure was done. When you go back in there, you can either put the vas deferens back to the vas deferens, and that has the highest chance of success rate. Sometimes you have to put the vas deferens back to the epididymis or the sperm-holding tank, and that's smaller and that has like a 60% to 70% chance of success. It's lower. But if you can put the vas deferens back to the vas deferens, that success rate is really high. So if you look at all comers, you end up around 90% to 95%. That's really the biggest thing in determining the success rate and then also just, like we mentioned, how far out you are from having the reversal and to some degree just how the individual surgeon did the vasectomy.

Interviewer: If someone say listening to this and considering whether or not they should have their vasectomy reversed, what is, you know, what is the ideal candidate for a procedure like this? Like is anyone say, you know, not a good candidate? What makes a good person for this?

Dr. Hotaling: That's another really good question. So obviously somebody who wants to have kids in the future and somebody who if the wife is younger, that can be helpful, although it's not impossible to do it if their wife is older. Also for couples who want, you know, multiple kids, it can be helpful as well. And just cost considerations. You know, the cost of a vasectomy reversal is a lot less expensive than the cost of in vitro fertilization. It's like a third the price. So that's kind of the other option, the other consideration.

Interviewer: And is reversal ever covered by insurance?

Dr. Hotaling: No.

Interviewer: Okay. So it's out of pocket?

Dr. Hotaling: It's always out of pocket. Yeah.

Interviewer: What are some of the risks with getting this type of procedure, of getting it all back together?

Dr. Hotaling: Well, the biggest risk would be that it wouldn't work, which is really, really low. You know, the recovery is usually pretty minimal, a little bit of bruising, but not terrible, sore for, you know, maybe five days afterwards. We do use long-acting numbing medication that lasts for four days. So patients really don't have much pain from that. And then you have to take it easy for three weeks or so. In terms of the complication, some patients can get pain that lasts longer than that afterwards. As I mentioned, the chance that it couldn't work or just chance of some bruising or a very rare chance of infection, although that is exceptionally, exceptionally rare as in I've been doing this for eight years and I've only ever seen it happen once.

Interviewer: Wow.

Dr. Hotaling: So that's not common.

Interviewer: Okay. So here on The Scope we've talked before about vasectomies and what the procedure is like, what to expect. It's an outpatient procedure, you come on in and, you know, you heal up for a week or so, right? With a reversal, you know, like the day of the surgery, what are they expecting?

Dr. Hotaling: So they'll, you know, they won't have anything to eat or drink after midnight. They'll come in, in the morning. You know, they'll get an IV put in. They'll get drifted off to sleep. They'll go to sleep. Once they're asleep, we make two small incisions, one on either side of the scrotum, and then we go in and find where the blockage and we bring a high powered . . . we have this new digital microscope, it's like a $700,000 microscope that actually allows us to see in 3D with special glasses on.

Interviewer: Wow.

Dr. Hotaling: It actually is really helpful to do the procedure. So we bring that in. Then we put the tubes back together again with 12 sutures that are finer than a human hair and then put the local numbing medication and close everything up. Each incision is shorter than an inch on either side.

Interviewer: Oh, wow.

Dr. Hotaling: So two incisions, really small. Then you would wake up with some . . . And all the stitches melt away on their own. You'd wake up with some sort of biologic superglue over the incisions and then some gauze on the scrotum. And then you'd go home later that day. And most patients just take some Ibuprofen and Tylenol and that's it.

Interviewer: Wow. And you were saying that it's take it easy for a little bit and then three weeks until you're back to . . .

Dr. Hotaling: Yeah. It's really just no like sex, bike riding, or heavy lifting for three weeks. But you could be back on your computer doing work the next day. Often if I do the surgery on a Thursday, patients are back at work again certainly by Monday. And if I did the surgery on say a Tuesday, often by Thursday or Friday.

Interviewer: Once they're all healed up and once they're feeling good, how do we know, I guess, if it was a success?

Dr. Hotaling: Yeah. It's a great question. You know, we have had patients who get pregnant before we ever checked the first semen analysis.

Interviewer: Wow.

Dr. Hotaling: But usually we check in like 8 to 10 weeks, we check the sperm test. And it can take up to a year, even up to a year and a half, depending on the type of like reconstruction that we do.

Interviewer: Oh, wow. So it's not just you magically are?

Dr. Hotaling: Most patients, when it's successful, have sperm right away.

Interviewer: Oh, wow.

Dr. Hotaling: But it can take longer.

Interviewer: Okay. So, you know, you'll do a test and find out if it was successful and go on from there?

Dr. Hotaling: And then we would repeat it again in three to six months if we didn't show any sperm.

Interviewer: And I would imagine that this type of procedure is something you want to make sure you go to a good doctor, a good surgeon, or a good urologist. You know, what should a man be looking for in a doctor to perform this?

Dr. Hotaling: Yeah. So typically somebody who's done a fellowship in male infertility, which both myself and Dr. Gross here have. We're actually getting another partner, who's starting in September, who's also done a fellowship in male infertility. So you want someone who's fellowship trained. You want someone who does a lot of these. And I think also doing it, you know, in the operating room with the patient asleep, with kind of the best equipment you have, and we sort of tick all those boxes here. Some people do do them in the office with local numbing medication. You know, I don't believe that that's necessarily the best way to do it in my opinion.

Interviewer: So we're looking for someone with a fellowship, someone who's performed the procedure a few times and probably a lot of times, right? And a good center, right?

Dr. Hotaling: Yeah. That's exactly right.

Interviewer: For a patient who is considering getting this procedure done, what is it about say University of Utah Health or maybe another medical center? What is the things that a big center like ours can offer to them with their procedure?

Dr. Hotaling: Yeah. Typically we can also . . . we offer the ability, because we have a full IVF lab and andrology or sperm lab, we can do a little biopsy of the testis at the same time and freeze some of that testicular tissue in case the reversal doesn't work, you know, and you could use that, which saves the patient a significant amount of money because they don't have to have another procedure in case it doesn't work. You want somewhere, you know, that does a lot of them and really has the best equipment.

Interviewer: You were just telling me that you have fellows, you have other . . .

Dr. Hotaling: Mm-hmm. We have other people that we work with. And the surgeons here are still doing the entire surgery, but we have really good assistants. A lot of places, it may be, you know, a surgical technician who's assisting the surgeon, and it really helps to have, you know, great assistants, or if it's a super complicated case, myself and my partner, you know, we'll sometimes do those together.

Interviewer: Four ways to naturally boost testosterone. Dr. Jim Hotaling is a urologist and a men's health expert. What can I do?

Dr. Hotaling: Simple things you can do are work on losing weight. Even a 10- to 15-pound weight loss can make a big difference. Also, exercise, particularly anaerobic exercise, such as lifting weights. Eating a balanced diet, trying to avoid processed foods, particularly sugar. That can result in changing energy levels and also mess with the natural circadian rhythms that reflect your testosterone production. And the other big thing is sleep. A lot of men have sleep apnea and that can make a big difference in their natural testosterone production. Testosterone levels are a reflection of your overall health. And if you work on making these changes, you should notice a significant difference in two to three months.

updated: April 23, 2021
originally published: May 30, 2019

Interviewer: You've been diagnosed with low testosterone. You don't want to do the creams and pills. Are there other things you can do? We'll talk about that next with Dr. Hotaling on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Dr. James Hotaling is a urologist and also an expert in men's health here at University of Utah Health Care. And guys that have been diagnosed with low testosterone, what else can you do, other than the creams and the pills?

Dr. Hotaling: There's really only three things that have been proven to naturally raise testosterone levels, the first of which is just weight loss. A lot of men are overweight and don't take great care of themselves. So trying to have a normal weight can help a lot, even losing as little as 15 to 20 pounds can make a huge difference. So that's one thing.

Interviewer: And for guys, that's a challenge because, as we get older, we tend to put on about a pound of fat a year, I hear.

Dr. Hotaling: That's absolutely correct. We have a Men's Health Center that's based South Jordan, and we actually have a nutritionist who a lot of our patients see because it's not that men don't want to take care of themselves. It's just that I think a lot of men view going to the doctor as a sign of weakness. So they need some help to learn how to take care of themselves. So that's the first thing. The second thing is exercise, particularly weight lifting. That's very clearly been shown to boost testosterone and human growth hormone. It's actually the only thing that can boost human growth hormone, which can then also drive testosterone.

Interviewer: Are we talking about Olympic strength-type training, or just going in and building up a sweat?

Dr. Hotaling: Yeah, just building up a sweat. Even lifting weights as infrequently as twice a week for 30 or 40 minutes can make a significant difference and it can also boost your metabolism for one to two days after you do that. So it can help with weight loss. And then the third thing is just trying to eat a healthy diet, avoiding a lot of excess sugar and that kind of thing, which, again, ties into weight loss. So those are really the three . . . and then, I guess, the fourth thing would be getting adequate sleep.

We know that when men are sleep-deprived, that can make a big difference in their testosterone production. We particularly see problems in people who have shift work, where they work at night and their circadian rhythm gets all flipped around. Typically, testosterone peaks at about 4:00 a.m. along with cortisol. So that's all tied to your body's rhythms. And the amount of testosterone you have varies minute-to-minute and hour-to-hour. So those things are all things that can help. I think it's also really important to outline the things that don't help, or haven't been proven to help, if that makes sense.

Interviewer: I bet you alcohol is on that list, isn't it?

Dr. Hotaling: Yeah, it is. Again, that goes . . . that's what the biggest thing is. No supplement has ever been shown to make any difference. There are all kinds of natural testosterone boosters, DHEA. And Utah actually is the national, and perhaps the international, hub of supplements. I mean, there are companies like Essential Oils, which are billion-dollar companies and there is no data that any of that makes any sort of difference. And some of it may even be harmful for men. So that's one thing.

I think the other thing that men should watch out for, we also see a lot of men who take Propecia, or finasteride for hair loss. And that can actually have effects on your testosterone, your sex drive, and even your fertility. So that's another good thing to avoid if you're concerned with that.

Interviewer: So avoid the bad, do the good, and about how long until men start seeing maybe some changes?

Dr. Hotaling: Unfortunately, weight loss, for most people, is a slow process, especially if you're going to have sustained weight loss. I mean, you could lose at most one to two pounds a week. But I think if men stick to a healthy diet and lift weights, they should see a difference in four to six weeks and start feeling better. And there has been data that that's essentially something that's been proven over and over again in the literature. Those are really the key things for men.

And I think the other really important thing men can do is just regularly see a primary care physician. Most men don't. Men seek health care at a rate that's about 30 or 40% lower than women. And part of the reason I'm in here talking to you today is that most of the things that bring men to see a doctor are urologic conditions because they disproportionally impact quality of life, and, we might say, men functions, if you will. So I think it's just really important to get in and see a doctor regularly.

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Interviewer: Testosterone therapy, generally speaking it's safe, but there are some side effects. What do you need to know? Why is it important to have a doctor part of your treatments and not just buying it off a TV ad? We'll talk about that next on the scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier healthier life. You're listening to The Scope.

Interviewer: If you're on testosterone treatments, it's important to be regularly monitored by a physician to avoid potential risk. Dr. Jim Hotaling is a neurologist and a men's health expert at University of Utah Health Care.

So let's say I'm a man. I saw the TV ad for testosterone treatments and now I'm taking them. Are there some possible risks?

Dr. Hotaling: I mean I think the biggest thing we see very frequently, and I define frequently as I probably see one to two guys a week with this, is that testosterone will make men sterile. It's actually been trialed as a male birth control. It only works on about 90, 95% of men. So it didn't actually make it as male birth control. But that's the biggest thing. It will drop your sperm count to zero in most instances.

The other issue is that it can raise your red blood cell count in some men to unsafe levels. Particularly the injections can do that. It can also cause fluid retention. Theoretically we used to think that it would increase your risk of prostate cancer. But there really isn't a lot of data to actually support that.

And then there's been a lot of data about cardiovascular disease, testosterone and increasing the risk of stroke or heart attack. That really as it turns out, the major study that sort of showed that, which is a paper in a very prominent medical journal, has been shown to be methodologically flawed in a number of different things. And actually there's a lot of data that shows that men with testosterone actually do better from a cardiovascular disease standpoint.

I think generally speaking it's a very safe drug as long as things are monitored appropriately. We check labs on our patients every three to six months for the first year and then annually thereafter. Generally speaking we have very few, if any, adverse events from men being on it. So that in a nutshell are what the major concerns are.

Interviewer: So the people that are probably the target for the television commercials tend to be older. So they might not be concerned about their child rearing days are done. Are there dangers? I always understood that there just wasn't enough research to say whether or not it's safe at this point. And I hear a lot of comparisons to estrogen treatments in women.

Dr. Hotaling: Yeah, so there have been some huge trials done on estrogen treatments. One of the big issues is with that is increasing the risk of blood clots.

Testosterone treatments actually raises estrogen levels in men as well. And that can be an issue. That can get to an unsafe level especially in overweight men. Their fatty tissue has an enzyme in it that will convert testosterone to estradiol which is a female hormone and that can get to unsafe levels.

I think the big issue with testosterone is that we have patients who have been on testosterone for 5, 10, 15 years and we don't have follow up. We don't have the research to know what the exact effects are for being on it for that long. We think generally speaking it's very safe as long as it's used in a reasonable and measured fashion.

Interviewer: So originally in this conversation I was going to take it in the direction of, somebody saw the ad on TV, they're getting the creams in the mail now and I was thinking it's a dangerous thing. But it sounds like you're saying it's not a dangerous thing.

Dr. Hotaling: I think if it's monitored appropriately and men are on it for the right reasons, I think it can make a big difference in their quality of life.

Interviewer: So if I was on it because of a TV ad, it's a good idea at some point to go to a urologist and have some labs done.

Dr. Hotaling: Yeah, definitely. We see a lot of people who are not really appropriately managed. There's a lot of these testosterone clinics that never see the patient and maybe have a phone interview and I think if men are on testosterone they need to see a physician regularly, have appropriate labs monitored, and know that it can make them sterile.

I would say no man of reproductive age who is planning on having children in the future should be on testosterone. There are alternatives that we can use that men have low testosterone and symptoms that are of reproductive age and can boost their testosterone and actually improve, not hurt their fertility.

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Interviewer: Andropause is the male version of menopause. We'll find out more about that next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Dr. Jim Hotaling is a urologist and also a men's health expert here at University of Utah Health Care. Andropause, what is it?

Dr. Hotaling: There is a natural decline in testosterone in men after the age of about 30 or 35, testosterone goes down significantly. One of the things that's really tricky is we don't know what the normal testosterone is in a 20 year old, 30 year old, 40 year old, 50 year old. We know maybe in a 50 year old and above what an abnormal testosterone is, which is usually a total testosterone, depending on who you look at, below 350 or below 300.

But again this is a lab test that varies minute to minute and hour to hour and it has to be checked before about 10 in the morning to be accurate. So if a man goes to get their testosterone checked at 4 pm it's almost always going to be low. One thing that's difficult is the testosterone industry has had the most successful marketing campaign in the history of medicine.

So it literally took testosterone from in 2000 being about a $100 million a year industry, I think this year it will clear 2 or 3 billion. It's actually taught at Harvard Business School, the whole concept of low T as exactly how you should do marketing. And a lot of men come in because they're concerned with that. In summary andropause is real, but and this is the big but, you don't treat a number.

You really only treat patients if they have symptoms of low testosterone and have low testosterone. Ideally on one to two measurements in our opinion and everybody's bias, but urologist are great people to do that because they understand a lot of the issues that impact men's health.

Interviewer: So what exactly is it? Is it just a natural lowering of testosterone? Is that all andropause is?

Dr. Hotaling: Essentially, yes. The testosterone will decline in a man every year past the age of 30 or 35.

Interviewer: And is it the male version of menopause?

Dr. Hotaling: It is in the sense that it's a decrease in hormone levels and everything else. But for women it's a different issue because at some point they stop ovulating. Men really never stop producing sperm. There are people who've produced children in their 90s, which that's a topic for a different day, but men never stop producing sperm.

And it's not as severe as it is in woman. It's a very gradual decline and at some point, in some men, it declines to a point where it does cause symptoms and that is where I think there is some resemblance to menopause.

Interviewer: And that's where you as a urologist or a men's health expert would perhaps then consider doing some sort of therapy?

Dr. Hotaling: Yeah, that's correct and typically the therapy is testosterone replacement. There are other medications we can use. The downside to testosterone replacement is it will make men sterile, some men permanently. Most men not. But we can use other medications to actually boost testosterone and keep men's' fertility intact.

There are also some surgical procedures, one in particular we can do to actually help increase a man's testosterone.

Interviewer: So decreasing testosterone or going through andropause is just normal?

Dr. Hotaling: Yeah, it is normal and I think that's the key thing to understand. The testosterone companies would have you believe that you should treat a number. And what's tricky about testosterone is anyone, no matter what their testosterone starts at, will feel better when you put them on testosterone. That doesn't mean that everybody should be on testosterone and I think that's the real challenge.

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