Search for tag: "vasectomy"

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Scot: Welcome to a very special Valentine's edition of "Who Cares About Men's Health." Did you hear that, Troy? Did you hear what . . .

Troy: That wasn't me. That was Mitch.

Dr. Smith: That was Mitch 100%.

Mitch: All of our very special episodes give me such anxiety. What is the topic today, Scot? Let us hear. What's Valentine's Day going to be about?

Scot: Yeah, you guess what our topic for Valentine's episode is going to be?

Mitch: I don't know. Emotional openness or . . . I don't know. What is it?

Scot: Vasectomies.

Mitch: You know what? I'll give it a solid B-plus. I think this is a good thing. Yeah, love this. Okay, great.

Troy: It works for Valentine's Day.

Scot: Does it? Did you get the tie-in? I was afraid you wouldn't get the tie-in.

Mitch: No, I feel it.

Troy: V-Day has a whole new meaning.

Scot: Actually, a vasectomy could be an amazing gift because women have traditionally borne the responsibility of birth control, right? And sometimes it impacts their hormones, and some of it is uncomfortable, and some of it is a daily grind, it's a responsibility, or all of the above, right? So what if you could take that weight off of your wife and put it on you?

From what I understand, a vasectomy is one of the most effective forms of birth control, and it can remove a lot of stress when you're having sex. But there are some crazy things on the internet about vasectomy side effects, and there are also some legit concerns. And we're going to find out what's legit, what's not, plus also how to figure out if vasectomy is right for you and your partner and what to expect.

This is a Men's Health Essentials episode about vasectomy for the vasectomy curious of "Who Cares About Men's Health," providing information, inspiration, and a different interpretation of men's health.

My name is Scot Singpiel. I bring the BS and I'm on Team V. The MD to my BS, Dr. Troy Madsen.

Troy: Hey, Scot. I just want to know did you give your wife a vasectomy for Valentine's Day? Is that how this kind of all came up?

Scot: No, I got it a couple of years ago.

Troy: But not on Valentine's Day.

Scot: But not on Valentine's Day.

Troy: I just wanted to know how many men have actually done that.

Mitch: What do you put in a box or card for that?

Troy: Yeah, exactly.

Scot: Always with his unique perspective, Mitch Sears.

Mitch: Hey. Hello. I'm not concerned about this, but I am curious to learn more about it.

Scot: All right. And the most manly guy on the planet because, get this, he performed his own vasectomy on himself.

Troy: This is amazing. This actually blew my mind when I heard this, so I hope you're going to describe this in detail for us.

Scot: It's urologist Dr. John Smith on the show.

Dr. Smith: Man, I thought my wife was the only person who loved to start conversations with that story.

Troy: That is seriously the manliest thing I've heard.

Scot: I know.

Troy: I have sutured myself up and I tell people that, and they're like, "Whoa, are you serious?" But to tell someone I did my own vasectomy, that would just be next level. I've never heard of that before.

Scot: Yeah, on a scale of one to awesome, how do you feel about that, Mitch? That John did . . .

Mitch: I just can't even imagine. Did you have to? Were you in an emergency vasectomy situation, or what was going on?

Dr. Smith: I mean, all of that is up for interpretation. My wife and I had surprise twins during the beginning of the pandemic, and that was a shocker. And so once we had the twins, she literally looked at me and said, "When are you getting your vasectomy?"

Scot: And going to another provider never was something you considered?

Dr. Smith: I mean, I considered it. I probably should have done it. I mean, probably not the brightest move I've ever made in my life, but it's worked out just fine. I mean, it was one of those where someone no-showed their vasectomy. I wasn't going to throw that stuff away, so I made the executive decision to just do it.

Mitch: You just sat down and did it?

Dr. Smith: Yeah.

Troy: And just to clarify for any listeners who are thinking of doing this, this is a . . .

Dr. Smith: Don't.

Troy: . . . procedure you do on a regular basis.

Dr. Smith: Oh, yeah. I mean, volume-wise, I'm one of the highest-volume vasectomy folks at the University of Utah.

Troy: So this is not an unfamiliar procedure. But you did it on yourself. That's amazing.

Scot: This is a "don't do it at home" sort of . . .

Troy:Yeah, don't do this at home.

Dr. Smith: I would not take what I did and make it something that's the smartest thing I've ever done.

Scot: So, as a guy who had the procedure, I had a misconception. I thought that I was going to show up and there was going to be an operating room full of people, right? I thought there was going to be just a ton of people, but there wasn't. There was one guy. That's one of the things we're going to talk about, one of the misconceptions people have.

But before we get into that, John, what are some of the crazy things that men hear about vasectomy on the internet that they ask you about?

Dr. Smith: I mean, a lot of them will come in and they'll be like, "I'm going to be able to have an erection? I'm going to be able to . . . I'll still ejaculate? This won't impact my testosterone levels? I'll still feel and have testosterone?" Pretty much anything that you can think of when it comes to your genitals being in the crosshairs. There's a lot of misconception out there.

Scot: And it's not true. All those things you said . . . I'm not going to all of a sudden have the desire to start watching Hallmark Channel movies or something, right? My voice isn't going to get higher.

Dr. Smith: No, not at all. And so yeah, a lot of the misconceptions are there. It doesn't change erectile quality. It doesn't even change the amount of ejaculate. The sperm themselves make up about 5% of the ejaculate. And so there's not even a really noticeable decrease in the amount of ejaculation. Your testicles make the testosterone and sperm. They don't stop making testosterone because you got a vasectomy. All those things are all misconceptions.

Scot: Mitch, Troy, have you heard about any kind of crazy things about vasectomy that you've wondered about? I've got one here that I saw on the internet.

Mitch: Yeah. The big one that I've ever heard and when I've talked to people before, they're like, "Ew, no, I'm not going to do that," is the sexual dysfunction stuff. It's the, "I won't be able to ejaculate again," or, "It won't be the same," or, "I won't have . . ."

Scot: Or the pleasure, right? It's going to be less pleasurable.

Mitch: Yeah. And I guess none of that is true.

Dr. Smith: It'll be less pleasurable if you had another kid that was screaming in the background. I'm just kidding. That was terrible of me. But consequence-less intercourse does have its appeal.

Scot: Yeah. And on the other hand, it's really almost freeing. It can make sex better because it's one of the most effective forms of birth control, if I understand correctly, right?

Dr. Smith: Yeah. It's very effective. The pregnancy risk after a vasectomy is 1 in 2,000. And that's not 1 in 2,000 ejaculations, by the way.

Scot: Sure. Okay. I mean, it kind of just makes things freer. And then knowing that I took the responsibility on and my wife doesn't have to go through the stuff she used to have to go through anymore, I think it's cool. I mean, that's my take.

I've seen on the internet that sperm will build up and that could be a problem. Is that true?

Dr. Smith: Very rarely is that a problem. There's a 1% risk of chronic testicular pain after the procedure, which that is one of the possible reasons you could have the chronic testicular pain. But oftentimes, that is not the case. The sperm have a life cycle, they die, and then they're absorbed by the body, so it doesn't really hold true.

But some people do notice chronic testicular pain and they get a vasectomy reversal and the pain goes away. So there is some thought that there may be some truth to that, but it's not a common thing.

Scot: I will admit that was the one potential side effect that I was concerned about, because that could impact your life for the rest of your life. But it's a very, very low chance.

Dr. Smith: You've got a 1% chance of chronic testicular pain is what most of the literature will say. That chronic testicular pain, often there are ways to mitigate that. It sometimes will involve another procedure or another surgical intervention to get rid of that pain. It is a rare occurrence. But when it happens, it's definitely not something that you're going to be like, "Man, I'm so glad that happened to me."

Scot: Troy, any misconceptions you want to clear up?

Troy: I don't know if it's a misconception. I know some people have talked about some of the pain they've experienced after a vasectomy and . . .

Scot: Like just procedural pain? Pain from the procedure itself?

Troy: Yeah, procedural pain. And I know it's a common procedure to have around the Super Bowl. I think some places make a big push then because the idea being that you're going to just sit on the couch all weekend and have an ice pack on your groin to ease the pain.

Scot: Or March Madness, right? You've got an excuse to sit around and do nothing.

Dr. Smith: We've done a Vas Madness a few years.

Troy: Vas madness, yeah.

Dr. Smith: Where you get them in and do it before the tournament.

Troy: And is that common? Are people typically saying, "Hey, I'm just going to have to sit on the couch for two or three days because it hurts too much to walk"? Or is that more of an excuse to watch a lot of basketball?

Dr. Smith: I'm not going to sell anybody out here. Most of the time, we recommend after the procedure to take it easy for a couple of days, about 48 hours after the procedure. Some folks are a little bit more aggressive. Some folks are a little bit more conservative as far as telling you to take it easy for four or five days.

I usually tell my patients ice 20 minutes on, 20 minutes off, for the first couple days and then get back to your routine as it feels okay. No heavy lifting for about five days after the procedure. You can't get in a pool or hot tub or submerge it in water for about 10 to 14 days while the small incision heals. Other than that . . .

I mean, some people will tell you that you can have sex within a couple of days. Some people say wait a week to have sex. It varies between who does your procedure.

Some people will say you can shower the night of the procedure. Some people say to wait to shower a couple of days after the procedure. Again, there's not a huge variety of people that are getting infections or anything from this.

Troy: No running?

Dr. Smith: I usually tell people they can go running when things feel better. I can tell you that I know a couple folks who went golfing the day after they did their vasectomy. Not that they did their own, but after they had their vasectomy done. And they said they were fine. There were no problems.

The big thing that you worry about when you are too active too soon is a small blood clot in the scrotum. Not the kind that goes to your heart or lungs, but a hematoma is what they'll call it. Just a collection of blood in the scrotum. And it makes things a lot more sensitive and painful during the recovery and makes the recovery a little bit more miserable for a couple of weeks.

Scot: Also, I've read that some people are concerned it can cause prostate cancer or it's been linked to cardiovascular disease. Talk about that. That's not true, though, is it?

Dr. Smith: No. A lot of that has been debunked. I mean, there's a lot of literature out there about other things as well that say that. But there's no clear link to getting a vasectomy and then having prostate cancer. There were some articles that came out and most of that has all been debunked, and it's not true.

Scot: And then I didn't know this. There's a no-scalpel vasectomy. Is that kind of the common way now, or what?

Dr. Smith: Well, it's all a gimmick, right? You've got to open up the scrotum to get where you've got to get to start. So it's one of those where you've got to make a hole in the scrotum at some point, whether you poke a hole with a sharp instrument, whether you use a scalpel, you've got to open it up anyway. There's no magic to just the vas deferens just coming out without making some kind of an opening in the skin.

Scot: Do I need to be concerned about, first of all, the way they're making the hole? I mean, is one way any better than the other really?

Dr. Smith: Honestly, no. I mean, the scrotum is very robust as far as its healing capacity it's going to be fine. In three to four weeks, you're not even going to know that somebody was there regardless of how they got in.

Scot: All right. And then as far as how they're actually going to . . . if they're tying or if they're cauterizing the vas deferens, does that make a difference? Should you request one over the other?

Dr. Smith: Well, most people will cauterize and then do something else, or just cauterize. And so the cautery is the one thing that the American Urologic Association says is best practice, is to have mucosal cautery of the lumen of the vas deferens. And so that's something that I'm pretty sure everybody does.

And then on top of that, some people will put clips. Some people will do something called fascial interposition. And that's pretty much where there's an opening in the fascia of the scrotum, and sometimes you'll tuck one end of the vas deferens underneath and put a clip or a stitch over the top of it.

So it's kind of like putting one of them in the basement and one of them in the upstairs so that they can never meet again, is kind of a way to think of it. They call it fascial interposition.

Some people will just tie a ligation stitch around both ends. I mean, there are different variations. You could talk to 50 different urologists and have 50 different ways to do it.

Mitch: What's the thinking behind that? Is it just if the two somehow accidentally meet up again it will heal?

Dr. Smith: Right. So the thought is that you can have someone who's . . . I call them super healers because I don't know of any other way that this happens. But where you can have those mucosal ends grow back together and just recanulate and make a tube again.

I mean, that happens. Very rarely does it happen. I have a friend of mine who actually had it happen where he had a vasectomy done, and he told me he actually had a second vasectomy done. I haven't confirmed that in his medical records, and he still says he has active sperm.

Mitch: Is he Wolverine?

Dr. Smith: He has to be, man. I checked for adamantium, but I did not see any on first glance. I'm not sure.

Troy: Did he know it had reconnected because he had another kid, or what? How did he find out?

Dr. Smith: Usually, we have folks get a semen analysis in 8 to 10 weeks. Some people say six to eight weeks. Again, it varies between folks that are doing this. You get to a semen analysis that looks to see if there are any mobile sperm, how much sperm there are if there are any, and if they're moving. And that gives you a good idea of whether you should lose the protection or not.

Troy: Well, speaking of reconnecting . . . I'm going to put this out there as a misconception, and maybe it's not. But the misconception being that it's very easy to reverse a vasectomy. If you get it done and you want to have it reversed in five years, it's a simple thing to do and you can go on and feel confident you're going to have kids at that point. Is that a misconception?

Dr. Smith: So a lot of it depends on time. The vasectomy reversal can be done. The longer that things are scarred down, the less successful the reversal is. But the reversals are pretty successful. I mean, a high number, we're talking three-quarters or more of them, are able to have sperm there after the reversal procedure. Also, individual doctors have different kinds of success rates that they'll quote you.

The thing that you've got to realize with that, though, is insurance is not going to cover that. So you're going to hit that on your own. It's going to cost you $6,000, $8,000, $10,000, depending on where you get it done, cash to do that.

Obviously, insurance paid for you to get a vasectomy so that they wouldn't have to pay for another kid. And so a lot of that becomes out-of-pocket expense for the person who gets the reversal.

Scot: So I think a lot of guys want to know what the procedure is like. It was almost a non-event. I was a little intimidated going into it. Like I said, I thought it was going to be this big procedure. I think it was done in like 15 minutes. The pain wasn't super bad. I went and bought a couple bags of peas and iced like I was told to and took it easy for two or three days, and everything was great.

I'd read some of the crazy stuff, that it was going to decrease your sexual pleasure, and yadda, yadda, yadda, and none of that happened. And it just feels great not having to worry about it. Is that pretty accurate? Did I describe the procedure pretty well? I mean, just kind of the overview, John?

Dr. Smith: Yeah. I mean, it's a simple procedure that's done in the office. And I don't want to simplify anything because surgery is never a big deal until it's on you. And then obviously, when it's on your genitals, it's an even bigger deal. But it's a very commonly done procedure. It takes 15 to 20 minutes, maybe 30 minutes, in the office. It's minimally invasive. I do mine through a single incision that's about a centimeter to a centimeter and a half long. Numb things up with lidocaine and just take care of it.

Scot: Don't even feel it. Don't even know. It is kind of weird though because you're sitting there in a chair, and you're kind of watching the doctor do it, but you're not seeing what the doctor is doing, because you've got some blankets or something up there. So you know something is going on and you're actually kind of seeing that something is going on, but I didn't feel a thing.

Dr. Smith: Yeah, once you're numb . . . I mean, the worst part is the numbing. When I did mine, that was the worst part, was getting numb. And most men when they're done, they're like, "Oh, the numbing was the worst part. After I realized I was numb, I could just relax and hang out."

Scot: I don't even think the numbing was that bad, really. I don't remember it.

Dr. Smith: Listen to this guy. What a tough guy. "It didn't even bother me, man. My name is Scot."

Scot: I still don't measure up to you, but . . .

Troy: Yeah, I think you're trying to outdo John on this one, Scot.

Dr. Smith: It hurt, man. I did not like numbing it up. I'm not going to lie to you. That was the worst part by far. But again, once it's done, that is the part that people say is the worst.

And then you had a great recovery. Most people do have a good recovery like that. I was very similar to that. I had some minimal discomfort for a few days. Bruising for 7 to 10 days in and around the scrotum.

I did not get a hematoma, thank goodness. I mean, they happen about 1 in 20 to 1 in 30 vasectomies. So they're not super common, but they're the most common "complication" that you have after the procedure. If you do get one of those, your recovery is not quite as fun. I tell you guys it gives you the man flu for a couple of weeks. You're not going to want to do much. But that's kind of what to expect for it.

A lot of guys come in they're like, "Man, I was really worried and scared about this and it wasn't as bad as I thought." I hear that quite a bit.

Troy: And you mentioned insurance coverage earlier too, John. It sounds like this is covered by insurance.

Dr. Smith: So a lot of insurances will consider this preventative care. You need to check, obviously, with your insurance company. But if you think about it, it makes sense for them to pay for a vasectomy. Then you don't have to worry about taking care of another kid on the insurance for 18 years, or 26 years. And so a lot of them will have that.

So we'll have a mad rush at the end of the year where people think that they've met their deductible and they need to go get their vasectomy. But then a lot of times, if you look at your insurance coverage, you could have done it into March, April, May, it didn't matter because it was considered preventative care.

Now, not every insurance is that way, but a lot of them are because it's advantageous for them to obviously have that done to decrease another kid coming on to the policy.

Troy: Yeah, a calculated decision on their part.

Dr. Smith: Yeah, exactly.

Scot: As we get ready to wrap this up, what type of guy would be a good candidate for a vasectomy? Are there some people that are better candidates than others?

Dr. Smith: Almost everybody is a good candidate. Oftentimes, if there is a difficult exam or something where we think it needs to be done in the operating room, it can be. Most everyone is able to be done in the office.

Obviously, a good candidate would be someone who's not interested in fertility any longer and does not want to have any more children. And so those folks would want to come in.

We have them have a consultation to go over all the risks/benefits before they have the actual procedure, and then come back for a second visit for the actual procedure. That way, they have the ability to do that.

Also of note, when we talked about insurances, government insurance makes you wait 30 days from a consultation to have the procedure done so that you have time to think about it.

I was told when I did my training that that was because some places were doing the vasectomies on people who were in mental hospitals, things like that, without consent. And so the government changed it to where they had to have consent and wait 30 days, and yadda, yadda, yadda.

But all of the government insurance does require a 30-day wait period and a form to be filled out. So Medicaid and other government insurance, you have to do that.

Scot: Something I remember, I had my consult and they asked me the same thing. They asked me how many kids I have. Zero. "Are you positive that you don't want to have kids?" Well, I'm to the age and my wife's to the age where that's probably not even a smart thing from a health standpoint, and we've decided that that's the case. And they did ask if I talked to my wife about it. You would recommend that as well? This is a conversation that should be had between both partners. You shouldn't just go out and surprise . . . do the Valentine's Day vasectomy surprise.

Dr. Smith: Right. If you've already had that conversation with your partner, and you guys have decided that's not what you're going to do, then I think you're pretty safe. But I think it is a wise thing to talk to your partner. If you don't have a partner, then obviously it doesn't apply.

Troy: And I have to ask this too, John. Let's say someone out there is thinking they're not married, but they don't want to worry about the issues with possible pregnancy with partners, and so they decide to have a vasectomy. How effective is a vasectomy at preventing STDs?

Dr. Smith: It's not at all.

Troy: So you're still using a condom for those guys.

Dr. Smith: Yeah, absolutely. I mean, that's not going to stop an STD in their tracks at all. That's just going to make it so you're not going to get someone pregnant, but it's not going to stop transmission of any of that stuff.

Scot: By the way, I think Troy knew the answer to that question.

Troy: I had to ask it.

Dr. Smith: Was Troy baiting me in?

Troy: I was baiting you. I had to ask it. I think that maybe potentially that could be a misconception, that you think, "Hey, I had a vasectomy. Great. I don't have to worry about pregnancy."

Scot:Yeah. Woohoo.

Troy:You're right. Not a big concern. Far more effective at preventing pregnancy than condoms or oral contraceptives, but doesn't do anything for STDs.

Dr. Smith:Absolutely.

Scot: Yeah. You might forget that. I could definitely see that.

Well, if you're considering having a vasectomy, of course, if you have any concerns or questions, if you've seen something crazy on the internet that we didn't address today, then definitely talk to a urologist.

If you have other concerns, like what it's like, for some reason other guys that have had them, it's been my experience, love to talk about them. I don't have any qualms about it.

I don't know if there are some people that think it makes you less manly or anything like that, but from my personal experience, I'm really glad that I got one.

I will admit it was a little strange thinking that this is it. I've made the decision that under no circumstance . . .

You do consult men that this is not a reversible procedure, even though there is potential to reverse it if you've got the cash and if you do it soon enough?

Dr. Smith: Correct. I usually tell people that this is reversible, but I don't do it to be reversible.

Scot: Yeah. Right. Your job is to do it so it works and those things don't grow back together. But beyond that, I mean, it's been great. So I would highly recommend it if you are done having children and you don't want to have to worry about birth control anymore.

Dr. Smith: I concur.

Scot: If you have any questions, you can email us. The email address is hello@thescoperadio.com. And we've just given you a Valentine's Day gift idea, so you're welcome. Just don't make it a last-minute gift. Have that conversation.

Troy: Last-minute gift. Yeah, it sounds like maybe the gift would be proposing the idea rather than coming home and showing the incision on your scrotum.

Scot: Yeah, that's a good idea. Thank you for listening, and thank you for caring about men's health.
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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.

Announcer: Health information from experts supported by research from University of Utah Health. This is thescoperadio.com.

Interviewer: When it comes to vasectomy, there are a lot of myths that you might hear about from friends or maybe you've even read them on the internet and they're simply not true. And a lot of times, these myths could contribute to the fact that maybe not as many men get a vasectomy in the United States compared to other parts of the world.

Dr. Alex Pastuszak is a urologist and a reproductive expert at University of Utah Health. And I'd love to get you as the expert to address some of these common myths that I found out on the internet about vasectomy and find out if they're true or not. I think one of all them that you hear is it's called getting snipped sometimes, which makes me think that this is a pretty major surgical procedure. Is that true?

Dr. Pastuszak: Great first question, great leading question. And ladies and gentlemen, I'm here to tell you that this is one of the least invasive procedures that a guy can have or a human being can have for that matter, because literally we're talking about two half-inch incisions, one or two half incisions in your scrotum and a quick pulling up of your vas -- clipping, cutting, putting it all back in there and suturing it up. All of this takes 15 minutes, very quick, not invasive.

Interviewer: All right. So getting snipped, that's really unfortunate isn't it that people refer to it as that?

Dr. Pastuszak: I mean it is factually correct, but it's not invasive.

Interviewer: Yeah, okay. What about this myth? It's really, really painful. Oh, it's going to hurt.

Dr. Pastuszak: Not true. If we did it back the way they would have done it back in the 1200s or 1400s before there was any form of anesthesia, then yes, maybe. But we use really good local anesthesia. We give you some oral meds that also numb things up a little bit for you. So the pain scale here is really minimal.

Interviewer: All right. And what about recovery pain? Sometimes I hear that it can be kind of painful to recover?

Dr. Pastuszak: Yeah. You know, I'll be frank with you. I tell guys to expect that, you know, they will feel like they got kicked in the boys for a day or so, on and off, so it's not constant and then that goes away.

Interviewer: All right. And that's really kind of a small price to pay when you think about it that from then on out, for the rest of your life, you don't have to think of birth control for you and your spouse?

Dr. Pastuszak: Think about the freedom that comes with a minor bit of pain for a day or two.

Interviewer: Absolutely. All right. What about this myth? It will affect my testosterone production, and all of a sudden I'm going to start watching "Gilmore Girls" and I'm going to have a high-pitched voice. My muscles are going to go away.

Dr. Pastuszak: Two words -- not true. Now, let me say just a word about that, because I think it's important. Okay? So guys, testosterone doesn't come up through your vas up into your body. It goes into your bloodstream. Your testicles make testosterone. Doing a vasectomy is not going to stop your testicles from making testosterone. Your testosterone levels may go down as you get older, but this has nothing to do with whether or not you had a vasectomy.

Interviewer: All right, that's good. What about this one? It's going to change sexual function or it's going to reduce a man's pleasure.

Dr. Pastuszak: Not at all. Your penis stays the way it was before vasectomy. And testosterone is really important in all those processes and, just like we said, we're not messing with that.

Interviewer: The key thing I'm picking up here is it's what are we actually doing, and we're just cutting that one little small tube that allows the sperm to go out into the world.

Dr. Pastuszak: That's right.

Interviewer: What about this one? This is a little bit more serious. It can cause prostate cancer, or it has been linked to cardiovascular disease if you get this procedure done.

Interviewer: There is no convincing evidence right now. There have been a couple of papers, but there is no evidence that would really suggest that vasectomy actually causes prostate cancer or is related to cardiovascular disease. These studies were all based on big cohorts that were not necessarily vetted very well. So there were imperfections in these studies, and in the urologic community right now, there's nobody who has changed practice as a result of any of them. So proof is certainly not 100% or even close to it.

Interviewer: It sounds like perhaps other things could have caused these things, not vasectomy in the data.

Dr. Pastuszak: Right. You know, guys will get prostate cancer as they get older.

Interviewer: That's just going to happen.

Dr. Pastuszak: It's just going to happen, exactly. Same thing with cardiovascular disease. Just because you link it to a vasectomy doesn't mean it's true.

Interviewer: And finally, how about this one that my sperm is going to build up? Now I'm saying this is just what I found on the internet. I mean, I don't know how somebody believes this, but apparently somebody does. My sperm's going to build up, and my testicles will explode as a result.

Dr. Pastuszak: So that, that's one of my favorites. And it's a legitimate question, right, because you are blocking the exit of sperm from the testicles.

Interviewer: And as high schoolers we know what that did.

Dr. Pastuszak: Right. Exactly, the blue and five letter word after that. The answer to this is that know your boys are not going to explode after you have a vasectomy. The body just reabsorbs the sperm that are made in your testicle. I mean, it knows that they have nowhere to go, and then it's just going to soak them right back up. So don't worry about it.

Interviewer: All right. Any other myths out there?

Dr. Pastuszak: You know, I think you've covered it pretty well. I did also just want to touch on the orgasm one, because we talked a little bit about sexual function and we talked about sensation but not orgasm. No effect on orgasm either. Guys, just be reassured that this is a very local thing that we're doing. We're going to keep you from having babies in the future, and it's not going affect anything that you associate with your sexuality, manhood or your livelihood.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

Interviewer: You've had all the children you and your partner want. Your family is complete, and now you're considering permanent birth control. But how do you decide who gets it done? Is it the dad, and he gets a vasectomy, or is it the mom, and she gets tubal ligation?

Dr. Alex Pastuszak is a urologist and a fertility expert at University of Utah Health. What is your take on this question, tubal ligation or a vasectomy?

Dr. Pastuszak: So, Scott, I'm going to come right out and say that I would be strongly in favor of the vasectomy.

Interviewer: All right. But that's what you do, so I would expect that. Do you have some more support for it?

Dr. Pastuszak: Right, yeah. So, no, this has nothing to do with my pocket.

Interviewer: Okay.

Dr. Pastuszak: But it has everything to do with the safety and the cost of the two procedures relative to one another.

Interviewer: All right. Break that down.

Dr. Pastuszak: So I would tell you that vasectomy is the safer and cheaper option compared to tubal ligation. So let's go ahead and, just like you said, break that down.

So what are the risks of tubal ligation? So we know that, just like a vasectomy, it can include bleeding and infection. Unlike vasectomy really, though, it can include injury to other organs because you're dealing with the tubes that are inside a woman's pelvis, which are really close to a lot of other sensitive structures.

Tubal ligation requires general anesthetic or strong regional, so the anesthesia is already more significant, and the side effects from that can be more significant than that for a vasectomy. And then just in terms of pregnancy itself. So while tubal ligation is just as effective, effectively, as vasectomy, so more than 99 percent, you can still run the risk of an ectopic pregnancy or incomplete closure of fallopian tube which results in pregnancy.

Now, if you counterpoint those against the risks of a vasectomy, then you're really just talking about bleeding, infection, some pain, and maybe failure of that vasectomy as the main risks. Very few.

Interviewer: And recovery is also much quicker for a vasectomy versus tubal ligation.

Dr. Pastuszak: Right. Because tubal ligation, again, you need to make an actual hole in the abdomen, which by surgical standards in this case, it's a minor surgery, but it's still much more major than a vasectomy.

Interviewer: Gotcha. What about the cost? I think this'll be a short conversation because vasectomy is cheaper.

Dr. Pastuszak: Well, it's cheaper, and the reason it's cheaper is just because you can do it in the office under local anesthesia.

Interviewer: Gotcha, gotcha. Is there a reason why a couple might actually want to get a tubal ligation versus a vasectomy in spite of the reasons that you just gave? Is there anything that you're aware of?

Dr. Pastuszak: So unless there's an actual reason that a man cannot physically get a vasectomy, and I can't think of one off the top of my head, they may exist, or the woman is already undergoing another surgical procedure, like a Caesarian section, and at the time of that procedure wants to go ahead and have that tubal ligation, I don't see any reason why a tubal ligation would be or should be preferred over a vasectomy.

Interviewer: The difference is, though, a tubal ligation, a pregnancy could still occur that could be . . .

Dr. Pastuszak: That could be damaging to the woman.

Interviewer: Yes, exactly.

Dr. Pastuszak: In the setting of, say, an ectopic pregnancy.

Interviewer: Which means?

Dr. Pastuszak: Which means that the pregnancy actually starts in the fallopian tube, and since that fallopian tube is now closed, that fertilized egg can't get to the uterus, and so it starts growing in the fallopian tube, which becomes an urgent or emergent surgical situation for the woman.

Interviewer: And, as of right now, there are more tubal ligations than vasectomies in the United States, isn't there?

Dr. Pastuszak: That's right.

Interviewer: Yeah. Even though the other one is the clear winner, it sounds like, to me.

Dr. Pastuszak: Yes.

Interviewer: So, in this conversation, is there anything else that you would recommend for a couple to consider while having it, other than just kind of the facts that you laid out?

Dr. Pastuszak: So I think the couple really does need to have the facts because, you know, guys are (a) afraid. I shouldn't say afraid, but guys do not tend to seek medical care, right. In the US, women are often the driver of their own and their partner's and family's medical care. So that is one barrier to more men having vasectomies. In fact, maybe not most, but a lot of the men I see in my office come because their partner, their female partner asked them to come, not because they have taken the responsibility.

You know, and I would kind of put this back in the men's court just to sort of say, well, how sexy do you think your woman thinks you are, you know, if you're sitting there and pushing back against this vasectomy? What do you think she would think if you said, "Honey, I'm going to go ahead and get this vasectomy, and I'm going to do this for us and for our family"?

Interviewer: Yes, because it's a safer and a more economically cheaper option. That's pretty sexy.

Dr. Pastuszak: I think so.

Interviewer: So I think, finally, if in spite of all this information, a guy still has it in about getting that vasectomy, what would you say at that point? Because, to me, the course of action seems obvious, but men can still be hesitant. What would you say at that point?

Dr. Pastuszak: So I really do think information is power, and I know that men are hesitant. You know, at the very least, go get the facts. Go see somebody who knows what they're talking about this. Go see your local urologist. Just talk to him about it. He's not going to commit you to having a vasectomy in the office that day. It's your decision, but at least know objectively what you're walking into. And I will tell you, most of you will go with the vasectomy after you talk to him.

Announcer: Health information from experts supported by research. From University of Utah Health, this is thescoperadio.com.

Interviewer: A vasectomy is one of the most effective forms of birth control available. But there can naturally be some apprehension about a procedure that's been nicknamed "getting snipped." Joining us is urologist and male fertility specialist, Dr. Alex Pastuszak from University of Utah Health. And in order to help make this a little less scarier procedure, Doctor, I'd like you to give us an overview from preparation to procedure what to expect during and what recovery looks like. But first of all, let's talk about the procedure itself first. So where does it happen? Where does it all start?

Dr. Pastuszak: Yeah, great question, Scott. So a vasectomy is one of the easiest procedures that anybody can undergo. We either do it in the clinic or in an operating room as a day surgery. So it's very simple.

Interviewer: All right, a very simple operation, which is fantastic. What exactly happens? Now, again, there's that getting snipped thing, which brings up visuals that I don't want to talk about. But it's nothing like that actually. It's very non-invasive.

Dr. Pastuszak: No, exactly. I mean, we make one or two very small holes in your scrotal skin, and we just pluck your vas up. We'll clip it. We'll cut it, make sure the two ends don't come back together, and then we'll put it right back. All of that takes anywhere from 15 to 40 minutes.

Interviewer: So actually, probably preparing for and recovering from it takes a lot longer than the surgery. I mean . . .

Dr. Pastuszak: That's right.

Interviewer: You'll probably spend more time in the waiting room than you will actually getting the procedure done.

Dr. Pastuszak: Absolutely. I actually tell guys to budget about an hour, an hour and a half. And as I just told you, a minority of that is actually spent doing the procedure.

Interviewer: A lot of guys think it's kind of painful. So it does use local anesthetic, which is another advantage, right? You're not completely going under. It's just in the area, like if you went to the dentist, for example, and had a tooth extracted.

Dr. Pastuszak: That's right, and that's part of what makes it really safe. And a lot of guys come in very anxious about it. But we give them some medication to relax ahead of time. And like you already said, they get some local anesthetic. At the end of it, most of them ask me, "Why was I so anxious? I shouldn't have."

Interviewer: Yeah, I got you. And so I guess I'm a little anxious about the fact I'd be awake during this procedure, right? So should I be concerned about that, or how do you kind of alleviate, you know, that stress?

Dr. Pastuszak: Not at all. Well, usually, guys are actually pretty relaxed by that point.

Interviewer: From the medication. Okay.

Dr. Pastuszak: From the medication. But if they're not, please bring your iPad, bring your iPod, bring your iPhone or your Android, listen to some music. And, you know, you should expect to have very professional, courteous staff. They'll help laugh you up during the procedure, too, if you're anxious. We're good at that.

Interviewer: Okay. So the actual procedure, pretty painless. How do you prepare for the operation? So, you know, it only takes 15 minutes there. But what do I need to do before I come in?

Dr. Pastuszak: Well, so you should bring some tight-fitting underwear or a jockstrap because you're going to leave with your scrotum supported and you're going to want to have that for the following week just to sort of prevent your boys from jumping up and down and causing any undue discomfort. You should come in with a clean genital area. We don't necessarily require that you shave. But if you'd like to, you can do that the day of, and we'll do any sort of trimming that we need to in the clinic. And you definitely need to bring someone to drive you home because, like I said, these relaxing medications will basically be like drinking two or three martinis.

Interviewer: Okay. So I got you. What about any sort of medications or anything like that? Do I need to worry about that before surgery?

Dr. Pastuszak: Yeah. We don't want you to be on any anticoagulants. So if you take aspirin regularly, I would stay off of it for about a week. If you take any other prescription medications that would thin your blood, you should also make sure that the doctor who prescribed that is okay that you're off that. But I would be off that for a week. And also fish oil. A lot of guys don't realize that fish oil is an anticoagulant. So I would not take that for at least a few days to a week before the procedure.

Interviewer: What about after the procedure?

Dr. Pastuszak: So these are going to be the best couple of days of your life because . . .

Interviewer: That's what I hear. Pick something to binge-watch.

Dr. Pastuszak: Exactly. No, we don't want you being a complete couch potato, but you kind of have, hopefully, free reign in the house depending your partner. We do want you to rest. No real strenuous activity for three to five days. It's a great idea to buy a bag of frozen peas. In fact, some of my colleagues have branded ones that you put on your scrotum and keep them there not enough to freeze your boys, but just enough to kind of keep the discomfort at bay.

It really only takes a few days to heal from this. The discomfort is transitory. It'll be there for a few days to a week, but it's very minor, and you'll be back up and running before you know it. Point of note, you do want to get up and walk around while you're resting. You don't want to be a complete couch potato because you don't want blood clots in your legs. But sack out for a little bit.

Interviewer: All right. And how long until I'm back to work? So I get the procedure. I go home on, like, say, a Monday. When can I expect to go back to work?

Dr. Pastuszak: Yeah, that's a great question. So, basically, we don't want you lifting anything heavy for three to five days. So depending on what you do, just be aware of that, you know. If you're a guy at a factory who lifts 50-pound boxes every day, desk duty for a few days.

Interviewer: Got you.

Dr. Pastuszak: If you're, you know, a corporate executive, lawyer, doctor who just kind of pushes pencils or stands and does surgery, a day or two should be fine.

Interviewer: All right. And when will the patient know that the procedure was actually effective because it's not immediate?

Dr. Pastuszak: Right. So it takes your body three months to make sperm. So we only know that that tube is occluded with no sperm coming out three or more months after your vasectomy. Also, keep in mind that you need to ejaculate 10 to 20 times to clear the pipes between when you have your vasectomy and when you go in three or more months later to get your semen analysis.

Interviewer: All right, and the great thing about that is this is one of the . . . it might be the only birth control procedure you can test for effectiveness, that's not somebody getting pregnant.

Dr. Pastuszak: That's right. That's right. And, you know, just talking about birth control, you should use a second form of birth control while you're waiting for that three-month period to be over.

Interviewer: Got you. Are there any risks I should be aware of?

Dr. Pastuszak: Yeah. So any procedure comes with risks, but the risks for vasectomy are very minor. And the three main risks include infection, bleeding, and pain in the testicles that is present after the vasectomy itself, or develops weeks to months after the vasectomy itself. All of those risks are less than 1% to 2% of all patients who have a vasectomy.

Interviewer: Wow. So that is about as safe as it gets when you're talking about a surgical procedure, it sounds like.

Dr. Pastuszak: Absolutely. If you want to have a great sex life without worrying about getting your partner pregnant, vasectomy is the way to go.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.

Interviewer: Six reasons women love men that get a vasectomy. Dr. Alex Pastuszak is a urologist and reproductive expert at University of Utah Health, and he's counseled thousands of patients through this decision. And today we're going to find out the top six reasons that women love men that get a vasectomy. Let's just start with number one.

Dr. Pastuszak: Reason number one, they don't have to think about birth control anymore. I mean, it's one thing less on your to-do list. Instead of having to go get your birth control every month, either from the pharmacy or from your doctor, you've got your guy who's already taken care of it. Once a vasectomy is done and the lab results come back and there's no more sperm, you're good to go.

Interviewer: All right. Yeah, that's awesome, because so often the woman is responsible for birth control, and, you know, even with other long-term options, in three years you've got to go back or whatever. So it's one and done as they say.

Dr. Pastuszak: One and done.

Interviewer: Okay. Six reasons women love men that get a vasectomy, number two.

Dr. Pastuszak: All right. So a vasectomy is really reliable. I mean, just think about the financial and emotional burden that an unplanned pregnancy can have on someone's life. A vasectomy is more than 99 percent effective. It's really only secondary to abstinence, which most couples, once they're in a partner relationship, don't really want to have. You can test to see that it's been effective, and it's going to prevent you from having a pregnancy down the road.

Interviewer: So that reliability, yeah, I mean a financial hardship or a really tough decision could come if you've decided, you know, we're done having children, and then you have to deal with that. So a vasectomy, very reliable. I like that. What about number three on the top six reasons women love men that get vasectomies?

Dr. Pastuszak: Another great reason is that there are no side effects for the woman, and quite honestly there are almost no side effects for the men either. Remember, the risks of side effects are really about in the 1–2 percent range. So other forms of birth control can have significant side effects for women.

Just think about all the hormonal manipulation that all of these birth control options, except tubal ligation, have. And this can leave women feeling awful, gaining weight, and just in general not wanting to continue with that birth control. Why not just one and done it and get that vasectomy?

Interviewer: All right. Six reasons women love men that get a vasectomy, number four.

Dr. Pastuszak: All right. So this kind of following on what I just said about tubal ligation, you don't need a tubal ligation as the female partner if your male partner has gotten a vasectomy. Why is that important? Because vasectomy is just as effective, safer, and cheaper. So why would a woman need to put herself through a more invasive, riskier, and more expensive procedure when a guy can just go ahead and get his done?

Interviewer: All right. And number five on the top six reasons women love men that get a vasectomy?

Dr. Pastuszak: It's a one-time cost. That's it. And it's usually extraordinarily well covered by insurance. Insurance companies don't want people to have babies. They want them to not have babies. So they'll cover this the vast majority of the time. So pay for it once, and that's it, no more ongoing expenses.

Interviewer: All right. And number six and the final reason that women love men that get vasectomies?

Dr. Pastuszak: It makes a man sexier, Scott.

Interviewer: How's that?

Dr. Pastuszak: What is sexier than a man taking responsibility for the family's birth control? I mean, think about it. Women do so much. A woman, in today's day and age, is still very often both a career person as well somebody who takes care of the kids, raises the kids, and runs the household. A guy can step up and do his part. In no way, any evidence that a vasectomy is going to affect a man's masculinity.

You know, there's

• no impact on testosterone,
• no impact on sexual function,
• no impact on an ejaculatory function,
• no impact on cancer risk,
• etc., etc.

There is absolutely zero reason why a man shouldn't get a vasectomy and be rewarded by being that guy who steps up.

Interviewer: How should a woman bring this topic up in a way that a man might be more open to it if he initially is not? Like if there's a woman listening, that's like, "I don't know if my husband is going to buy into this," and she's already laid out it's going to make you sexier, is there anything else that you would recommend?

Dr. Pastuszak: So I would find that a very compelling reason, but . . .

Interviewer: Yeah, I would think so. I think we should be done really, but, you know, maybe there's that one stubborn guy out there, because, you know, we do exist.

Dr. Pastuszak: You know, it may be a process. You know, but ultimately knowledge is power. I think the facts speak for themselves, and, you know, quite honestly, like getting a man in front of somebody who can actually tell him what the experience is going to be like, either somebody who's had a vasectomy or a urologist who does these day in and day out, is a start.

Interviewer: Got you. What's the next step after you get that buy-in from your man?

Dr. Pastuszak: Go see your urologist. Go see somebody who can give you the facts.

Are you happy with your family size? Have you had all the kids that you planned or a few more? Are you considering having your tubes tied? Let's talk about that.

Prior to the development of effective hormonal contraception, women choosing to end their childbearing through sterilization procedures had major operations to remove their fallopian tubes or had hysterectomies. Although the history of female sterilization is clouded with cases where women may not have given informed consent, since 1960, about the same time that birth control pills came on the market, techniques for female sterilization became less invasive and easier to do with less risk. The term used for these easier techniques is tubal ligation.

Now, there are many techniques and the timing for this procedure, and about 30% of American women have had a tubal ligation. Techniques include taking a suture and tying it around a loop of tube and then cutting the tied-off loop of the tube out. And then there are a number of techniques like this to remove the middle segment of the fallopian tube so sperm cannot get to eggs and fertilize them. Other techniques include putting a clip to close the tube permanently, or cauterize or burning the tube in the middle to close it.

The timing could be shortly after a baby is born, within a day or so, while the woman is still in the hospital, or at the time of Caesarian section when the tube is right there, or anytime between children, when the procedure can be done by laparoscopy. But half of tubal sterilizations occur right after the baby is delivered vaginally or by Caesarian, and that comes to about 350,000 tubal sterilizations a year.

The word "ligation" in the term "tubal ligation" means to tie. This unfortunate term translates into tying your tubes. This has led some women to assume if you had your tubes tied, it would be simple to untie your tubes, like untying your shoelaces. Tubal ligation can be reversed surgically for women who regret having had a tubal sterilization, but it's expensive and it doesn't always work.

For years, it has been noted that tubal sterilization decreased the risk of some types of ovarian cancer by 30% to 50%. Now, that's significant. Now, we're getting to the main topic of this little podcast. The lifetime risk of ovarian cancer in the U.S. is about 1.3 out of 100 women. Ovarian cancer is particularly deadly because it spreads early, and we don't have any early detection methods the way we do with breast cancer, like a mammogram, or cervical cancer with a Pap smear. Ovarian cancer comes in different types, but one of the most common types, serous ovarian cancer, may often actually arise in the end of the fallopian tube near the ovary. For this reason, women who have genetically-linked risks of ovarian cancer, such as the BRCA1 and 2 mutations with familial breast and ovarian cancer, are recommended to have their ovaries and their fallopian tubes removed when they finished having their families.

Recent studies have suggested that women who are planning a tubal sterilization who have their tubes completely removed have about a 60% reduction in the risk of these serous ovarian cancers compared to women who didn't have a tubal sterilization or women who just had part of their tubes removed at tubal ligation.

Now, there are other advantages to having the entire tube removed if a woman is planning a tubal sterilization. Tubal ligations have a known failure rate, a pregnancy after the procedure of as much as 3 to 5 pregnancies per 100 women over 10 years who had their tubal sterilization at the time other than when the baby was delivered, with laparoscopy. Women who had their tubes completely removed have a much lower failure rate, almost zero. Women who have a tubal ligation also have an increased risk of ectopic pregnancy or tubal pregnancy if they do become pregnant compared to women who've had their tubes removed completely.

Now, we know that putting a little clip on the tube, burning the tube, or cutting a loop of tube is quite simple and takes a very short time. Anybody could do it. Removing the whole tube takes a little longer. Studies recently published looked at women who were randomized to removing the whole tube at the time of tubal sterilization or cutting a loop out at the time of Caesarian section an easy time to do it as the tube is right there to look at and operate on.

One study used an advanced technique to take out the tube completely and found that time was only about five minutes longer compared to the standard procedure of taking out just a part of the tube. Another study using older techniques suggested took about 10 to 15 minutes longer. There was not significantly more blood loss with taking the whole tube out compared to just part of the tube.

The other issue is that if the entire tube is removed, you cannot come back and have your tubes untied or put back together again the way you might if only a part of the tube is removed. Of course, these days, many women who choose to have more children after tubal sterilization will use in vitro fertilization and it doesn't matter if you have part of a tube or no tube. Although IVF is expensive, so is surgically putting the tube back together again. And in some cases, IVF may be more successful.

So if you're planning a tubal sterilization, your tubes, not your husband's tubes, that would be a vasectomy, consider the following. If you have a BRCA1 or 2 mutation or have a strong family history of ovarian cancer, you should have your entire tubes removed when you have your tubal sterilization, whether it's right after the baby is delivered or sometime later. And often, women also had their ovaries removed.

If you have concerns about ovarian cancer, and you're planning a tubal sterilization, talk with your OB-GYN about taking the whole tube out. If you don't have a family history of ovarian cancer and the concern of the risk of ovarian cancer isn't high on your worry list, think about the benefits and risks that were just mentioned and discuss your options with your OB-GYN. Many OB-GYNs are discussing tubal removal as an alternative to tubal ligation when women are planning a tubal sterilization. Whatever you choose, we're glad you are informed about new options and old options in planning your family, and thanks for joining us on The Scope.

updated: September 10, 2020
originally published: August 9, 2018

You've been so good about your family planning. You've always used birth control, but when can you stop? This is Dr. Kirtly Jones from Obstetrics and Gynecology here at University of Utah Health Care and this is The Scope.

So you've spent all your life planning your children. You had your babies when you wanted them. You didn't have any extra babies. You've really been good at it, but when can you stop? The answer is when you or your partner are using some form of really good birth control so you can stop. If your partner has a vasectomy, well, that's great.

Now, a really good form of birth control was menopause. So let's talk a little bit about your contraceptive method and menopause. First, fertility, we know, declines starting at about 30. We know that women who are trying to get pregnant sometimes struggle in their late 30s and certainly do in their 40s. The difficulty is that a pregnancy in your 40s that's unplanned is a definite problem because women in their 40s who get pregnant, even though they're not very fertile, do have higher risks of complications in pregnancy, like high blood pressure and diabetes.

They're actually more likely, believe it or not, to have twins. And they have more complications in terms of blood loss and a whole lot of other problems just with the pregnancy. And of course, we all worry about the difficulties in chromosomal abnormalities in our babies that increases in women after their 30s. So women are more likely to have complications in pregnancy. They are more likely to have a baby with a chromosomal anomaly like Down syndrome and importantly, they are more likely to miscarry. And by the end of your 40s, you are really likely to miscarry.

However, you don't want to get pregnant even though your chances are low. So when, even if you're being very careful, when is it time to stop? Okay. So let's now talk about menopause. Menopause is defined as when you haven't had a period for a year. Then that last period a year ago is your menopause. Now, you have to be of the right age.

So the average 20-year-old who hasn't had a period for a year is probably not in menopause. She hasn't run out of eggs. She may have another reason for not having her periods. But women in their late 40s and early 50s who haven't had a period for a year are very, very likely to be in menopause. So if you haven't had a period for a year, then you're likely in menopause and you can stop using your contraceptive method.

However, it's difficult to know if you're in menopause based on your periods if you're using a contraceptive method that changes your periods. So let's take, for example, birth control pills. Birth control pills block ovulation but give you hormones that make you have a period every month. So you can be in menopause, have no more eggs, be completely infertile, but because you're taking the pill, you'll have a period every month.

So how do you know, if you're on birth control pills, that you're in menopause? Well, the difficult answer is you have to stop your pills and see what happens. If you stop your pills, and you're about 52, and you don't have a period for six months, then you're in menopause. But what happens if you are 52, and you're still fertile, and you stop your pills, and you get pregnant? Well, the option is, of course, to stop your pills, see what happens, and use a different method, a barrier method, use condoms, use foam. Remember, you're not very likely to get pregnant because you're not very fertile and you're not very likely to stay pregnant because you're likely to miscarry. So that's one option.

The other option is to say, "Well, why don't I just stay on my pills because going through the perimenopause," those years when your periods are totally unpredictable and not very pleasant, "why don't I stay on these nice little periods that I like on the pill until I'm about 54?" We know that at 54, about 90% of women have gotten through menopause. At 50, the average age of menopause, only 50% of women are menopausal. But by 54, about 85 to 95% of women are menopausal. So you just stay on your pills and stop at 50 and you're very likely to be done.

Let's talk about an IUD that has hormones in it. For women who have an IUD with hormones in it, many of those women have very light periods or no periods at all so you may not know that you're in menopause. You may have some hot flushes because your estrogens have gone away. You may use a blood test, which doesn't work very well for women on the pill, but it can work for people with a hormone-containing IUD. You could do a blood test called FSH and if that is really high, then it's likely, not guaranteed, but likely, that you've run out of eggs and you're in menopause.

Or you can just stay on that IUD that has some hormones in it until you're about 54. And many women in their early 50s who have hot flushes may want to take a little estrogen and they have the progestin protection. They protect their uterus lining against abnormalities with that little hormonal IUD. So wait until you're a little older and then take your hormonal IUD out.

If you're taking a shot like Depo-Provera, about 80% of women on Depo-Provera don't have periods so you won't know when you're in menopause. Well, the same kind of strategy goes with Depo-Provera as it does with the hormone-containing IUD. You can just wait till you're a little older or you can stop, use a backup method. You can stop your shots, use a backup method, and wait and see if you start your periods again.

So this is kind of a complicated question. The good news is that for women who stop their method, whatever it might be, at 50, then, in fact, the chances of getting pregnant are very low. How low is low for you, though? If the chances of getting pregnant and having a baby is 50 to 1 in 100, is that a number that you're willing to take a risk for? Not me. For me, that's no, I wouldn't take a 1 in 100 risk of a baby, that with all the complications of a pregnancy at 50 is. So I was much more willing to push my contraception out to 54 and then say, "Now I'm ready to be done."

So it's a personal choice. It's one that you discuss with your partner, with your family, if that's what you want to do, in terms of what their thinking about future childbearing, what kinds of risks are they willing to take if you do get pregnant? But definitely talk with your clinician because there are some options that are really good ones to make this transition with low fertility, but still some fertility, and some good therapy for menopausal symptoms.

So many women actually use a low-dose birth control pill to help them with their menopause symptoms. So that's the difficult answer for a difficult question, but I want to say good for you for having been such a good contraceptor all these years. And thanks for joining us on The Scope.

updated: January 28, 2021
originally published: September 29, 2016