Fatherhood, Fertility

The Olympics of Microsurgery

You know it when it’s happening. The moment you have to rise to the occasion. It’s shut up and put out time. You summon all of your faculties, as only your best will do. A performance, race, speech, interview, exam or surgery. We all have these moments. I treasure mine.

The Case of All Cases

The couple shows up from a distant land. Unable to conceive, he is found to be sterile due to a blockage in the tubing of his reproductive tract. He remembers having a painful infection “down there” in his 20’s that was treated but still managed to scar the tiny tubes inside the epididymis near the testicle. Kind of like a vasectomy that you didn’t want.

He’d been all over and had seen other docs. They all told him to “just grab some sperm” and go to IVF-ICSI. “It works great,” they said. But he, like me, likes to fix things that are broken. “There must be a way to repair this so that I can have kids at home instead of in a lab,” he said to me.

“I agree.” I told him. As Woody Allen said: “Sex is the most fun I’ve ever had without laughing.” And it’s still a great way to have kids. But alas, this is a very challenging microsurgical case, testing the technical limits of even the best of us. In our field, it’s not for the faint of heart or the casual microsurgeon. I consider a routine vasectomy reversalmore like “practice” compared to tackling one of these babies.

As Small as Small Can Be

For his epididymal obstruction, he chose microsurgical reconstruction. It takes about 3-4 hours to explore the area under an operating room microscope, squirt the tubes to see what’s blocked, and bypass the blockage by connecting an teensy-weensy epididymal tubule (about 2/10ths of a millimeter in size) to the rest of the system, thus bypassing the blockage. The sutures used for this are about 1/10th the diameter of a human hair and they must be “thrown” so delicately that I often hold my breath to do it. And then you find yourself suturing a tube so thin you can see through it and so small it’s about twice the size of the period at the end of this sentence. Trust me, we’re way beyond steady hands here. The difference between perfect and terrible technique is one of the finest lines I’ve known in life. But what a glorious thing when all 250 knots, enough to make a suit, are neatly tied in place and the whole thing literally self-assembles, looking like it was made that way. Talk about flow!

I saw him back in the office 6 weeks later and his sperm count had returned, wigglers and all. His face lit up.

“Am I really gonna be a Dad now Doc?” he asked.
“I think so,” I said. “And the old fashioned way.”

 

This article first appeared on Dr. Turek’s blog.

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Author: Dr. Paul Turek, Medical Contributor

Dr. Paul Turek is an internationally known thought leader in men’s reproductive and sexual health care and research. A fellowship trained, board-certified physician by the American Board of Urology (ABU), he has received numerous honors and awards for his work and is an active member in professional associations worldwide. His recent lectures, publications and book titles can be found in his curriculum vitae.

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