Rising Vasectomy Volume Following Reversal of Federal Protections for Abortion Rights in the United States - Raevti Bole
June 8, 2023
Ruchika Talwar interviews Raevti Bole on the impact of the recent Dobbs ruling on vasectomy patterns. Dr. Bole's research reveals an immediate, statistically significant increase in vasectomy consults and procedures in the wake of the Supreme Court's overturning of Roe v Wade. Most notable is the shift in demographics, with younger men and those without children now seeking vasectomies. Dr. Bole stresses the importance of patient autonomy and informed consent in making these decisions, acknowledging a possible shift in counseling approaches. Talwar and Bole reflect on the potential implications of these trends, including the potential increase in vasectomy reversal rates and changes in healthcare provider roles. Bole emphasizes the need for appropriate training for all practitioners and anticipates continued far-reaching impacts of legal decisions on healthcare.
Biographies:
Raevti Bole, MD, Urologist, Men’s Health and Andrology Fellow, Cleveland Clinic, Cleveland, OH
Ruchika Talwar, MD, Urologic Oncology Fellow, Department of Urology, Vanderbilt University Medical Center, Nashville, TN
Biographies:
Raevti Bole, MD, Urologist, Men’s Health and Andrology Fellow, Cleveland Clinic, Cleveland, OH
Ruchika Talwar, MD, Urologic Oncology Fellow, Department of Urology, Vanderbilt University Medical Center, Nashville, TN
Read the Full Video Transcript
Ruchika Talwar: Hi everyone. Welcome to UroToday's Health Policy Center of Excellence. I've taken the past few videos to spotlight some important health policy related articles that have been published in the field of urology. Today, I'm really excited to be joined by my friend Dr. Raevti Bole, who is the Men's Health and Andrology Fellow at Cleveland Clinic. Thanks, Dr. Bole for joining us.
Raevti Bole: Thanks, Ruchi. Really excited to join you here today.
Ruchika Talwar: So congratulations on your new article. Your study explored the differences in vasectomy patterns after the recent Dobbs ruling. Is that right?
Raevti Bole: That's right.
Ruchika Talwar: Great. Why don't you jump right in and give us a rundown of what your aims were, what you were hoping to accomplish, and a bit of background on what led you down this analysis.
Raevti Bole: Sure. So as you just alluded to, in June of 2022, the US Supreme Court overturned Roe v Wade, which had previously established a federally protected right to abortion during the first two trimesters of pregnancy. And because of that, each state then of course had the power to make its own abortion law. And this had, of course, a direct and very immediate impact on women of reproductive age. But as urologists and reproductive health specialists, we also began to wonder, has this legal decision affected men in any capacity? And at the same time, there were a lot of news articles with stories of men calling urology clinics in droves asking for vasectomies right after the news came out. And that's important because historically women have been the ones to bear the brunt of the decision to undergo permanent contraception. Tubal allegations are more common than vasectomies worldwide and in the US as well.
And because we do a very high volume of vasectomies at the clinic, at the Cleveland Clinic every year, my senior author, who's also my PD, Dr. Sarah Vij, she said, "We got to study our numbers. We have to find out what's going on in our state." And so we were able to do a study across our Cleveland Clinic hospital system, which as you know, is a big academic center, but it's important to note that we also include 13 community hospitals. So we were able to include a pretty large subset of patients in the state of Ohio. And then, as you said, we were actually the first to publish confirmation that yes, more men are actually having vasectomies after this legal decision came out. So that was huge.
Ruchika Talwar: Yeah, absolutely. So tell me more about the type of men who are having vasectomies. Obviously, your overall number went up, but was there any difference in characteristics?
Raevti Bole: Yeah, there were. So first, just in terms of the number, we were blown away by how rapidly that number went up. So first, just in terms of consult requests, when a patient just calls the call center and says, I'd like to talk about this issue, we saw a 35% increase in just patients calling about having vasectomies.
Ruchika Talwar: Wow.
Raevti Bole: Then in terms of patients who actually had visits, we saw 22% increase in patients who actually were coming to visits, because of course, you're going to have a little bit of attrition in patients who actually show up in that specified timeframe where we were looking. And then in terms of procedure number, we actually saw that the number of vasectomies we were performing per month after this decision doubled.
Ruchika Talwar: Wow.
Raevti Bole: So huge increase in numbers that you just couldn't explain by chance alone. All of this was statistically significant. So that was huge.
And then in terms of the type of men, one thing that really took us all back is that the men were a lot younger. So we saw the average age that men were having vasectomy went down about three years from 38 to about 35. And then when we looked at how many men under 30 are actually getting this procedure, we saw that that percentage doubled. So it went from about 10% before this decision to about 24%. So big increase in younger men getting the procedure. And that's important just because if you think about the average male, when does he get a vasectomy? It's usually about mid to late thirties. So a lot more men getting that vasectomy about half a decade earlier. And then more men who didn't even have any children were getting vasectomy. And that percentage also doubled from something like 9% to 18%.
Ruchika Talwar: Interesting. Now, especially in that cohort of men who do not have any children, do you all alter your counseling in that situation, especially in the face of everything that's been going on with the Dobbs decision?
Raevti Bole: Yeah, that's a good question. I think traditionally, urologists or physicians in general have maybe felt like they had to do some extra counseling for those men because of saying, well, perhaps they don't know what they're getting themselves into, or maybe they'll change their minds down the road. And I think perhaps that way of thinking has shifted a little bit to where you still absolutely want to counsel patients to say, listen, this is a permanent form of contraception. You cannot reverse it other than by a surgical procedure. And that's not a hundred percent, although it is very, very successful the closer you do it to when you have the procedure.
But in a well counseled patient who is making this choice of their free will, who has a good understanding of why they're doing it, there's a good understanding of the risk and benefits, I don't think that there's a particular number of kids that they need to have or not have before they're allowed to have a procedure. And I think that's the important part about patient autonomy, is that if they understand what they want and they know their own mind and they have the education, which is really our job as doctors and urologists to give them that information, then I think there's more of a shift towards saying, let's help you make that decision for yourself and your family.
Ruchika Talwar: Yeah. Yeah. I think you bring up a bunch of really good points there. Now, I think you all laid out the limitations of your analysis really well in your paper. You mentioned obviously this is a single institution cohort, as well as the fact that despite you having a good comparison arm, you did basically compare the 2021 and 2022 cohorts. Another thing to keep in mind is that this legal issue varies significantly state to state. Can you give us a little bit of background on Ohio's current climate in accessing reproductive healthcare?
Raevti Bole: Yes. So in Ohio, there was a heartbeat bill that was activated pretty soon after Roe v Wade was overturned. But at the time that we were doing the analysis, and I believe even currently, there was an Ohio State judge who blocked the law for taking effect based on a challenge from the Ohio ACLU. And so that is still something that's pending.
Ruchika Talwar: I think that'll be really interesting once we have more data over time to look at how this may vary state by state or region by region, depending on the political landscape of it. And I know this wasn't necessarily mentioned in the study, but it's something that's been on all of our radar. For those of us who follow urology related health policy, at least. We are hearing of instances where there are other providers, not necessarily urologists, and in some cases actually not necessarily physicians either, who are looking to take up vasectomies. And there's been legislation introduced in certain states, for example, that would allow naturopaths to perform vasectomies or more protections for family practitioners who perform vasectomies. Obviously, there is a shortage of urologists in rural areas, so this may help alleviate some of that. But just, again, I know this wasn't addressed necessarily in the paper, but I would just be curious to get your thoughts on if you can foresee that this issue affecting urology as time goes on in other ways.
Raevti Bole: So I think in terms of vasectomy availability, I think for a urologist who comes out of residency and then further on in practice is very well versed in doing these sorts of procedures, there are ways that we can increase availability and access for certainly people who are trained to perform vasectomies to do more as patients need it. And in certain populations, we ourselves, we have Saturday clinics where we'll open up extra days, especially around the times when men are more likely to want to have things done near the end of the year. And certainly after we were seeing this legal decision come out. So I think it's important to recognize the population that you're in, and as a urologist, open up access as well within your own community for men to be able to get that done.
And then in terms of other practitioners, and I think it's important to make sure that people are trained, that they have the numbers and the experience to be able to do these procedures safely. As surgeons, these are very safe procedures for us to do because we have that experience and that repetition. And so I think it's important for anyone considering their ability to be able to do these just to make sure that they can do them well. And I think that's the most important thing to be able to offer safety and efficacy to our patients and not only just be thinking about, well, what can we offer access? So I think it's important to offer everything all together.
And in terms of further things that are going to affect urologists, I think that's a really interesting point that you bring up.
Traditionally, the rate of a vasectomy reversal has been hovering around 6%. I wonder if that number will change. And I don't know. I hope that the people who are now getting vasectomies in bigger numbers represent men who perhaps were thinking of getting vasectomies anyway, and had this impetus now to go ahead and get that procedure. I hope it's not people who felt compelled to do something that they didn't want to do, but that remains to be seen. And so I think that's what's interesting about this decision is that legal decisions on healthcare have such a broad impact. And a lot of these are so far reaching at the population level. We just don't know what we're going to be seeing in the next years and decades to come.
Ruchika Talwar: Yeah, absolutely. I couldn't agree more. I think you hit the nail on the head there. Despite urology not necessarily being directly responsible for reproductive healthcare for women, as reproductive specialists, urologists definitely are affected by these sorts of decisions. And I think it'll be really interesting to not only look at national trends in the type of analysis that you and your group performed, but also take a downstream look at vasectomy reversal rates like you talked about. It'll be interesting to see not only if rates go up, but even if the interval between initial vasectomy and reversal changes in the era of all of this. So all questions that we'll have to stay tuned for.
Raevti Bole: Absolutely.
Ruchika Talwar: I'll be eagerly awaiting your follow up studies, Raevti.
Raevti Bole: That's a great point.
Ruchika Talwar: Thanks so much for joining us today. I think this is a really important conversation, and it's again, just the beginning of future changes within the field of urology that we may notice from this decision. Congratulations again on your study and to our audience, thanks again for tuning in for another UroToday Health Policy Spotlight. We look forward to sharing more important health policy content with you in the future.
Raevti Bole: Thank you.
Ruchika Talwar: Hi everyone. Welcome to UroToday's Health Policy Center of Excellence. I've taken the past few videos to spotlight some important health policy related articles that have been published in the field of urology. Today, I'm really excited to be joined by my friend Dr. Raevti Bole, who is the Men's Health and Andrology Fellow at Cleveland Clinic. Thanks, Dr. Bole for joining us.
Raevti Bole: Thanks, Ruchi. Really excited to join you here today.
Ruchika Talwar: So congratulations on your new article. Your study explored the differences in vasectomy patterns after the recent Dobbs ruling. Is that right?
Raevti Bole: That's right.
Ruchika Talwar: Great. Why don't you jump right in and give us a rundown of what your aims were, what you were hoping to accomplish, and a bit of background on what led you down this analysis.
Raevti Bole: Sure. So as you just alluded to, in June of 2022, the US Supreme Court overturned Roe v Wade, which had previously established a federally protected right to abortion during the first two trimesters of pregnancy. And because of that, each state then of course had the power to make its own abortion law. And this had, of course, a direct and very immediate impact on women of reproductive age. But as urologists and reproductive health specialists, we also began to wonder, has this legal decision affected men in any capacity? And at the same time, there were a lot of news articles with stories of men calling urology clinics in droves asking for vasectomies right after the news came out. And that's important because historically women have been the ones to bear the brunt of the decision to undergo permanent contraception. Tubal allegations are more common than vasectomies worldwide and in the US as well.
And because we do a very high volume of vasectomies at the clinic, at the Cleveland Clinic every year, my senior author, who's also my PD, Dr. Sarah Vij, she said, "We got to study our numbers. We have to find out what's going on in our state." And so we were able to do a study across our Cleveland Clinic hospital system, which as you know, is a big academic center, but it's important to note that we also include 13 community hospitals. So we were able to include a pretty large subset of patients in the state of Ohio. And then, as you said, we were actually the first to publish confirmation that yes, more men are actually having vasectomies after this legal decision came out. So that was huge.
Ruchika Talwar: Yeah, absolutely. So tell me more about the type of men who are having vasectomies. Obviously, your overall number went up, but was there any difference in characteristics?
Raevti Bole: Yeah, there were. So first, just in terms of the number, we were blown away by how rapidly that number went up. So first, just in terms of consult requests, when a patient just calls the call center and says, I'd like to talk about this issue, we saw a 35% increase in just patients calling about having vasectomies.
Ruchika Talwar: Wow.
Raevti Bole: Then in terms of patients who actually had visits, we saw 22% increase in patients who actually were coming to visits, because of course, you're going to have a little bit of attrition in patients who actually show up in that specified timeframe where we were looking. And then in terms of procedure number, we actually saw that the number of vasectomies we were performing per month after this decision doubled.
Ruchika Talwar: Wow.
Raevti Bole: So huge increase in numbers that you just couldn't explain by chance alone. All of this was statistically significant. So that was huge.
And then in terms of the type of men, one thing that really took us all back is that the men were a lot younger. So we saw the average age that men were having vasectomy went down about three years from 38 to about 35. And then when we looked at how many men under 30 are actually getting this procedure, we saw that that percentage doubled. So it went from about 10% before this decision to about 24%. So big increase in younger men getting the procedure. And that's important just because if you think about the average male, when does he get a vasectomy? It's usually about mid to late thirties. So a lot more men getting that vasectomy about half a decade earlier. And then more men who didn't even have any children were getting vasectomy. And that percentage also doubled from something like 9% to 18%.
Ruchika Talwar: Interesting. Now, especially in that cohort of men who do not have any children, do you all alter your counseling in that situation, especially in the face of everything that's been going on with the Dobbs decision?
Raevti Bole: Yeah, that's a good question. I think traditionally, urologists or physicians in general have maybe felt like they had to do some extra counseling for those men because of saying, well, perhaps they don't know what they're getting themselves into, or maybe they'll change their minds down the road. And I think perhaps that way of thinking has shifted a little bit to where you still absolutely want to counsel patients to say, listen, this is a permanent form of contraception. You cannot reverse it other than by a surgical procedure. And that's not a hundred percent, although it is very, very successful the closer you do it to when you have the procedure.
But in a well counseled patient who is making this choice of their free will, who has a good understanding of why they're doing it, there's a good understanding of the risk and benefits, I don't think that there's a particular number of kids that they need to have or not have before they're allowed to have a procedure. And I think that's the important part about patient autonomy, is that if they understand what they want and they know their own mind and they have the education, which is really our job as doctors and urologists to give them that information, then I think there's more of a shift towards saying, let's help you make that decision for yourself and your family.
Ruchika Talwar: Yeah. Yeah. I think you bring up a bunch of really good points there. Now, I think you all laid out the limitations of your analysis really well in your paper. You mentioned obviously this is a single institution cohort, as well as the fact that despite you having a good comparison arm, you did basically compare the 2021 and 2022 cohorts. Another thing to keep in mind is that this legal issue varies significantly state to state. Can you give us a little bit of background on Ohio's current climate in accessing reproductive healthcare?
Raevti Bole: Yes. So in Ohio, there was a heartbeat bill that was activated pretty soon after Roe v Wade was overturned. But at the time that we were doing the analysis, and I believe even currently, there was an Ohio State judge who blocked the law for taking effect based on a challenge from the Ohio ACLU. And so that is still something that's pending.
Ruchika Talwar: I think that'll be really interesting once we have more data over time to look at how this may vary state by state or region by region, depending on the political landscape of it. And I know this wasn't necessarily mentioned in the study, but it's something that's been on all of our radar. For those of us who follow urology related health policy, at least. We are hearing of instances where there are other providers, not necessarily urologists, and in some cases actually not necessarily physicians either, who are looking to take up vasectomies. And there's been legislation introduced in certain states, for example, that would allow naturopaths to perform vasectomies or more protections for family practitioners who perform vasectomies. Obviously, there is a shortage of urologists in rural areas, so this may help alleviate some of that. But just, again, I know this wasn't addressed necessarily in the paper, but I would just be curious to get your thoughts on if you can foresee that this issue affecting urology as time goes on in other ways.
Raevti Bole: So I think in terms of vasectomy availability, I think for a urologist who comes out of residency and then further on in practice is very well versed in doing these sorts of procedures, there are ways that we can increase availability and access for certainly people who are trained to perform vasectomies to do more as patients need it. And in certain populations, we ourselves, we have Saturday clinics where we'll open up extra days, especially around the times when men are more likely to want to have things done near the end of the year. And certainly after we were seeing this legal decision come out. So I think it's important to recognize the population that you're in, and as a urologist, open up access as well within your own community for men to be able to get that done.
And then in terms of other practitioners, and I think it's important to make sure that people are trained, that they have the numbers and the experience to be able to do these procedures safely. As surgeons, these are very safe procedures for us to do because we have that experience and that repetition. And so I think it's important for anyone considering their ability to be able to do these just to make sure that they can do them well. And I think that's the most important thing to be able to offer safety and efficacy to our patients and not only just be thinking about, well, what can we offer access? So I think it's important to offer everything all together.
And in terms of further things that are going to affect urologists, I think that's a really interesting point that you bring up.
Traditionally, the rate of a vasectomy reversal has been hovering around 6%. I wonder if that number will change. And I don't know. I hope that the people who are now getting vasectomies in bigger numbers represent men who perhaps were thinking of getting vasectomies anyway, and had this impetus now to go ahead and get that procedure. I hope it's not people who felt compelled to do something that they didn't want to do, but that remains to be seen. And so I think that's what's interesting about this decision is that legal decisions on healthcare have such a broad impact. And a lot of these are so far reaching at the population level. We just don't know what we're going to be seeing in the next years and decades to come.
Ruchika Talwar: Yeah, absolutely. I couldn't agree more. I think you hit the nail on the head there. Despite urology not necessarily being directly responsible for reproductive healthcare for women, as reproductive specialists, urologists definitely are affected by these sorts of decisions. And I think it'll be really interesting to not only look at national trends in the type of analysis that you and your group performed, but also take a downstream look at vasectomy reversal rates like you talked about. It'll be interesting to see not only if rates go up, but even if the interval between initial vasectomy and reversal changes in the era of all of this. So all questions that we'll have to stay tuned for.
Raevti Bole: Absolutely.
Ruchika Talwar: I'll be eagerly awaiting your follow up studies, Raevti.
Raevti Bole: That's a great point.
Ruchika Talwar: Thanks so much for joining us today. I think this is a really important conversation, and it's again, just the beginning of future changes within the field of urology that we may notice from this decision. Congratulations again on your study and to our audience, thanks again for tuning in for another UroToday Health Policy Spotlight. We look forward to sharing more important health policy content with you in the future.
Raevti Bole: Thank you.