1. Fibrin Glue Vasectomy Reversal®

2. Who am I? Why am I here?

3. Urethroplasties/GU Reconstruction Male and Female Slings/AUS Neuromodulation Urodynamics ?

5. 1: Fibrin glue assisted 3-suture vasovasostomy.J Urol. 2005 Oct;174(4 Pt 1):1360-3; discussion 1363. 2: Evaluation of a fibrin sealant free of bovine-derived components in an experimental vas anastomosis study. Urol Int. 2000;65(4):196-9. 3: Vasal reanastomosis using fibrin glue combined with sutures: which combination of sutures in a delayed protocol? Experimental study in rats. Eur Urol. 1998;33(3):318-22. 4: Fibrin-glue assisted vasoepididymostomy: a comparison to standard end-to-side microsurgical vasoepididymostomy in the rat model. J Urol. 1997 Oct;158(4):1602-5. 5: Delayed vasovasostomy: experimental study using fibrin glue. Eur Urol. 1997;31(2):182-6. 6: Delayed vasal reanastomosis in rats: comparison of a microsurgical technique and a fibrin-glued procedure.Br J Urol. 1996 Aug;78(2):271-4. 7:A randomised trial of fibrin sealant in peripheral vascular surgery. Vox Sang. 1996;70(4):210-2. 8:Fibrin glue and conventional sutured vasal anastomosis in the rat. J Surg Res. 1995 Nov;59(5):601-5. 9:Microscopic vasovasostomy: current practice and future trends. Microsurgery. 1995;16(5):325-32. Review. No abstract 10:Fibrin-glue vasovasostomy as an alternative to the conventional two-layer suture techniqu? Investig Urol (Berl). 1994;5:253-11: Comparison of vasovasostomy techniques in rats utilizing conventional microsurgical suture, carbon dioxide laser, and fibrin tissue adhesives. Urology. 1993 May;41(5):479-83. 12:Vasovasostomy in rabbits using fibrin adhesive prepared from a single human source.J Urol. 1993 Jan;149(1):183-5. 13: Fibrin glue vasal anastomosis compared to conventional sutured vasovasostomy in the rat. J Urol. 1991 Jun;145(6):1288-91. 14: Comparison of microsurgical vasovasostomy techniques in the rat. Eur Urol. 1990;17(3):241-2.

6. Division of Urology Contact Information Erin T. Bird, M.D. Associate Professor of Urology Scott & White Hospital, Texas A&M Health Science Center College of Medicine Temple, TX 76508 Phone: 254-724-1773 E-mail: abanderson@swmail.sw.orgabanderson@swmail.sw.org Fibrin Glue Vasectomy Reversal® Patient Guide How much will the vasectomy reversal cost? Is there a money back guarantee? Why is the vasectomy reversal price at Scott & White so inexpensive? How is the Scott & White procedure different? What is fibrin glue? Is it safe? How long is the procedure? What is a VE (vasoepididymostomy)? How is success measured? What type of follow-up is expected? What can be expected following surgery? Appointments Scheduling Surgery Date Payment

7. 9-year period 1,469, 5 institutions sperm were present in the semen in 865 of 1,012 men (86%) pregnancy occurred in 421 of 810 couples (52%) less than 3 years patency was 97% and pregnancy 76%, 3 to 8 years 88% and 53%, 9 to 14 years 79% and 44% and 15 years or more 71% and 30%. The patency and pregnancy rates were no better after 2-layer microsurgical vasovasostomy than after modified 1-layer microsurgical procedures and they were statistically the same for all patients regardless of the surgeon. When sperm were absent from the intraoperative vas fluid bilaterally and the patient underwent bilateral vasovasostomy rather than vasoepididymostomy, patency occurred in 50 of 83 patients (60%) and pregnancy in 20 of 65 couples (31%). presence or absence of a sperm granuloma at the vasectomy site affected results. Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group. J Urol. 1991 Mar;145(3):505-11. Belker

8. 88 97 82 71

13. 85% Patency 40+% Pregancy

14. 85% Pat. 40+% Preg.

16. video

17. Use Exactly…And the VV market

18. Competition/Free Market Healthcare Google Search Yahoo Search

19. Web Site Development Scott and White Link

20. Hits and Clicks Yahoo – March 2006 –17K “impressions” –196 clicks –$130 Google – March 2006 –4500 “impressions –124 clicks –$165 2-6 vas reversals/month

21. Cost Breakdown – $4,500 Surgeon 1,500 Anesthesia 500 Clinic 1,300 Supplies/Overhead 1,200

22. Patients by Region – Year One

23. Temple Experience 200420052006 PDF

24. Validation of a Vasoepididymostomy Predictor Model: Is Vasoepididymostomy Truly Predictable Preoperatively? Parviz K Kavoussi MD, Erin T Bird MD

25. Introduction 50% divorce rate in United States 500,000 men undergo vasectomies annually 2-6% of men will desire reversal at some point Range in microsurgical training for reversals (V-V vs V-E) Sheynkin YR, Hendin BN, Schlegel PN, Goldstein M: Microsurgical repair of iatrogenic injury to the vas deferens. J Urol 1998; 159:139-141.

26. Model Constructed to Predict Need for V-V vs V-E Model based on: –Age –Time period since vasectomy Model validated in a 7 institution study Purpose: Allow referral to urologists trained and comfortable performing V-E’s Parekattil SJ, Kuang W, Agarwal A, Thomas AJ. Model to predict if a vasoepididymostomy will be required for vasectomy reversal. J Urol. 2005 May;173(5):1681-4. Parekattil SJ, Kuang W, Kolettis PN, Pasqualotto FF, Teloken P, Teloken C, Nangia AK, Daitch JA, Niederberger C, Thomas AJ Jr.Parekattil SJ, Kuang W, Kolettis PN, Pasqualotto FF, Teloken P, Teloken C, Nangia AK, Daitch JA, Niederberger C, Thomas AJ Jr. Multi- institutional validation of vasectomy reversal predictor. J Urol. 2006 Jan;175(1):247-9 r

27. Methods IRB approval obtained 115 consecutive patients who underwent reversals included No exclusion criteria All underwent reversal by fibrin glue technique

28. Methods Predictor model applied to all patients Predicted outcomes analyzed with respect to outcomes with consideration to actual procedures performed Maximum follow up 30 months Median follow up 16 months

29. Results Out of 115 patients, 40 would have been predicted to require V-E on 1 or both sides, but actually underwent bilateral V-V Follow up data was available in 62% of these patients 88% of these were patent and 52% achieved pregnancies thus far

30. Predicted V-V, had V-V Number of patientsNumber successfully patent Number achieved pregnancy 70 (42 had f/u data)41 (98%)15 (36%) Predicted V-E, but had V-V Number of patientsNumber successfully patent Number achieved pregnancy 40 (25 had f/u data)22 (88%)13 (52%)

31. The assessed pre-operative nomogram to identify patients who might benefit from a V-E vs those who will simply need a V-V is not a reliable predictor in our patient population seeking a more affordable fibrin glue vasectomy reversal option

32. Conclusions Results of fibrin glue vasectomy reversal are comparable to published series Limited marketing resources are required Dealing with failures and fertility couples in general…. Future Directions