Ask the Doctor

From Jim:-
My questions concerns the potential for complications for someone who had testicular torsion surgery some years prior to wanting a vasectomy. I am 30 years removed from torsion correction surgery (bilateral “tack”) I have two rather large scars on my scrotum and large tortuous vessels that end near both incision scars. I am extremely testicle shy and don’t like them handled by doctors or even my wife. I still feel some deep pulling type pain with the wrong type of movement in my scrotum. I am a veterinarian so I have some experience performing follow-up surgeries in a region previously worked on, and I can only imagine the scarring and adhesion formation would severely complicate a routine vasectomy, not to mention be much more painful. Am I misguided with my worries? Should I be looking at other options for birth control, or possibly electing a vasectomy under general anesthesia for less pain and anxiety in the exam room? The thought of a needle, however small, being directed into my scrotum is unimaginable.
Thanks for any help you can give.

Performing a vasectomy on a man with previous scrotal surgery, regardless of the type of scrotal surgery, is a more complicated procedure than in a man without previous surgery. I would definitely recommend having the procedure done with a surgeon who specializes in performing vasectomies. Most men can still undergo a traditional vasectomy in the office under local anesthesia even in the setting of previous scrotal surgery. Patient anxiety can be overwhelming and necessitate having the procedure done at a surgery center with deeper anesthesia. In men who have concerns about needles near the scrotum, thay can have a no-needle technique performed using a MadaJet instrument to deliver the local anesthesia. I have also given patients anxiety reducing medications prior to the operation when necessary. If all else fails, relying on some alternative form of contraception might be the only answer.

Dr. Karpman’s website

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From Jeff:-
Thank you for taking the time to answer questions. I have the following question that I did not see in the archives and hoped you could help with: I’m wondering if getting a vasectomy using cauterization is significantly safer than one where the vas are just tied. By safer, I mean is there a significantly less chance of the vas rejoining over time with cauterization compared to without? If I get one without cauterization, should I get yearly semen checks? Thank you.

Studies have shown that out of all the known techniques for performing vasectomy, cauterization has the lowest risk of failure. Combination techniques that excise a segment of the vas deferens, ligate the ends and cauterize the ends have the highest success rates.

Dr. Karpman’s website

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I had vasectomy 15 years ago. I would like to donate my sperm to my sister in-law because her husband’s sperm count is too low. Can this be done and if so, what procedure must be done?

Using donated sperm from a family member is an option for any man who desires. Usually, it is done when no sperm are available from the husband and the couple would like to avoid an annonymous sperm donor or desires having some genetic component from the paternal side. In men who have had a vasectomy, sperm can be retrieved easily but it can only be used for IVF/ICSI.

Dr. Karpman’s website

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From Karl:-
I’m hoping you can help as my GP was quite unhelpful and suggested my results were to be expected after my reversal op. In 2002 a had a vasectomy and in Sept 2008 had it reversed. All appeared to go well, yet my wife and I have been TTC since the reversal with no luck. I tried a couple of Home Semen tests which tested count and motility which were both positive, then recently had a proper test at the local hospital. Most things look fine, apart from the Antibodies and the round cells.

Please reply as I’m struggling to get any solid answers from my GP, he has now had to contact a specialist to get advice, yet I’ve still heard nothing back.

Anti-sperm antibodies are a common finding after vasectomy and vasectomy reversal. Despite their presence we still see a 65% pregnancy rate after vasectomy reversal and their significance in impairing conception is uncertain. White blood cells (WBC’S), or round cells as they are commonly reported, can be a sign of infection or unwanted inflammation in the male reproductive tract. WBC’s can produce reactive oxygen species which are free radicals that can damage sperm membranes and the genetic integrity of the sperm causing fertility problems. These WBC’s can come from the epididymis, prostate or seminal vesicles. My practice is to obtain semen cultures and treat men with a combination of anti-biotics, anti-inflammatories and anti-oxidants.

Dr. Karpman’s website

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From Charles:-
After watching some of the videos of vasectomy reversals, I am wondering why a micro stent is not placed in the vas during the procedure. The video showing microdots emphasized the accuracy of attaching the two vas ends to insure the lumen is kept open. Why couldn’t a small, permanent stent be inserted in each end to align the lumen and prevent it from being intruded upon during suturing?

Stents have been utilized in the past for vasectomy reversal. Unfortunately, the results of stenting compared to traditional 2-layer vasovasostomy in the hands of an experienced surgeon have been disappointing. Randomized control trials have demonstrated lower patency and pregnancy rates in men undergoing stenting compared to the traditional 2-layer microsurgical vasovasostomy. I have included a link to one such trial. Perhaps in the future, with the development of new biomaterial and refinements in micro-technology, we will see new stents come to market that are more effective and have comparable or better results than the ones we have studied in the past.

Dr. Karpman’s website

http://www.ncbi.nlm.nih.gov/pubmed/9112508?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=8

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From Mike:-
I had a vasectomy done around 1992. I have never had any pain or discomfort and no more children so I guess it worked.lol. My problem is this. I noticed a while after the procedure that I had what seemed like a third testicle had attached itself to one of my testicles. Over time it kept growing and I told my GP who said it was common because it was sperm that was caught in the tube that was cut (or some kind of explanation like that) and not to worry. He called it a sperma something but I can’t remember. I had ultrsounds done and was told again not to worry. Well it has grown to a rather large size (probably the size of two regular testicles at least if not more) but there is no discomfort. Can you explain to me what this is and if I should consider having it removed. Thank you for your time.

This sounds like a sperm granuloma, but I am always hesitant to give any reassurance about a growing mass in the scrotum on the testis as this also may represent something more serious such as a tumor. All men with new masses on the testes or in the scrotum should seek immediate evaluation by their physiscian. Physical exam and scrotal ultrasonography are the only ways to differentiate these processes. A sperm granuloma is a benign process resulting from sperm leaking out of the vas deferens after vasectomy. The fluid is encapsulated by the body and can grow in size. Ususally, no treatment is required unless the size of the lesion becomes very large or causes discomfort.

Dr. Karpman’s website

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On Sept 25 I had a In office vasectomy. I am 35 years old and have two wonderful boys. My wife and I do not want to have any more kids.

Please let me know what you think.

Unless the patient is missing a vas deferens on the side in which the vein was cut, sperm will most likely be present in the semen analysis. I think that performing pathologic evaluations on the vas deferens sample is a good idea and helps identify a problem with the procedure immediately, if one exists. That said, I have never had a surprising result such as the one mentioned above. However, I have heard of other physicians encountering the same problem. It is difficult to confuse a vein for the vas deferens as the consistency of the two structures is quite different but can occur with less experienced surgeons. The only consequence of cutting the vein instead of the vas deferens should be that the vasectomy will not work and will need to be re-done. We routinely cut/ligate the spermatic cord veins during varicocelectomy procedures in order to improve testicular health. If the vasectomy works, then it is because you are missing a vas deferens on that side.

Dr. Karpman’s website

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I had my vasectomy two days ago and it seemed to go well. The pain was not and is not bad at all. However when I took the bandage off yesterday and took a look I discovered what appears to be a staple on my scrotum. I’ve heard of staples being used in surgery and my understanding is that there might be some small clips used internally on the vas deferens but the doctor who performed the surgery told me nothing about this and how I might deal with it for aftercare. Is this normal? What happens when I fully heal? Will the staple be there permanently? Please advise.

It appears that the metal object in the attached pictures is a titanium clip like the ones we use for occluding the ends of the vas deferens at the time of surgery. In this case, it almost appears that the surgeon used the clip to close the wound. Clip migration out of the wound is a rare occurence and usually happens later after the surgical procedure than 2 days.

Dr. Karpman’s website

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From Roy:-
Attached are pictures 8 days post vasectomy. One shows a picture of the scrotum with both incisions visible. A second picture shows the folding of skin around the incision due to the stitching. A third picture shows the fold pulled back on one side to show (somewhat) how deep the stitch pulls the skin under the fold.

Thank you for your response.

The pictures appear to represent the normal healing process 8 days after a bilateral vasectomy procedure. The puckering seen in the picture is normal this soon after the procedure and will likely resolve with some time. The associated symptoms may or may not be related to the scrotal skin findings. It is difficult to say if the underlying vas deferens is tethered to the skin without physical examination. It is difficult to make any long-term conclusions about the outcome of any procedure so soon after the surgery.

Two weeks after the surgery, the pinching and pulling has been substantially reduced. The vas deferens was not stitched to the scrotum. However, the scar tissue around the incision and stitching is fairly thick and still somewhat sensitive if squeezed. Would a steri-strip, rather than stitches, have likely reduced the pinching and scarring? Or is use of a steri-strip not a (good) option for this type of surgery? Thanks.

Theoretically, a good idea. We like to use Steri-strips whenever possible in surgery for closure of small wounds. However, in practice, a Steri-strip would not work. They require a flat surface for the adhesive to be effective. The surface of the scrotum is full of peaks and valleys and would not provide an adequate contact surface area for Steri-strips.

Dr. Karpman’s website

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From Gabrielle:-

My boyfriend had a laser vasectomy in January of this year. Are laser vasectomies reversable?

Are there any other ways to become pregnant without having a reversal? I know your article/responses explain procedures for reversal, but I was not sure whether they are in reference to the older style of vasectomy (clamping?) or all? Thank you for your time in advance.

The type of vasectomy performed does not make any difference on reversal success rates. All vasectomies are based on the same concept that the vasal lumen should be permanently occluded. Laser vasectomies are no different. Likewise, vasectomy reversal success is independent on the technique used for occlusion of the vas deferens. There is no evidence supporting an advantage in the use of a laser for vasectomy procedures.

Dr. Karpman’s website

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