Ask the Doctor

From Edie:-
I have a friends with benefits situation, I am a 47 yr. woman and my BF is 35. We have been together 2 1/2 months and he INSISTS on using condoms even though he had a vasectomy at 23 and I have missed 2 periods since Sep 09. He said when he had the vasectomy done the Dr. told him since he had the clamp procedure done there was a slight possibilty that he could get someone pregnant. I told him they have to say that for legal reasons and he is worring way too much. My ex of 17 yrs had a vasectomy after the first year of marriage and so did another boyfriend I had at 19. I told him if I was going to get pregnant it would have been with these 2 guys as we used no protection. He doesn’t even let me play with his penis on my vulva for fear I will get pregnant! Who is right?

The real question in this situation is “Has the man had his sperm count checked after the vasectomy or recently?” Vasectomies have been know to fail on rare occasions. The Vasclip procedure was a procedure done for vasectomy in the past and is no longer available. A recent study done on the Vasclip has shown that 25% of men will still have little channels through which sperm can travel even after the procedure. Recently, a new company caleed Pro-Vas is trying to market a similar type of occlussive device for perfoming vasectomies. The company does NOT have any clinical data to support their claim that the procedure is any more effective than the Vasclip and only received FDA approval because of its similarity to the VasClip procedure. I would caution men about this procedure until there is clinical data available to review that shows this device to be effective as a sterilization procedure.

The statistical probability of getting a 47 year old woman pregnant is extremely low, but not zero so we can never tell a man or woman that they do not need to use protection while having sexual intercourse. The best recommendation to any man who is concerned about his fertility potential after a vasectomy is to get his semen analyzed with a pelleted sample to determine his ability to get someone pregnant. This test is not expensive, is available at any laboratory and results are known within 24 hours.

Dr. Karpman’s website

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From Susannah:-
My husband is 36 and had a Vasectomy, via regular micro surgery, not laser surgery, 6 years ago while married to his ex-wife. He has four children and I do not think fertility has ever been a problem for him. I am 37 and have two children and I also have had no trouble in the past conceiving or carrying to term. My questions are: My husband tends to scar and gets keloids from surface cuts, not horrible thicked, raised, dark scarring, but enough to notice. Is Vasectomy reversal an option for us? Would it be better to go with laser surgery this time vs. tradition surgery? He also says that since his procedure, his ejactulations seem to ooze out like a lava flow rather than spurt out (sorry for the graphic details). Is this a factor to consider? Does this indicate that more internal scarring has occurred than normally expected? Will this contribute to vasectomy reversal failure?

The type of vasectomy performed rarely limits our options at the time of vasectomy reversal. The only limitation to vasectomy reversal surgery is when large segments of the vas deferens are removed at the time of vasectomy by aggressive vasectomy surgeons. Laser vasectomy is still performed by only a few surgeons around the country. There is no proven benefit for using a laser during the vasectomy procedure and some surgeons use it as a marketing gimmick to attract men to get their vasectomy done at their center.

Keloids and hypertrophic scars do occur in some men and are more commonly seen in men with darker skin. I am not aware of any relationship between keloid type scarring of the skin and worse outcomes during vasectomy reversal. Men who form keloids and hypertrophic scars do need to be aware of the fact that their skin incision might show some scarring greater than a man that doesn’t form these types of scars. I would probably recommend that men who are prone to scarring be given a course of strong anti-inflammatory medications in the early post-operative period.

Dr. Karpman’s website

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From Brian:-
I am really angry about the way my stitches look post vasectomy. Is it normal for them to look like this? Although it is somewhere that can’t be seen, it still bothers me. Is this something that could have been prevented? The photo was taken 6 days post op.

The attached photograph appears to be that of a relatively normal healing process for a vasectomy procedure. The size of the incision is a little generous, but otherwise looks normal for 6 days after surgery. The nice thing about operating on the scrotum is that it is a very forgiving area of skin and most scars will not be apparent after a period of time.

Dr. Karpman’s website

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From Doug:-

Hello. I think the website is an excellent source of information, but had 2 quick questions.

I also had a question on the titanium clips. It seems odd that they place them on the vas, then just let everything slide back in. isn’t there a risk that those clips might bump up against a teste or something?

The purpose of wearing masks during any surgical procedure is as much for the protection of the surgeon from bodily fluids as it is for the patient. That said, I don’t know of any studies that have shown that when surgeons wear a mask during the vasectomy procedure that the risk of infection is lower than if they didn’t wear a mask. The infection rate during vasectomy procedures is incredibly low to begin with (1%) and, therefore, most surgeons wear a mask based on their own preferences.

Tight fitting underwear or a scrotal support are encouraged for use immediately after the vasectomy procedure for patient comfort and to minimize any hematoma formation. Minimizing the movement of the testes and scrotum after the procedure decreases patient discomfort. Compression of the scrotum and surgical site can help reduce swelling and/or hematoma formation after the procedure. The scrotum has a large potential space and any slight ooze can accumulate into a lot of fluid if left unopposed. A golden rule in medicine is that all bleeding stops with direct pressure to the bleeding site.

The vasectomy procedure is performed on the vas deferens in the spermatic cord located above the testicle. Theoretically, anything can happen, but practically we do not get any complaints from patients that they feel the clips rubbing or touching other structures in the scrotum. Patients have reported that they can palpated the clips through the scrotal wall if they poke around down there. Titanium clips have been used extensively by vasectomy surgeons for many years because of their effectiveness, reliability and lack of side effects.

Dr. Karpman’s website

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When men opt for vasectomies, it is possible to ask the doctor to cut a 6-8 inch instead of a small inch during the procedure? I’m worried if I get one and it is cut small, it would recanalize. Is it possible to ask them cut it wider?

I do not recommend excising unnecessarily large portions of the vas deferens during the vasectomy procedure. There are no studies showing that the larger the segment excised makes for a more reliable procedure. In fact, the most efficacious way of performing a vasectomy is to cauterize the ends of the vas deferens. This has been shown to be even more effective than cutting or tying the ends of the vas deferens alone. Most vasectomy surgeons employ several of these techniques during the procedure to ensure a successful vasectomy. With the lack of any advantage in terms of vasectomy effectiveness and the increased difficulty it makes for elective vasectomy reversal, should the need arise, I do not recommend excising unnecessarily large segments of the vas deferens during the vasectomy procedure.

Dr. Karpman’s website

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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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