Ask the Doctor

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.

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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.

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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.

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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.

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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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From Mike:-
I can’t find any information out there about the normalcy of fertility testing prior to getting a vasectomy. As I’m considering the procedure, I’m wondering if it would make sense to get a fertility test done first, to determine whether or not I’m even fertile (obviously, I don’t have any kids) before deciding to have more-or-less permanent elective surgery.

Is it ever standard practice to test sperm first to see whether a vasectomy would possibly be an unnecessary surgery? What if a patient requested it?

Any man that has an indication that there might be a sperm production problem should get tested for the presence of sperm prior to undergoing a vasectomy. However, the presence of any sperm regardless of how low the count is capable of impregnating a woman. Therefore, only men with complete absence of sperm on at least two centrifuged semen analyses should consider themselves naturally sterile.

Dr. Karpman’s website

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From Amy:-
I apologize if you’ve seen this question before. I did search the website and could not find an answer to it. My husband had a vasectomy in 2006. He was given the “all clear” in early 2007 and since then has visited the doctor for a semen check once a year. The checks are always clear so my question is, does he need to keep going every year to be checked, or can we assume he’s “safe” now? It is important that I do not get pregnant (for health reasons on my end), so we are not opposed to getting him checked once a year. Just want to know if it is unnecessary. Thank you very much for your time and help.

Repeated checks for the presence of sperm years after a vasectomy are not necessary. Vasectomies are very durable especially after several years of repeatedly negative test results.

Dr. Karpman’s website

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From Alicia:-
Hello Dr. Karpman. I appreciate your time answering the questions submitted to you. I have looked through your archives and have not seen my issue addressed, and hope you may be able to help me. My husband is scheduled for a vasectomy reversal on Dec. 15 of this year. He has two children ages 8 and 10 from a previous marriage. His vasectomy was done 8 years ago. He said that he had been told by his doctor that he had a low sperm count at some point in the past, but he’s not really sure of what the numbers were (he’s not a real “detail” guy!). We have been told by the doctor’s office who will be performing the procedure that they will examine his sperm level before performing the reversal. This begs the question, for me anyway, what happens if they don’t see any sperm? Should they continue the procedure? I asked the woman who runs the office (maybe his nurse, not sure), and she said “obviously there will not be any sperm present because he has had a vasectomy”. It made me feel really stupid, so I was afraid, at that point, to ask for clarification. I had always assumed that men who had undergone vasectomies still produce sperm, it just doesn’t flow out the penis. Is this correct? Is there any way to check his sperm production levels before we spend all this money on a reversal? Or are sperm counts only “checkable” after the procedure is done, when it may be too late. I would just really hate to go through all this time and expense if it were for naught, especially if it could be determined by this doctor beforehand, and he still performed the procedure anyway to receive the payment. Any information you could give us would be most helpful. Thank you for your time.

The only way to confirm that a man’s fertility potential is present in the absence of sperm as is the case after a vasectomy is to perform a physical exam measuring the size of the testes and to obtain hormone tests such as FSH. These two tests are not 100% reliable but give us the best prediction of a man’s fertility potential, along with his previous history of paternity. Surgeon’s performing vasectomy reversals should always check for the presence of sperm in the vas deferens at the time of vasectomy reversal. However, the absence of sperm from the vas deferens does not signify poor production but merely that a secondary blockage may have developed and the “bypass” operation is required. Unfortunately, there is no better way to predict a man’s fertility potential until after the reversal. Couples in situations where there might be a spem production problem or problems with ovarian function should consider the alternative of sperm retrieval with IVF/ICSI.

Dr. Karpman’s website

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My husband just called me and was very upset. Last week he had an appointment to schedule a Vasectomy and the DR had a hard time locating his vas deferens, telling him he was too small in the private area and thats why he (the DR) had a hard time finding the vas deferens. That of course made my husband very upset. He scheduled his vasectomy for a week later, which was today.

A simple procedure is turning into a huge hassle. Is this DR right in what he is saying to my husband? Is the vas deferens really that hard to locate?

The vas deferens can be difficult to palpate and the difficulty of palpation is related to the patient’s anatomy and the physician’s familiarity with anatomy in this region. In these difficult situations, you never want to force a physician to perform a surgery in a situation he/she is not comfortable in. My recommendation to any patient in this situation is to either go along with your surgeon’s preference for performing the vasectomy, or choose another surgeon.

Dr. Karpman’s website

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From Meagan:-
My husband had a vasectomy clip done about 4 years ago. We are wanting to get that reversed but unfortunately cannot afford the more expensive, highly spoken of doctors. Is there a difference in pricing since it was the clip instead of the cutting procedure? Also, are the chances of getting pregnant greater since he wasn’t actually cut? Thank you for your time.

Regardles of the type of vasectomy procedure, the best chances for a successful vasectomy reversal is to have it done using a microsurgical approach by a fellowship trained and experienced surgeon. Vasclip used for the vasectomy does not change outcomes for vasectomy reversal success.

Dr. Karpman’s website

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