December 22nd, 2014
Sperm is produced in the testes. From there, sperm travels into a small gland that is located just outside the testes called the epididymis. It is here that the sperm stays as long as six weeks to mature. The tubes of the epididymis join together at the very end of the epididymis to form one common tube called the ‘vas’ or ‘vas deferens’. It is the vas that transports the sperm into the body where it enters the prostate gland. The prostate gland is responsible for making the seminal fluid that carries the sperm. The sperm from the testes plus the seminal fluid from the prostate join together to make semen. The semen is then ejaculated through the penis.
A ‘no-scalpel’ vasectomy is started by anesthetizing a small area of the scrotum (the skin sac that the testes are in) and then making a very small opening under the penis. This is accomplished after local anesthesia is injected under the skin. We make the small opening with a special tool that spreads the skin open rather than cutting the skin. The ‘no-scalpel’ technique allows quicker healing and less bleeding. We are then able to move each vas to the opening and then remove a small piece and then seal the ends using heated cautery or a suture tie.
By removing a piece of the vas and obstructing the channel, sperm is no longer able to be transported into the prostate and, therefore, infertility results. The operation usually takes 10 to 20 minutes, and most patients can get up and walk out of the office soon afterwards.
The operation does have risks. As with any operation, simple or complicated, there is a chance of bleeding, pain, or infection. We encourage men to stay off their feet after the operation for a few days and use ice packs to keep the swelling and bleeding to a minimum. We encourage men to wear a scrotal support or jockey briefs to provide some pressure to reduce bleeding, and we demand that patients not take aspirin for a week or so before their procedure and for a short time afterwards, if there are no complications. Despite precautions, complications from vasecteomy do occur. Some patients can have bleeding or infection. Some patients will have discomfort in their incision, and some people will have discomfort in their testes or around the vasectomy site for a period of time. This is due in part to the back pressure that builds up because the sperm cannot get out. For almost all of these cases, the pressure in the testes which causes sensitivity finally subsides. Another possible cause of pain is called ‘sperm granuloma’. This is caused when the sperm find their way out of the tied or cauterized end of the vas. This cannot be prevented in some circumstances and the sperm that is released into the tissue is irritating and causes a small nodule. These nodules usually resolve in time as the body seals them off, but can persist and can be painful. On rare occasions a sperm granuloma needs to be removed. This essentially is simply re-doing the vasectomy.Fortunately, all of these complications are rare and in most cases the discomfort that occurs is handled with a short course of anti-inflammatory drugs or pain medicine with good resolution. Another possibility is an infection in the epididymis called epididymitis. This again is rare and can be caused by the back pressure or infection or inflammation within the epididymis. Epididymitis is treated with bed rest, elevation and antibiotics, and in almost all cases resolves quickly.
Vasectomy has a few unique risks or complications and these include the possibility of recanalization. Recanalization means that, despite removing a piece of the vas and sealing the ends, the ends grow back together making the man fertile once again. In almost all instances recanalization takes place within the first few months after the vasectomy. To make certain that recanalization has not occurred we demand that patients come in for semen checks to make certain that no sperm are seen. Once no sperm has been confirmed on two semen checks two weeks apart, we feel secure that the patient is sterile and does not need to come in for further sperm testing. Since a fair amount of sperm is stored downstream from the portion of vas that is removed, the initial ejaculations always contain sperm. After the obligatory one week wait before engaging in sexual activity, we encourage patients to become active sexually with PROTECTION. After about a dozen ejaculations the first specimen can be brought in for microscopic examination. If that shows no signs of sperm, a second one can be brought in two weeks later. Some patients have very poor migration of sperm in the vas after the vasectomy, and cases of persistence of sperm in the semen checks can be seen from six months to a year. While this is rare and even if the sperm counts are low, we do not consider you sterile until we have had two completely negative sperm counts two weeks apart. If, after a prolonged period of follow-up, sperm continue to persist in the semen checks, particularly sperm that are active, we feel that recanalization has occurred. While this occurs in only a small percentage of patients, it does necessitate a repeat vasectomy on both sides.The semen specimens that are needed for your checks do not have to be fresh. We are not looking for sperm motility or action, and we consider any dead sperm seen as a potential pregnancy. The semen specimens can be placed into a jar such as a baby food jar or one of the containers that we give you. The easiest method of collection is to use a condom and dump the contents of the condom (not the condom itself) into the jar. The jar does not have to be refrigerated and can be brought in the following day.
Another potential complication of vasectomy is the long-term effects of the procedure. Controversies have existed for years about the possible side-effects of vasectomy. Large studies have been done throughout the country looking at groups of patients who have had and have not had vasectomy, and almost all of these studies have shown absolutely no difference in any medical problems. A recent study, however, has suggested the possibility that there may be a slight increase in the chances of developing prostate cancer in men who have had vasectomy. This difference does not show up for more than two decades, and the structure of the study that was done is open to a fair amount of criticism. Larger studies have not shown this same finding, and further study is being done. We would be glad to discuss with you and your partner any of the above risks or complications, and provide you additional reading, if need be.
There are three small requirements that we have on the day of the vasectomy. First, it is necessary to shave a small portion of the hair off of the scrotum, and this should be done just under the penis where the penis joins the scrotum. We need a 2 to 3 inch circle of hair shaved. The shaving should be done on the morning of the vasectomy and then you should take a shower to wash away all of the cut hair. We would encourage you not to do this the day before because of the possibility of developing an inflammation or infection from razor burn. We strongly urge you not to consider the use of any depilatory creams to remove the hair. The second requirement is that you bring a pair of tight jockey shorts or a jock strap to provide scrotal support and for us to be able to place bandages in the underwear for security. Boxer shorts don’t provide support and will not hold any bandages that are placed without tape. The third requirement is for you to bring someone to drive you home. While this may be logistically difficult in some circumstances, a small number of men feel somewhat uneasy after the operation because of the stress. While there should be no discomfort for one to two hours after the vasectomy, we would rather see the patient be able to lie comfortably in his automobile without having to drive home and fight traffic. We encourage you, if at all possible, to bring, or arrange to have, a ride home.
After the vasectomy we recommend that you go home immediately and get off your feet. It is not absolutely essential to stay bedridden for the next two days, but the more motion and movement creates increased chance for swelling of the scrotum and incision. Once you get home, we feel that ice packs for the first 36 hours are very helpful, both for pain relief and reducing swelling. Frozen zip lock bags of peas and corn can be thawed and refrozen and provide a very soft, pliable method of applying ice packs to the incision. Usually 15 minutes on and 15 minutes off works very nicely and does truly keep down the amount of swelling that is present. For discomfort, we also recommend the use of Tylenol or acetaminophen. Two Extra-Strength Tylenol (500 mg) tablets, can be taken every 4 hours as needed for pain. Narcotics are rarely indicated or needed for vasectomy. If you are not moving around, it should not be too uncomfortable, and Tylenol should be more than adequate pain relief. We encourage you to not use aspirin in the postoperative period. The nonsteroidal anti-inflammatories such as Advil, ibuprofen, Naprosyn, etc., are excellent pain medications as well. Unfortunately they, too, have some aspirin-like affects and raise the chances of postoperative bleeding. They could be instituted two days after the vasectomy, but we would encourage you not to use it on the day of the vasectomy or the next day. If you have any other questions about vasectomy, please don’t hesitate to ask us.