Vasectomy 101:Gainesville’s Northeast Georgia Urology Group, NGUA (Everything you wanted to know about a vasectomy but were afraid to ask.)

it is better to cure at the beginning than at the end

Everything you need to know and ask about a vasectomy “before” you have one done. (If you have a question or issue not addressed, mention it as a comment and I’ll address it gladly. I want this to be an “exhaustive” resource to those considering a vasectomy.)

Five myths about a a vasectomy often used by the reluctant male as an excuse not to have a vasectomy.

  • Is a vasectomy permanent? Well yes and no. A vasectomy is a procedure that takes a segment of the vas tube (the tube small tube that carries sperm from each testicle and epididymis) and then by various means occludes the remaining ends. The remaining ends can be tied with suture, burned or fulgurated (the body heals the trauma of being heated with scarring), or clips. The success rate of all the ways to “tie off” both ends are about the same. At Northeast Georgia Urological Associates we use a hand-held vasectomy cautery device with a long snout that burns the lumen of each end about 1/4 inch from the point where the vas was transected. So the procedure is performed with permanence in mind however a vasectomy can be reversed and there is a 1 in 3000 chance that a vas can recanalize. In regards to reversal this is done usually with anesthesia using a microscope, takes about three hours, not covered by insurance, has about a 75% success rate. For these reasons urologists recommend the couple making the decision to have a vasectomy “consider” the procedure permanent as you can’t count on either of the two above scenarios if at some point you elect to have another child.
  • What is the most common reason for wanting to reverse a vasectomy? In my practice the most common reason is the male with children who has had a vasectomy, divorces and now has remarried a younger women who has not had children,but wants to have children.
  • Will it hurt? It doesn’t have to. We give a sedative (like Valium or Ativan) and a pain pill (like Lortab or Percocet) before the procedure as a pre-med. These medicines are not given to “knock you out” but to relax you and decrease any anxiety that exists before the procedure and really before you reach the office as they are taken an hour before the procedure. In addition to oral pre-meds at NGUA we use the Madaject injector to put Lidocaine in and about the vas to “numb” it. As a result of these two things it is unusual for patients to experience any significant pain. The Madaject is “needle free” and this not only delivers the anesthetic medicines in small doses, the fact that the male patient knows that no needle will be involved in that “particular area” also lowers his anxiety about the procedure.
  • What is “No-Needle” vasectomy? Instead of using a needle to infiltrate the vas tube to numb it, a special device the Madaject, sprays a small amount of lidocaine in a powerful concentrated force into the skin of the scrotum and the vas tube. Patients often describe the feeling as a tiny rubber band tapping them on the skin. Again, knowing a needle is not involved in the procedure is a huge factor to a large percentage of men considering a vasectomy.
  • Do women make better patients than men and do women deal with pain better than men? This is an easy one. Men absolutely freak out about the potential of sharp objects in the vicinity of their “privates” in general and about pain in that area in particular. As one patient of mine last week stated as I started the procedure, ” I have protected and worried about injuring this area all my life and now I am willingly letting someone I don’t know cut something out down there! I have on our website that we “Cater to Cowards” and my wife told me not to put that phrase on the site that it was “embarrassing” to the male. Well, it is not at all. I have asked hundreds of men…they love it and many chose me to do their procedure because of the phrase and that their comfort is important to me. And let me add, I take that phrase to heart. If someone feels something that is uncomfortable, I am going to change something or give more medicines. There is no need in this day and time to have this procedure that is not for the most part pain-free.
  • What does “No-Scalpel” mean? How do you get into the skin where the vas is if there is no scalpel? The No-Scalpel revolutionized doing vasectomies for two reasons. First the phrase again appeals to the male hating the thought of something sharp near the family jewels. See…it is much like the No-Needle business. It negates a “male” objection to the procedure. Secondly the instruments are much better and easier to work with than the standard vasectomy instruments. It is basically two instruments, a sharp hemostat used to make a small puncture wound in the scrotal skin which is turned spread to open instead of cutting with a “scalpel.” The second instrument is designed to grasp the vas and deliver it into the small opening in order to work on it. Both instruments allow for the procedure to be done quicker with a smaller opening and indeed was both a marketing tool and improved the procedure as well.
  • Does the small opening need a stitch to close it after the vasectomy is completed? No, the opening is so small that it closes on it’s own with sutures. This is another appealing aspect of the No-Scalpel method.
  • How many openings are necessary on my scrotum? Just one. You do one side and let that retract and then do the other side through the same opening.
  • Is there a difference in which urologist does your vasectomy? Well yes and no. All urologists can find the vas, divide it, and fix each end to limit it recanalizing. But the attention to the male’s perception of pain, whether they use a needle or not, whether they make one or two openings, whether they make an opening so large that it needs stitches and if they use the No-Scalpel instruments is something that I think urologists vary in. So, the end result is the same…in my mind there is a huge difference in how you get there.
  • Can my wife stay in the room to observe? I think if a urologist insists that you can’t have your wife or significant other in the room that this may be telling as to his confidence in performing the procedure. I welcome wives to stay. I prefer they sit as opposed to standing to observe because of the occasional episode of someone getting queasy. I enjoy sharing the experience with the wife and it is a good opportunity to answer questions and show the wife what a vas looks like. I play music during the vasectomy and I turn it up a bit more to help with the anxiety issue.
  • What does a vas tube look like? It is the size and texture of spaghetti. I am sorry…have I ruined pasta for you from now on?
  • How much of the vas tube do you remove? About a one half of an inch. Probably the success of a vasectomy is more based on dividing the vas and occluding the remaining ends than how much of the vas is removed.
  • What is the best day to have a vasectomy done? We do vasectomies everyday. The best day is any day you have two to three days to be off for your feet. For most patients that day is Friday.
  • After a vasectomy where does the sperm go? Most of the sperm is reabsorbed or destroyed naturally by the body. There is a decrease production secondary to the pressure gradient cause by the vasectomy. Sometimes sperm leaks out of the surgical site and causes a “sperm granuloma.” A granuloma is an inflammatory response to the sperm as the body perceives sperm as a foreign body and hence reacts to it as something it must kill or fight. This results usually in an english pea sized mass that initially is uncomfortable, but in time becomes asymptomatic without consequence. Other patients however are troubled by the mass and require short term antibiotics and either anti-inflammatory pain medicine or something stronger like Lortab. I had a friend in whom I did a vasectomy that had a sperm granuloma and he called it a “sperm granola.” He’d call and say, “John, my sperm granola is back. Can you send me in some medicines for it?” If this possibility is unsuitable to you then you should not have a vasectomy because it is a common and real concern.
  • Does a vasectomy affect my sex drive? No. A vasectomy only takes the sperm portion(that fluid that comes only from the testicle) out of the ejaculate. It has nothing to do with the male hormone testosterone which is responsible for the male “horny-ness” and as a result does not affect libido or the male sex drive. This is probably the biggest myth about a vasectomy that the male will use as an argument not to have a vasectomy other than the fear of pain.
  • Does a vasectomy change the quantity or volume of my ejaculate? Yes, but very little. The portion of the ejaculate that actually comes (no pun intended) from the testicles and related to sperm is about 5-15%. It will hardly be noticed.
  • Where does the majority of the ejaculate (if it is not the testicles and sperm) come from? Most of the ejaculate comes from the prostate and the seminal vesicles. These two glands add nutrients to the sperm to ensure it makes its way to the female in top-notch fashion and healthy enough to do their work. Think the intro to the movie with Travolta in “Look who’s talking.”
  • Does a vasectomy change the way the ejaculate tastes? The seminal vesicles add fructose to sperm as energy. This supplies the necessary food stores for the sperm to get to where they need to be. So, if the ejaculate has a bit of a sweet taste to it, this would not be affected by eliminating the sperm portion of the ejaculate. You think this is a weird question don’t you? Well what if I told you we are asked this question about 10 times a year? If someone has asked me…someone else somewhere has thought of it don’t you think?
  • How about my erection? Does a vasectomy affect this? No. An erection is a complex result of blood supply, nerves, and the male hormone testosterone. None of these components is affected by the vasectomy. Oh yea…there is a psychological component as well to the erection that could conceivable be affected by a procedure in this area of the male anatomy, but this is rare.
  • How about climax, does a vasectomy make that different or not as good? Sorry, (to the male desperately looking for an excuse to give his wife as an excuse not to have a vasectomy “for the team or for the Gipper”) the climax is not affected.
  • What is post vasectomy pain syndrome? I personally never seen this, but there are patients out there who have had a vasectomy and for whatever reason the change in the dynamics the procedure cause a long-lasting pain the testicles that is significant. I am aware of reports of patients who have had a vasectomy reversal soley for the reason of correcting this pain. I  think this is rare, but happens. I don’t feel it is a reason not to have a vasectomy for fear of this as it is an uncommon occurrence.
  • When can I go back to work? If you have a desk job, it would be unusual for a patient not to back to work in three days. If you have a job with heavy lifting, I’d advise telling your boss and co-workers that you plan to have a vasectomy and if it would be possible to “gradually” get back to the strenuous work you are accustomed to.
  • My wife tells me that if she is not worried about not getting pregnant and not having to take the pill that she’d be more receptive to having sex more often. Is this a reason to have a vasectomy? If this were true, well sure. I have found that this is true early on after the vasectomy, but does not “stand up” over time. The wife will revert to her old ways…whatever that is. I had a neighbor who did a vasectomy for this very reason and this is what he told me several months later, “She lied.”
  • What are the post vasectomy instructions to the male having a vasectomy? No sex for a week, no unprotected sex untill two sperm specimens examined by the urologist that did the procedure, off your feet for two days, pressure to the incision the first hour after the procedure and then two hours of ice to the scrotum for two hours. Of all the post op instructions the two most important are: No unprotected sex untill you are told there are no sperm. Off your feet for 48 hrs after the procedure.
  • How is it that people get pregnant after a vasectomy? The most common reason is probably that the patient and his wife had sex before they made sure all the sperm were gone from the vas tube “beyond” the vasectomy site. In other words, the sperm already in the system have to be ejaculated to clear the system of sperm. I am aware of a law suit of a patient and his wife getting pregnant because they had unprotected sex shortly after a vasectomy but before they made sure there were no sperm.
  • Are there other reasons for a pregnancy after a vasectomy? Yes, recanalization, but this is unusual and is usually detected by the diligent patient and urologist who continue to check the post vasectomy specimen to be sure there are no sperm left. I have had about 5 patients in my 26 year career whose specimen would not clear despite many post-vasectomy specimen checks. This probably represented recanalization. I reperformed a vasectomy with immediate clearing of the sperm. So…if a patient doesn’t bring a specimen back for evaluation and “assumes” he is clear…well this is where the pregnancies come from. Just like in “Gone with the Wind,”  “You ain’t clear untill I says you clear.”
  • Is a scrotal support necessary after my vasectomy? We used to tell each patient to go bring a scrotal support to wear after the vasectomy. The thinking was that the patient could put gauze in the support and hence have a “pressure dressing” to prevent swelling and motion of the testicles. If you have a scrotal support that is fine. If you don’t I don’t think you should make the purchase. Brief underwear pulled up snug with gauzes will serve the same purpose. The key is limiting the mobility of the testicles and applying pressure to the area to prevent bruising.
  • Can I get a vasectomy if my wife isn’t ready to stop having babies? This comes up often. Legally, if the male is of age to make treatment decisions about his body, then the wife’s consent is not necessary. (You may want to check your state regarding this.) Having said this, I’d recommend being on the same page as your spouse. Obviously the best thing for the marriage may not be the thing you want as an individual. If at all possible we like to see both spouses consent to the procedure. As my grandmother said, ” It takes two mules to pull a cart John.”
  • How many ejaculations does it take to clear all the sperm from beyond the point where the vasectomy was performed? About 25, although this varies.
  • What do you do if the sperm don’t clear, i.e. you keep seeing sperm in the ejaculate months after a vasectomy? This occurs fairly frequently. What we most commonly see is a “few dead sperm.” Think of a vas as a river with little bends in it that could conceivably harbor sperm that come out in small numbers with the ejaculate. If we see repeated rare dead sperm, this usually clears with time, certainly within three months. If however rare or numerous live sperm are seen, this must be followed diligently, the patient made aware that pregnancy could occur and if the numbers increase or with time they don’t go away, a re vasectomy is order.
  • What percentage of patients never return for their follow-up semen analysis to be sure they are sperm free? It is higher than you think. Probably approaches 40% I did a vasectomy on two if my brothers and despite my urging they neither returned with a specimen to be sure all was well. If one of them had a pregnancy….who do you think they would have blamed. You guessed it…me. I tell all of my patient’s wives that, ” You are not free to have unprotected sexual activity untill I say so. And, that is after I have checked two semen specimens completely free of sperm.
  • How many vasectomies does a urologist have to have done to be good at it? All urologists have been humbled by a vasectomy at one time in their career. If they say they haven’t they are not being honest. It is a very simple procedure in concept…identify the vas, take out a segment, tie off both ends and that’s it…right? Well…there are variations in the male scrotum. Since these are usually done as an out-patient and with the male patient awake…there are variations in the male patient’s comfort level with a sharp instrument near their testicles. Some males are anxious from the get go and as a result hamper the procedure. In the perfect storm, i.e. a small high and tight scrotum, a slightly overweight patient, an anxious patient, a vas that is situated posteriorly and hard to find, or a vas with a prominent sheath (the layers of fascia around the vas tube), then the procedure can be very difficult. I learn something about every time I do a vasectomy. They still can be difficult to me and I have performed probably several thousand over my 25 year urologic career. Obviously, the more you do something the better you are at it.
  • What is a scrotal hematoma? Although the incision made to perform the vasectomy is very small and in and of itself doesn’t need any sutures, the vas tube is very vascular. The trick to a clean vasectomy with minimal risk of post-procedure bleeding is separating the arteries and veins of the vas from the segment of the vas that will be transected. If a small vessel, usually a vein, is transected and not noted by the urologist or if because of exertion by the patient after the vasectomy (remember we said off your feet for 48 hrs, but not all patients follow our instructions) then there will be a slow ooze of blood that forms a mass. Depending on the size of the vessel and the free space in the scrotum a collection of blood (hematoma) can form and be quite large….orange size or greater. This is an unfortunate occurrence and there really isn’t a suitable surgical procedure for a contained and non-infected hematoma so the recommendation is usually to just give it time to resolve or absorb on its own. The swelling is unsightly, usually turns the skin of the scrotum bluish-black and can take weeks to resolve. If you ask enough friends how they did with their vasectomy you will probably encounter someone who is happened to.
  • Can a male in his 50’s or 60’s achieve pregnancy? Yes, men will continue to have viable sperm in their ejaculate so it is not unreasonable for the male who is older and marries a younger person and they don’t want to have children, for the male in his 60’s to have a vasectomy. Do the math…78 when the child starts college? I don’t think so. Because women have menopause they are different in that they have a “biological time clock” i.e. no more pregnancy after menopause. The ovaries stop working, the uterus is not suitable pregnancy and the hot flashes signal this phase of the female’s life.
  • Does insurance cover a vasectomy? Yes, in most cases it is considered an office visit so that the expense is similar to an office visit. One can call the number on the back of the insurance card to check the benefits. In our office, we will happy to do that for you….we do it all day long and we are good at it.
  • Does insurance cover a vasectomy reversal? No not usually. I have had an occasional patient whose insurance did but most do. Think about it…they’ll pay for something that prevents more things an insurance company would have to pay for, and not pay for something that increases things to pay for. Ya follow.
  • What does a vasectomy cost? Usually somewhere between $700 and $1000. If you are having to pay cash because of no insurance or a high deductible in some instances arrangements can be made to “get er done.” It happens every day that a couple have agreed that they prefer no more children, decide to have a vasectomy but because of delays in scheduling, for whatever reason, get pregnant. If you and your wife have made the thoughtful decision to have no more children, I advise to move forward with the vasectomy.
  • Are vasectomies easy to schedule? Yes…In my office we do them every day of the week and it is not unusual for our staff to “add a vasectomy on” at the end of the day on a Friday as a special request of a couple whose schedule “opened up” and this was the only time they could have a weekend to recuperate and that the grandparents could keep the children.
  • Why is there pain up into the inguinal area after a vasectomy? Why does it sometimes bruise up into the inguinal area after a vasectomy? If you look at the anatomy of the vas tube you’ll see that it goes from the testicle in the dependent portion of the scrotum, the up the scrotum to the inguinal canal (the groin) and then turns posterior to enter the prostate just below and behind the bladder. When someone has pain or bruising in the inguinal area the inflammation or blood is just tracking up the course of the vas. Since there are two vas, a vasectomy is actually two separate procedures on either side of the scrotum. This why one side may be fine and no pain, and the other has some swelling, pain and bruising up into the inguinal canal. This is usually of no consequence but is probably the most common reason a patient will come back to be examined several days after a vasectomy. Often times the exam is normal but the pain in an unusual location away from the surgical site concerns and confuses the patient. The concept of “referred pain” has a role here too as the truama to the area of scrotum has the same nerves that follow the vas up the inguinal canal. So the pain in the scrotum is “referred” to other areas where that nerve goes and innervates.
  • Where is the opening made to do the vasectomy? Usually only one peno-scrotal grain of rice sized opening. (This the junction of where the penis hangs over the scrotum. If you lift up the penis the peno-scrotum is that area where the scrotum and penis meet on the under-surface  of the penis.)
  • If you don’t use a scalpel, how do you make the small opening and why is this better? A bit of marketing and remember how scared men are of knives in that area. The sharp hemostat punctures the skin after it is numbed up and the it spread to make the opening. Most people do feel this is better, spread skin bleeds less and heals better than cut skin. Don’t ask me why.
  • Will fluid still come out with ejaculation after a vasectomy? Will it look the same? Yes there will still be fluid, most of the fluid in the ejaculate comes from the prostate and seminal vesicles. Since the portion of the ejaculate from the testicles in the form of sperm is so small, one will usually not notice any change in the character of the semen.
  • If I am having a vasectomy and one side is done, and then I change my mind and ask the urologist to stop, can I still achieve pregnancy? I bet you think this is an odd question but I am sure this has happened. The answer is yes, in the majority of patients you only need one testicle to achieve pregnancy. I have often asked the patient after finishing one side and before doing the second,” You still have time to back out. Do you want me to continue to the other side?” I personally have not had a taker on this, but I have had a wife start crying at the beginning of the procedure which prompted me to stop and allow the couple more time to discuss the situation and that they were both on the same page of proceding. Sometimes they have proceded and other occasions the couple has left to reconsider at home.
  • Are vasectomies ever done in the hospital? Yes, but insurance coverage may be a problem. For the patient with the tight scrotum and overly sensitive to the area in terms of manipulation of the scrotum or intense anxiety…the hospital is a good but uncommon option.
  • Which male makes the ideal vasectomy patient? Well…first of all he won’t be telling you he passes out if he hears the word blood or needle. He doesn’t faint easily and has no problem with dentist appointments. His scrotum hangs down…funny huh? Tight high up scrotum-difficult to do; loose thin skined hanging down scrotum-a piece of cake. We do “em” all but some patients are easier than others.
  • Have you ever found testicular cancer in the process of doing a vasectomy? Yes…in a consulation and examining to be sure I could feel the vas and that there were two, I detected a testicular mass that was cancer and required an orchiectomy. It has only happened to me once but I check for it before every vasectomy patient I do.
  • How long does it take you do a vasectomy? Less than fifteen minutes or two the three songs. I have toyed with a commercial stating, ” Your vasectomy in less than 15 minutes or your money back.” I mentioned it to a friend as I was beginning to perform his vasectomy. He said, “John. Please, take your time. I am in no hurry.” He did not like that particular marketing angle.
  • What is the strangest thing that has ever happened to you while performing a vasectomy? This is easy. It was an attractive young couple in which the wife wanted to stay in the room, which I encouraged. When I stated that I am going to put in the numbing medicine, the patient turnbuckles his leather belt and hurriedly pulls it off with the resultant repetitive slapping sound as the belt goes through all the belt loops and puts it between his teeth. I was a bit surprised but did notice that there were other teeth marks on his belt of varying age, color and depth of penetration. He grimaces and says through his teeth and the belt, “You can go ahead doc.” I said, ” I don’t think that the belt is necessary. The medicine I have given you and the local should make this painless for you.” “That’s okay…this is how I do all my procedures,” he says as his face is becomes swollen and red from the anticipation of my procedure. Against my better judgement I proceed all the while the patient is grunting  and snorting  around the belt in his mouth. “Sir. Is that really necessary? I think you are going to make yourself sick.” By this time his wife who I distinctly remember was wearing a low-cut blouse, gets up to hold his hand and pat him on the head. “Is he hurting you dear?” she asks. “No, not yet,” he says in an abbreviated fashion through his teeth. At the point my instruments touched his scrotal skin, the patient straightened and then passed out, the belt still firmly ensconced in his mouth. The wife seeing this says, ” I don’t feel well.” She begins to turn white and falters back toward the chair. I leave the patient and catch her before she falls. The way I catch her put my head to her bosom and I am holding her there trying to put her feet on the chair and her head on the ground all the while face to face with her breasts. I get her situated, get the belt out of the mouth of the patient(with some difficulty) and then call a nurse to help. When the nurse arrived the wife is on the floor with her legs elevated on a chair, the husband is white as a sheet and slowly coming to. After about ten minutes both are revived, the wife now sitting in the chair and I begin to discuss whether we should proceed or do something another time, maybe in the hospital or something. “No, I am fine. Let’s go ahead and do this thing.” I said, “I don’t want you to use the belt this time. I think your doing that started the whole thing about passing out.” We do  the procedure, the wife and the patient this time do fine. As I was finishing the post-procedure instructions, the wife who just minutes before was in my arms and in intimate contact says with much concern,”Dr. McHugh. Thank you so much. If in the future if I decide to  have another baby will you be there for me?” What she meant to say was “If we want another baby, will I be able to guide them through the process of a vas reversal?” Nevertheless I responded, “Yes mam. I will be there for you.”

One Reply to “Vasectomy 101:Gainesville’s Northeast Georgia Urology Group, NGUA (Everything you wanted to know about a vasectomy but were afraid to ask.)”

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