Scalpel / No - Dr Jonathan Follows

2 What You Need To Know About Your VasectomyFirst ConsiderationsVasectomy should be consideredpermanent and irreversible.Most vasectomies can be reversedby removing the scar tissue andreconnecting the healthy vas ends,but it’s expensive and not alwayssuccessful. Getting sperm flowingagain isn’t the problem, but for someunknown reason their ability to fertilizediminishes with time elapsed. Reversalwithin the first three years has about a70% chance of successful pregnancy.By ten years out, this drops to a 30%success rate, so vasectomy reversal isnot to be relied on.This is why you should be positive younever wish to sire any more childrenbefore you have a vasectomy.Sperm Cryopreservation (a.k.a.Pre-Vasectomy Sperm Banking)is “insurance” every man shouldconsider. It is not a guarantee of futurefertility but it may be a good idea ifyou ever want another child later (and asmall waste of money if you don’t).This service is provided at GenesisFertility Centre (tel: 604-879-3032).$400 is the cost of processing thesample and storing it for the firsttwo years, after which storage canbe renewed as you wish for about$200 per year. One specimen usuallysuffices. That usually yields enoughsemen for 8 to 12 attempts at artificialinsemination (AI), or, if AI doesn’t workin the first few tries, in-vitro fertilization(IVF).The following demographics are athigh risk of regretting their vasectomylater:• Single• Under 30• Never had children• Recently separated, divorced or in anunstable relationshipThose with a newborn should considerpostponing vasectomy until the babyis at least 6 months old, since that’swhen the risk of Sudden Infant DeathSyndrome (SIDS or Crib Death) isgreatest, about 1 per 2000 births.

What You Need To Know About Your Vasectomy3Sex After VasectomyA vasectomy has no direct bearingon sexual function. No better. Noworse. The ability to obtain andmaintain erections is unchanged.Since sperm comprise only 2% of thesemen volume there is no noticeablechange in the quantity or quality ofthe semen ejaculated. You’re like aSunkist orange, all juice and no seeds.The force and timing of ejaculation areunchanged. No effect on testosteronelevels, desire or libido occurs. Manycouples report a more relaxed andenjoyable sex life once the fear ofpregnancy is gone, particularly oncecondoms are no longer required, butthat is true of anything that takes theworry out of being close. Marriageproblems are rarely cured byvasectomy. A couple’s sexualproblems, lowdesire or sexualavoidancemay stemfrom fear ofpregnancy,but stress,children,fatigue or poorcommunicationcan be at play aswell. It would be wiseto discuss these issueswith your partner and yourdoctor and address thembefore the vasectomy, just toensure you are not disappointed laterbecause of unrealistic expectations.Vasectomy does not protect againstsexually transmitted diseases or AIDS.Condoms are therefore still requiredfor sexually risky behavior.

4 What You Need To Know About Your VasectomyNo-Scalpel / No-Needle VasectomyHow it’s done here...The No-Needle injector delivers afine jet of Xylocaine right throughthe scrotal skin onto the vas andsurrounding tissues. It requires only1/10th the volume of anestheticcompared with the needle method sothere is less tissue distension and lessrisk of bleeding. Also, it is a provenmedical fact that men prefer to haveneedles kept as far away from theirscrotums as possible.The “No-Scalpel” part refers to thetechnique of getting to the vas at thefront of the scrotum using two smallsurgical instruments developed inChina in 1974. There are no knives,scalpels, lasers or other hi-tech gizmosinvolved. It is “minimally invasive” sothere is less trauma to the tissues. Thesurgery and the recovery are usuallyfast and the pain is usually minimal.Once the vas is exposed by gentlypulling a small loop of it out the frontof the scrotum it must be blocked.(Occluded is the hi-tech term.) Theparticular method of occluding thevas varies from doctor to doctor. Iperform an open ended fascial technique.The vas is cut leaving two ends. Theend that carries sperm to the prostatewhere it mixes with the seminal fluid iscauterized and pinched, later to forma solid plug of scar tissue in the lumenof the vas. That end is further occludedby crimping a small titanium clipover its surrounding sheath. The endcoming from the testicle is cauterizedbut otherwise left unblocked. Theclip thus interposes tissue betweenthe two ends so they heal in differenttissue planes, reducing further the riskof sperm recannalizing a micro-channelthrough the roadblocks we’ve (wellme, really) set in their path. Since thehuman sperm is designed for tunnelingas well as swimming, we cannot be toocareful, hence the “double block”.After the vasectomy the testiclescontinue to produce immature spermbut the body’s recycling team, in theform of white blood cells, migrate tothe region, engulf and destroy thesperm and return the componentmolecules into general cellularbuilding blocks via the lymphaticchannels. By the way, the titanium clipspose no harm to health. They don’t setoff airport security systems and theydon’t interfere with MRI scans. After afew weeks you usually can’t feel themeven if you try.

6 What You Need To Know About Your VasectomyThe Possible ComplicationsRight Away:Syncope: That’s the medical termfor fainting. One particular subtype,vaso-vagal syncope, happens tocertain prone individuals when theyexperience a noxious stimulus, like thesight of blood, the smell of cautery,the idea of vasectomy, to cite buta few examples. It’s like a suddenpanic attack, then the nervous systemover-reacts to it’s own adrenaline andpumps out a bunch of vasodilators;chemicals that relax blood vessels,particularly in the abdomen andextremities. As blood pools to theseareas the blood pressure drops andthe person feels faint, dizzy andclammy or may even pass out briefly.In the First 10 Days:Hematoma: This results from bleedinginto the scrotum. It can get large andpainful, and turn the scrotum blackand blue. Incidence with conventionalvasectomy is around 3%. The NSVliterature puts it at 0.3%, but I’ve onlyseen 3 “big ones” in 16,000 (0.03%).Infection: Minor infections occur inabout 1 to 2% of patients. Seriousinfections, requiring intravenousantibiotics or drainage of an abscessoccur in about 0.2% of cases. Eventhese rare and serious infections usuallyresolve completely in a few weeks.Vasitis or Epididymitis: Inflammationand swelling of the tissue surroundingthe vas or extending down around theepididymis (the part just below thevas that joins it to the testicle) occursabout 10% of the time. It’s usuallymild and transient, no bigger thana grape, but rarely the swelling canget to the size of “a third testicle”.Needless to say, it can be painful, butthis too will settle with religious use ofindustrial strength non-steroidal antiinflammatorydrugs (NSAIDs). It cansometimes take a few weeks to settledown. Given that swelling is what themale genitalia like to do best, all thisis not surprising. In fact, inflammationand erection both produce swellingthrough almost identical biochemicalpathways. That is why I encouragethe liberal use of ibuprofen or otherNSAIDs for a full week post-op, evenif you’re not having pain. Tylenol isusually not as effective for this.Later:Sperm Granuloma: This as a smallinflammatory lump which can occurnear the cut end of the vas or in theepididymis weeks or even months aftersurgery. It can be painful, but it’s notserious and usually resolves with a shortcourse of an NSAID like ibuprofen.Chronic Post-vasectomy Pain: Thisis rare. Most pain settles within 1 to 2weeks with NSAIDs, if you take them. Ifthis doesn’t work then a longer, strongerNSAID is required. In about 1 per 1000pain will persist beyond this and anumber of other approaches may betried, including anti-depressant medsor other “pain modulating” drugs. Anexact cause of the ongoing pain isusually not apparent, but this conditionappears to be similar to other chronicpain syndromes, in that pain pathwaysin the spinal cord and brain appear toremain activated in the absence of anyapparent ongoing stimulus. Surgery to

What You Need To Know About Your Vasectomy7reverse the vasectomy is a last resortand is said to be 85% successful. Forsome strange bureaucratic reasonBC Medical will not cover the costof reversal even in this medicallyindicated situation. (Talk to your MLA!)Converting a “close-ended” vasectomyto an “open-ended” vasectomy hasbeen recommended by some but thishas not been shown to be effective.NOTE!If you are still experiencing pain ordiscomfort after a month, don’t ignoreit. Come and see me.Regret: About 2% of men come toregret having had their vasectomy.Typically it is a man who finds himselfin a new marriage, typically with ayounger partner who would like achild. These days some men seem tobe getting vasectomies younger. I justhope they (and you) don’t come toregret it down the road. So, “BE SURE!”The Risk of Prostate Cancer: NO!Vasectomy does not increase the riskof prostate cancer. Back in 1992 somelarge studies suggested an increasedincidence of prostate cancer in menwho had been vasectomized. By 1994,after careful review of the old data andthrough subsequent studies expertpanels of urologists and oncologistsconcluded that was not the case. Theyexplained that the earlier conclusionswere flawed by “selection bias”.Statisticians explain it like this:Men who have undergone vasectomyhave seen a doctor and are, demographicallyspeaking, better educatedand health conscious relative to theaverage, unvasectomized “Joe” whowould never see a doctor for a vasectomy,let alone a prostate check. Whennew studies controlled for this bias theyfound that vasectomy does not increasethe risk of any cancers or any otherdiseases. Some studies even suggestedthat vasectomized men actually livelonger, but again, this is probably justselection bias as well, given that vasectomitesare a healthier demographicpopulation. Surveillance is ongoing.Other risks: Very rarely somethingweird happens after vasectomy, likea bladder infection or a prostateinfection. By rare, I mean 1 or 2 in16,000 vasectomies to date.PPA (primary progressive aphasia) isa rare type of dementia. A neurologyjournal article in 2007 suggested apossible link to vasectomy but therehas, as yet, been no corroboratingdata from any other experts in thefield. Even if a link is eventuallyestablished, keep in mind that PPA is arare condition.If you look online you will find websitesand the odd book warning of thedangers of vasectomy, mostly related tochronic pain. Some go into great detailabout anti-sperm antibodies. Most mendo indeed form antibodies to their ownsperm after vasectomy but the levels godown over time, and the levels do notcorrelate to any symptoms, problems ormedical conditions. The overwhelmingmedical consensus is that they are of nosignificance. Still, you need to decidethis issue for yourself.And finally, the standard medicaldisclaimer:We can never be certain that researcherswon’t find some new risk at some pointin future, so every man must bear theresponsibility for his own decision.

What You Need To Know About Your Vasectomy9After Your VasectomyTypically there is mild discomfort for 5to 10 days. It’s usually in the scrotum,but it may radiate to the groin or eventhe lower abdomen (Up in the ovarieslike a menstrual cramp!). It can be onesidedor bilateral. Swelling is usuallymild. It often only starts on the thirdor fourth day. That’s why you need tofollow instructions whether you thinkyou need to or not.Following these instructionscarefully will ensure the bestprospect for an uneventful recovery.Activity: Go straight home and do aslittle as possible for the rest of the day,and the next. No yardwork! No drivingrange! No lifting the baby! No horsingaround with the kids! Nothing! I mean it.Yes you can go to the bathroom butonly if you absolutely have to (joke).You can increase your activity graduallyday by day, but remember to always erron the side of caution. Exertion at workor sports, and sexual activity are bestavoided for a full week. Lift nothing

10 What You Need To Know About Your VasectomyAfter Your Vasectomy continued...over 15 lbs for the first three days andnothing over 50 pounds for the rest ofthe week. If in doubt, don’t do it!Sexual activity should also be avoidedfor the first week. If anything comes upjust ignore it and it will go down again.Ice: Apply an ice pack over the gauzeand athletic support as soon as you gethome and ice as much as possible overthe next few days. A dozen ice cubes(give or take) in a waterproof plasticbag is undoubtedly the cheapest andprobably the best. It will take a while forthe cold to penetrate all the gauze, butyou’ve got lots of time. You don’t wantto freeze it, you just want to keep it cool.Wound care: The small wound is sealedwith skin adhesive so there is no messor bother. There should be no seepageor bleeding from the wound. Still, havea peek every once in a while to makesure all is well. The gauze is just to keepsome pressure on the wound for the firstfew days. It also elevates and protectsthe scrotal contents from the forces ofgravity. Take the strap and gauze off inthe morning and have a gentle shower.Each day throw away one or two piecesof gauze closest to the skin before youstep back in, so that the gauze pack isdwindled down to nothing over time.Once the gauze is gone you may wantto keep using the support. If so, wearit outside your underwear to avoid therough cloth on tender skin. The support,with or without gauze should cradlethings nicely out of the way. We don’twant your testicles hanging down andbanging around.Alcohol: No drinking for at least thefirst 48 hours post-op. Alcohol can thinthe blood and/or cloud the judgment.Don’t risk it. It’s not a good idea todrink with ibuprofen in your systemanyways. Not only should you not drink,you should also stay away from drunks.Pain and its management: Weprovide you with ibuprofen 600 mg, 3times a day for a week. This is not justfor pain. It also prevents inflammation.Typically a mild delayed inflammatoryreaction begins around the third orfourth day and results in some swellingand pain around the vasectomy site,above the testicle on one side or theother, occasionally both. This is yourcue to take it easy and do more icingas necessary. People who get stomachupset from ibuprofen can substitute ananti-inflammatory like Celebrex. Thoseallergic to ibuprofen or aspirin cansubstitute acetaminophen if necessary.Remember, swelling is what this part ofthe anatomy prides itself in doing bestso take that anti-inflammatory for thefull week whether you think you needit or not.Call me promptly if you suspect aproblem may be developing.If there is:• Fever • Blood• Pain worse than a “3 out of 10”• Swelling larger than a grape.NOTE:Bruising under the skin is no greatconcern unless it is swollen or painful.

What You Need To Know About Your Vasectomy11After Your Vasectomy continued...Blood in the semen can occur in thefirst few ejaculations and is of noconcern. You shouldn’t be messingaround yet anyways!Follow-up visit: I’d like to see youback for a brief follow-up in 5 to 14days if possible. I check on healing,have you fill out a brief questionnaireand review your next assignment…semen testing in 8 weeks. Don’t forgetthe backup birth control until we’vedone the test to ensure the vasectomyworked. (The proof’s in the pudding!)Rich’s rules for an uneventful recovery:• Go straight home and sit with yourfeet up as much as possible for thefirst few days.• Ice the scrotum, through the gauze, asmuch as possible for the first 2 or 3 days.• No lifting, straining, exerting orexcessive walking for the first 3days. A desk job can be resumed in48 hours but more strenuous workshould be avoided for up to a week.• No ejaculation for a week. If you don’tfollow this one you void the warranty.(Just kidding, there is no warranty.)• FEVER, BLOOD, PUS, SEVERE PAINOR SWELLING? These are not normal.Call me if this happens. (You will getmy cell phone number at surgery.)• Arrange for a post-op visit in 5 to 14days.If everything is fine after the recheckyou may resume your normal activitiesbut use common sense. Start lowand go slow. Complete healing cansometimes take up to a month.Post Vasectomy Semen Testinga.k.a. ‘Making sure that Elvis has leftthe building!”Vasectomy does not work immediatelyso you must use backup birth controluntil we do the test and declare yoursemen free of sperm. The top endof the vas, where it empties into theurethra, called the ampulla, can harborholdout sperm in its nooks and cranniesfor weeks, and occasionally months.That’s why back-up birth control isessential until we do a semen checkunder the microscope and ensure thatthere are no sperm left in the ejaculate.We have a zero tolerance policy. Thatmeans no sperm, dead or alive.We can do a test at 8 weeks. If it’sclear you can safely stop backupbirth control but we like to do adouble check at 12 weeks. Call mesuperstitious! I prefer to do the testat my office and give you the result onthe spot. That eliminates the risk of aclerical error or a miscommunicationfrom a garbled phone message orwhatever. Sound far-fetched? Wella Victoria urologist was successfullysued for wrongful birth when a couplewas told over the phone that thevasectomy had worked when in factthe test showed that it hadn’t.

12 What You Need To Know About Your VasectomyYou will need to call the office a fewdays ahead and book a date and timethat’s convenient for you to bring inthe semen sample within 4 hours ofcollection (not within an hour like theother labs require). You don’t need torun any red lights. This also gives usanother chance to meet face to faceand discuss any lingering concernsyou may have about anything andto collect your prize for havingsuccessfully failed the test. I can’t tellyou what the prize is. It’s a surprise.If the test shows that you still havesperm we don’t rush in to do anothervasectomy. We just stall for time. Mostguys will “come clean” within anothersix weeks but the occasional “diehard”will take longer; up to six months.How you get the sample into thebottle, whether by masturbation,interrupted intercourse or emptiedfrom a condom, is your business. Justspare me the gory details, make surethe top is screwed on tight and,if there’s been any “spillage”,please wash off the outside ofthe bottle.happens to you, remember: it’s yoursuperhuman sperm, not my shaky handsor failing eyesight that’s responsible,so don’t expect a contribution to thecollege fund from me!Even if you’re clear at 12 weeks, there isstill a small chance of re-cannalization(a.k.a. failure) later down the road. I’veseen it once in 16,000 cases. If you’reparanoid about it this for any reason,we can do another semen test at anytime but it’s not considered necessary.This is still about a thousand times saferthan most of the other standard birthcontrol methods out there. Remember,nothing in life is 100%, except death.(Not everybody pays taxes, y’know!)All kidding aside, you and yourpartner need to read this bookcarefully and ensure that all yourquestions are answered before youhave a vasectomy.A Failed Vasectomy: Thepersistence of any live spermsix months out from thevasectomy indicates that thelittle suckers have managedto “break on through tothe other side”. In thispractice, over fifteen yearsand 16,000 vasectomies,that happens in oneout of every 400vasectomies. If this

DR JONATHAN FOLLOWS AND DR BARRY RICHTel 604-539-1915 Fax 604-539-1983 www.nsv.caPLEASE BOOK ALL APPOINTMENTS BY CALLING OUR OFFICE AT604-539-1915.Prior to Vasectomy:Appointments missed or cancelled without 72 hours notice aresubject to a $100.00 cancellation fee.RICH/FOLLOWSNo-Scalpel/No-NeedleVasectomy Clinic64th AvenueNClinic197th StreetSuperstoreWillowbrook Dr.WillowbrookShoppingCentre200th StreetWhite Spot10Fraser Highway1A301B - 6351 197 Street, Langley BCTel 604 539 1915READ THIS BOOKLET CAREFULLY WITH YOUR PARTNER.ENSURE THAT ALL YOUR QUESTIONS ARE ANSWEREDBEFORE YOU HAVE YOUR VASECTOMY.© 1997-2011 Barry Rich MD Inc. All Rights Reserved