Vasectomies

Dr Durward Black Urologist VasectomyOver 3,200 minimally invasive vasectomies have been performed by our urologist, Dr. James Durward Black, Jr. MD, FACS.

If you have questions, come in to discuss them. It doesn’t matter if it’s for an initial consultation or a second opinion.

If you come in you will ALWAYS see Dr. Black, a board certified urologist, not a nurse and not a general practitioner. A vasectomy consultation is good for one year.

Free 90 day follow up.

Most insurances are accepted and we can check to see if you need a referral or pre-certification.

Call Us @ 770-386-1076

Most insurance is accepted and we can check to see if you need a referral or pre-certification. To make an appointment, call 770-386-1076 during office hours or click here 24/7 to make an appointment request online.

Vasectomy

Just the thought of surgery in this area is a source of great anxiety for many men. Today’s vasectomy is not the same vasectomy that your father had. The introduction of minimally invasive operations like the percutaneous and the no scalpel vasectomy have revolutionized vasectomies.

A vasectomy is the surgical sterilization procedure for men. This means it is a permanent form of birth control similar to a tubal ligation in women. A vasectomy consists of dividing the vas deferens in two in order to stop the addition of sperm to the rest of the semen. Semen is the combination of fluids from the testicle, the prostate, and the seminal vesicles.

While most men fear that this will affect their masculinity, libido, and erection, this is not the case. Testosterone, the male sex hormone, does not travel up the vas deferens. It is secreted directly into the blood stream. There is no decrease in sex drive or libido. The nerves to the penis are totally separate from those to the testicle and in no way does vasectomy cause ED. As a matter of fact, a significant number of people enjoy sex more often with more spontaneity once their fear of pregnancy is gone.

The vasectomy is carried out most often in the doctor’s office under local anesthesia. Until recently, anesthesia was accomplished by injection of a small amount of numbing medication and used a small, 28-gauge needle. Since August of 2015, I have been doing a “no needle anesthesia”. I use an instrument called a Madajet. This instrument sprays the anesthetic through the skin without using a needle. This is similar to the way some immunizations have been given in the past. Most patients describe the procedure as having the same feeling as a mild thump with a rubber band. I had previously used a small, 28-gauge needle. Diabetic or allergy needles are the same size. Doing this in the office avoids the hospital, its charges, and the antibiotic resistant bacteria that thrive in hospitals.

In years past, this required shaving the lower abdomen, scrotum, and upper thighs. The hair growing back out was almost as bad as the procedure. I currently only shave a small portion of the front of the scrotum at the time of surgery. I do not ask men to shave before the procedure. The shave bumps that appear on many newly shaved men are a staphylococcal infection and are to be avoided. Shaving the site immediately prior to the procedure lowers the risk of infection. Until the late 1980s, two incisions made up to one inch long were required to do a vasectomy. Today, only one, 5mm puncture in the scrotal midline near the base of the penis is required. Previously, the bleeding and infection rate associated with vasectomies was 15-30% in the 1980s. Today, there is only a 1-2% risk of men having any bleeding or getting an infection. Past operations required most men to take up to 30-40 pain pills. Today, they often take nothing but Tylenol or Ibuprofen. A post-procedure prescription of #10-15 tablets of Hydrocodone or rarely Oxycodone is provided upon request.

The missed work depends on how strenuous your job is for you. If you do deskwork, you may miss as little as 2 days. For a job with lifting and straining, 3-5 days of missed work should be enough.

Sterility is not instantaneous as with tubal ligation. After a vasectomy, it takes about 15-20 ejaculations to empty all of the stored sperm (or 3-4 months for all of the remaining sperm to die). While the first few ejaculations may be uncomfortable, this discomfort rapidly diminishes over a few weeks. The epididymal congestion or “blue balls” feeling is usually fully resolved by 3 months, but in most cases, it is minimal by 3 weeks.

The failure rate of vasectomy and tubal ligation are quite similar and are about 1/1,000 to 1/2,000.

Sterility is evaluated by looking at a semen specimen under the microscope. Sterility is noted when no sperm are seen. Two specimens are checked at least one month apart to assure there has not been a failure due to the divided vas deferens ends growing back together.

I have done about 3,000 minimally invasive vasectomies in the last 26 years.

Why I Feel The No-Needle Anesthesia Is a Benefit To You:

Below is a list of reasons why the Madajet is not used by all urologists.

  1. Most Urologists don’t do it due to the expense of the equipment.
  2. Some Urologists just don’t believe that the injector is a real benefit and is just hype by the manufacturer.
  3. Other Urologists just like the tried and true method that they learned long ago and just don’t want to change.
  4. Some doctors worry about adding time to the procedure and loss of efficiency.
  5. Many medical personnel are so comfortable around needles that they can’t believe men are really afraid of a needle.

 

I started using the Madajet during the summer of 2015. It does take some time to teach the staff how to prepare the instrument, to teach everyone how to properly clean and sterilize the instrument, and begin to use and learn to efficiently use the device.

Just filling a syringe with Lidocaine and Marcaine in a 50/50 mixture and injecting this is a lot easier than learning something new.

My assessment after using this for the first 2-3 months was that placing the 6 Madajet activations (three to each vas deferens) is now as efficient a way to “deaden” the skin and the vas deferens for a vasectomy as was using the 28-gauge needle in the past.

I have found that the Madajet:

  1. It uses less medication making it easier to feel the vas deferens during the vasectomy.
  2. While most men are mildly needle phobic whether they admit it or not, this benefits all men from the truly needle phobic ones to the very stoic ones. Reduced anxiety makes the vasectomy easier for both the doctor and the patient.
  3. Once I learned how to efficiently handle the instrument, the numbing part of the vasectomy actually takes less time, is less painful, and invokes much less anxiety.

 

The anesthesia the Madajet provides is quite good, and it is uncommon to need to use a needle to supplement the anesthesia with any further medication. Additional medication is needed from time to time and a needle is used, but it is passed through skin that has already been deadened with only mild pressure being felt. The Madajet may not fully anesthetize patients with thick scrotal skin. Not all men’s scrotal skin thickness is the same. Thickened skin makes it harder for the Madajet to penetrate as deeply into the tissue around the vas deferens and may require additional anesthesia.

If you are interested, there are multiple YouTube videos of doctors demonstrating the no needle anesthesia during actual vasectomies. You just need to search for the term “no needle vasectomy” or for “Madajet for vasectomy.”

When I am asked if using the Madajet is really better, my response is that I think so. In the big scheme of things, the basics of the vasectomy (cutting the vas deferens and sealing the ends) are not changed. The amount of medicine is less, the anesthesia is as good as the standard injection, the vas deferens are easier to work on due to less volume of medicine, and men are more relaxed knowing there is no needle.

Section 1: The vasectomy pre-op visit

This it the time for you to get to know the person doing your procedure and to ask any questions that may be on your mind. It is used to fully explain the procedure and to allay any fears you may have. On this visit, a complete history will be obtained. This will tell your doctor if there are any special concerns that might affect your procedure.

For example, anyone on blood thinners will be evaluated to see if these can be safely stopped. Aspirin as well as Ibuprofen can be potent blood thinners in some people. Not stopping these can lead to more postoperative bleeding (hematoma formation) or bruising or a delay in recovery.

A complete description of the procedure with visual aids will be completed. This will include both the benefits and risks of the procedure as well as contrast and comparison to tubal ligation. Tubal ligation is the medical term for a woman’s sterilization, also known as “tying her tubes.”

A complete genital examination will tell your doctor if there are any special anatomical concerns such as varicose veins that might increase the risk of bruising. Your doctor will also look for epididymal cysts and any type of testicular sensitivity or pain. Finding this out preoperatively will help to avoid any problems that may cause delays in recovery. This examination will also allow your doctor to show you the vas deferens and where the local anesthetic will be injected.

Your urologist can discuss how may days off of work you may need, as well as when you may shower and resume intercourse.

Once all your questions have been answered and you are sure that this is the right decision for you, you may then schedule your procedure.

Section 2: The day of the vasectomy

On the day of the procedure, you will usually be at the office for about an hour. The actual vasectomy takes on average about 15-20 minutes. Oral medication for sedation is available on request, but must be arranged before your arrival for the procedure. Intravenous sedation is not available. During the procedure itself, you will be awake and will only be sedated if pre-arranged prior to that day. It is very unusual for most men to require a sedative. The vast majority of men do this under local anesthesia using the Madajet no-needle injector. It is advised that you have someone to drive you home after the procedure.

You will need to undress from the waist down and will be provided a cover up sheet.
Dr. Black will see if you have any new questions that might have come up since the pre-op evaluation. In our office, for your privacy, the doctor does the antiseptic skin prep and places the drapes before the nurse enters the room.

After the local anesthetic is injected using the Madajet needleless injector, a small area at the base of your penis and on the upper scrotum will be shaved and cleaned with antibacterial soap followed by a Betadine, iodine-based, skin prep.

Sterile drapes will be applied, leaving only your scrotum exposed before the nurse enters the room.

The procedure consists of a puncture on the upper scrotum at the base of the penis with exposure of first vas deferens then the opposite one. Each vas deferens has about 3/8 inch or 1 cm removed followed by eletrocautery to heat seal the ends. The surrounding muscular sheath is then closed further separating the two cut ends of the vas deferens.

After the 20-minute procedure, you will be checked for signs of bleeding, the Betadine will be cleaned off, and then bandaged with a sterile 4×4-gauze. You will need your preferred form of scrotal support to use at that time. The scrotal support will be used to hold the bandage in place. This allows the bandage to be held in place without tape. Boxer shorts will not work.

My staff will schedule a 2-month follow-up appointment with you. This is covered with the procedure, so no co-pay is required. We can also schedule a one week post-vasectomy appointment if you feel the need, you just need to call the office and let us know.

Please remember, you will need to continue some form of birth control until you have had 2 negative semen specimens about 1 month apart, starting at the two month appointment.

Section 3: Procedure follow-up after a vasectomy

We will schedule a 2-month appointment with you at the time of your vasectomy. Another appointment can be scheduled at your request for one week post-vasectomy.

The purpose of the 2-month visit is to see if you are having any problems and to evaluate you for sperm granulomas. Granulomas form when sperm leak from the end of the cut vas deferens. These granulomas occasionally cause pain, and large granulomas may increase the failure rate.

You will need to bring in a semen specimen for evaluation of sterility. It is not like a 20-minute old, fertility specimen. The ideal semen specimen is 1-2 hours old. It may be 2-4 hours if 1-2 hours is not convenient. Live sperm continue to swim for about 2 hours; if none are seen, then an older specimen is adequate. If multiple dead sperm are seen, then a fresher specimen may be needed to see if they were alive at 1-2 hours.

If your examination is normal and the semen specimen is devoid of all sperm alive or dead, then a second specimen is required approximately one month later to make sure the vas deferens has not grown back together in a delayed fashion. You do not have to be present for the second semen specimen evaluation, so no appointment is scheduled for this. You or your spouse may drop off your second semen specimen, and we will call you with the results. If a few dead sperm persist, you may need to bring in a third specimen and very rarely, a fourth.

If at that point you are sterile and you have no further questions or concerns, then no further follow-up will be required.

Only after 2 negative semen analyses is it safe to go off birth control.

Section 4: Vasectomy FAQ

How long after the vasectomy will it take until I am sterile?

Sterility is not immediate after vasectomy. You will not be sterile for 2-3 months or until 15-20 ejaculations.

When do I bring in the first semen specimen?

2 months

When can we stop birth control?

After two negative semen specimens.

When may I shower?

The next day.

When may I swim?

You may swim when the hole has closed completely. Usually the puncture takes 5-7 days to close. Please, do not get into lake water or a hot tub bath for 10-14 days

Do I need to use an ice pack?

You may use one, but it is not mandatory.

When can I have sex?

It is best to wait 5-7 days.

When can I stop using the scrotal support?

When you are comfortable walking without a support and you have no pain.

When may I resume my usual work out at the gym?

I recommend waiting about 1 week. Then try a light workout to see how you feel the next day. You can then slowly work your way back into a full routine over 1 week.

Will I need pain medication?

I usually give you 10 tablets of Hydrocodone 5/325mg. Most people are fine on only Tylenol or Ibuprofen.

When may I return to work?

You may return to work in 1-2 days for deskwork and in 4-5 days for more strenuous jobs.

How old can the semen specimen be? Is this the same as a 20-minute old infertility specimen?

No. It is not the same as an infertility specimen. It may be up to 4 hours old.

What do I put my specimen in?

You should have been given a specimen cup at the time of your postoperative visit. If you do not have a cup, any clean, disposable container will do. Some men even use a Ziploc bag.

Where is the procedure to take place?

The procedure is preformed in the office, not in the hospital.

Why the office and not the hospital?

The office avoids the expense of the hospital as well as exposure to its antibiotic resistant bacteria.

Who performs vasectomies?

About 75% of the vasectomies are done by urologists while the remainder is done by general surgeons and family practice doctors.

How common is vasectomy?

The USA has about 500,000 vasectomies per year. It is the fourth most common form of birth control after condoms, oral contraceptives, and tubal ligation.

Why vasectomy and not tubal ligation?

Vasectomy is minimally invasive, out patient, less risk, and less expensive with a quicker recovery.

Is a vasectomy covered by insurance?

Most insurance covers vasectomy. We will call your insurance company and check for you. Some people only pay an office’s co-pay while other insurance considers it a procedure applied against your surgical deductible.

What about Essure versus vasectomy?

Essure is a procedure done through the cervix and then evaluated again for success a second time through the cervix. Conformation of vasectomy success only requires a semen analysis.

May I store some of my sperm, in the sperm bank, before the vasectomy?

Yes you may. However, if you are that unsure about the vasectomy, you may want to wait before scheduling your vasectomy. Cryo-preservation costs about $50 -60 per month or about $600 to $720 per year.

How long does the procedure take?

Usually the total office visit is about 1hour; the actual procedure takes about 15-20 minutes.

Will I be put to sleep?

No, you will not. Almost all vasectomies are done in the office or clinic setting under local injection using a small needle. Oral sedation can be arranged upon request prior to your procedure but is rarely needed or requested.

Do I need to stop my baby Aspirin?

It is advised that you stop taking all forms of anticoagulation medication (Aspirin, Motrin, Ibuprofen Aleve, Naproxen, Coumadin, Warfarin, Plavix, and Clopidogrel) before having the procedure so as to lessen the chance of bleeding and bruising. Please discuss this at the time of your pre-op evaluation.

Why do I have to have a pre-op evaluation if I have already decided that vasectomy is right for me?

A full history and exam will be carried out to assess you for risk factors or physical findings that may complicate your vasectomy.

Do I need my wife’s permission for a vasectomy?

No, you do not, but it is recommended that it be a mutual decision.

Do I need to shave before the procedure?

No, you do not need to shave. I prefer to shave the site at the time of surgery. Shave bumps are Staph infections of the skin and may increase the risk of infection.

Do I need an ice pack or bag of frozen peas after the procedure?

No. Ice is optional and is left to your personal preference.

When do the stitches need to be removed?

In most cases, there are no skin sutures to be removed. If a skin closure suture is required, it will dissolve within 5-7 days.

Do I need a jock strap?

You need some kind of support, but it may be tight, white underwear, bicycle shorts, or a jockey strap, whichever is more comfortable for you. You do need to bring it with you on the day of the procedure. You will need it to wear home.

Will a vasectomy affect my erection?

No changes in erection will be noted.

Will I still produce fluid at ejaculation, or will it be dry?

Semen is made up of sperm from the testicle as well as fluid from the prostate and seminal vesicles. Only 5-10% of the ejaculate is sperm. The remainder of the fluid still comes out with ejaculation.

Will it affect my orgasm?

No, there will be no change after the immediate postoperative period is over. Initially, there may be discomfort slowly resolving over a 1-3-week period.

How will I know if the vasectomy works?

A microscopic examination of your semen specimen is required to determine if the procedure was successful.

When may I return to work?

For desk jobs, you may sometimes return to work the next day. For jobs requiring lifting, 3-5 days off of work is advised.

May my wife watch the procedure?

This is not usually allowed. Occasionally, observers will faint or cause other distractions. More often, their presence seems to worsen anxiety.

When may I go off birth control?

Birth control is typically required for an additional 8-12 weeks after vasectomy or 15 to 20 ejaculations. You must continue some form of birth control until you have 2 negative semen specimens.

Can a vasectomy be reversed?

Yes, it can be reversed. This is, however, usually not covered by insurance and costs $5,000 to $10,000 and has about a 50% fertility rate. So for practical purposes, it is permanent.

How often to people request a vasectomy reversal?

Nationally, it is stated that 1-2% of people will decide to have reversal.

Does the frequency of intercourse affect how quickly the sperm disappear from the semen?

Yes, the number of ejaculations does speed up the process. At the American average of intercourse 2 times per week, an average of 16 ejaculations or 2 months is required for most men to achieve sterility. More frequent ejaculation than 2 times per week can reduce the time to achieve sterility. It is noted, however, that most men are sterile after 3-4 months even with no ejaculation.

Is vasectomy better or worse than a woman having her tubes tied?

While they both have a failure rate of 1/2,000, there is less pain and risk involved in vasectomy.

How do I see if it works?

You simply bring in a semen specimen for microscopic evaluation. When no sperm are seen on 2 semen specimens one month apart, you may discontinue other forms of birth control.

When do I need to call for problems?

You should call the office if you have a discharge from the incision, rapid swelling over 1-2 hours, fever above 101°F, or if you just have other questions about recovery.

Will there be bruising of the scrotum?

There may be some bruising of the skin at the injection site or at the puncture site. Bruising will most likely show up 2-4 days after the procedure.

Do I need pain medication?

You may be prescribed narcotics such as Hydrocodone (Lortab), but most people do fine on oral over the counter medications such as Ibuprofen and Naprosyn.

Section 5: Woman’s Questions About Vasectomies

Vasectomy vs. Tubal ligation – What are the pros and cons? What are the differences between these two procedures??

Vasectomy is an out-patient, office-based procedure that is done under local anesthesia. It is minimally invasive. The puncture is a single puncture into the scrotum. Any bleeding is usually readily identifiable in the scrotum by office physical examination with no risk of transfusion. Infection risk is 0.5 to 1% and is again scrotal. It is cheaper than tubal, less invasive, and safer. There has never been a reported death from vasectomy in the United States. Success is verifiable by semen analysis.

Tubal requires a general anesthetic and is an out-patient hospital-based procedure. Due to hospital place of service, tubal usually costs more than a vasectomy. It requires 2-3 punctures ¼ to ½ inches each into the abdomen. All infections, bleeding, and scarring are intra-abdominal and may require a CT scan for diagnosis. Success is assumed and is not usually verified. Sterility can only be verified by way of hysteroscopy and tubal injection of contrast, but this is rarely done.

Should I consider Essure as a method of birth control?

Essure is an office-based procedure done vaginally by passing an instrument into the uterus and then up into the fallopian tubes to deposit a coil that causes scarring and therefore blockage of the tubes preventing pregnancy. A second procedure similar to the first is required to confirm success several months later. This usually requires 3 months of birth control. Reported complications include its migration into the abdomen requiring surgical removal. Not all patients can have both tubes implanted; tubal pregnancies have been reported as well. Recovery takes about 1-14 days with the average recovery time being 3-5days.