FitSugar

Going to the Dentist: What's the Deal With Sedation?

FitSugar — Tue, 18 Sep 2007 13:30:00 -0700

Even if you are one of those people who absolutely dreads going to the dentist, you know it is still really important to go regularly. You need to keep your teeth and gums healthy, so your dentist can prevent small problems from growing into dental disasters.

Now many dentists offer sedation dentistry. To ensure panicked patients make it to the twice yearly visits, many dentists offer sedation dentistry. You can opt for this method if you have sensitive teeth or gums, you don't easily go numb, if you have a lot of dental work that needs to get done, or if you have major dental anxiety or a phobia about going to the dentist. Whatever your reason, there are different degrees of dental sedation that are available.

Here's the run down of sedation methods you can try:

Nitrous Oxide Sedation: Ahh, laughing gas. I used to get this as a kid and it really helps to calm you down. You inhale it and it puts you in a state of complete relaxation, but you are still totally conscious. Since laughing gas doesn't block the pain, your dentist will still need to give you a shot of local anesthesia, aka Novocaine.

Oral Sedatives: Diazepam is one form of medication you can take the night before, or 30-60 minutes before an appointment, depending on the severity of the anxiety. Although you will feel calmer, with this option you will still feel the pain. So with this method you also still need to get a shot of Novocaine to numb you.

There are 2 more methods. To hear what they are read more

Intravenous (IV) Sedation: You basically get anti-anxiety drugs administered into the bloodstream. This also doesn't block the pain, so you'll still need to get a shot of Novocaine. You'll remain conscious and be able to understand and respond to requests from your dentist, but you may not remember much of what happened while you were in the chair. IV sedation makes you feel utterly relaxed and makes you not care about what's going on, and the drugs may also cause full or partial amnesia (only during the period of time when they're in your bloodstream. Time will feel like it passes quickly, almost like you were asleep.

General Anesthesia: This is where you are unconscious and completely pain free, so you don't even need the Novocaine. You won't be able to respond to anything, since you are basically out of it, and you'll need help breathing. This method is used if you need oral surgery, like all 4 of your wisdom teeth pulled. Someone will need to drive you to the office, stay with you during the procedure, and then will need to drive you home. Some people have negative reactions to the anesthesia and experience bouts of vomiting.

These 4 methods can be used to offer different degrees of sedation, ranging from being awake yet calm, to totally unconscious. You and your doctor can figure out what method may be right for you, depending on your level of comfort and the procedures that need to be done.

I think sedation dentistry is a brilliant idea. I don't know anyone who likes going to the dentist, so this can make necessary procedures a lot easier to handle for people who are afraid to have them done.

Fit's Tips: Looking for a dentist in your area who offers sedation? Click here to find one near you.

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Anesthesia: How Does It Work?

FitSugar — Thu, 23 Aug 2007 02:00:00 -0700

I'm going to be honest. When it comes to surgery, the idea of being "put to sleep" for a couple hours freaks me out. I will admit it, I am more afraid of the anesthesia than the scalpel. Are you freaked out a little too? Maybe if we knew more about anesthesia, we'd feel better about it.

When it comes to anesthesia, there are 4 kinds:

Local - this involves numbing a small area by injecting a shot just under the skin. (Lidocaine is a popular local anesthetic used by many dentists).
Regional - A certain area is made numb, but you are still conscious (an epidural is an example).
Sedation - This is also known as "twilight sleep." The person is just drowsy and it makes them more comfortable. Low levels of general anesthesia are used to produce this sensation.
General - You are given liquid or a gas that makes you unaware of what's happening, immobile, pain-free, and free from any memory during the period you were anesthetized (this is the stuff they use when you are having major surgery).

So how does it work? To find out read more

Scientists and doctors don't completely understand exactly how anesthesia works, but they speculate that blocking nerve impulses to your brain is what makes you numb. At a cellular level this occurs by blocking sodium channels in the nerve membranes. When sodium is blocked in this way, the nerve cannot conduct an impulse and therefore no sensation can be transmitted.

Where you go numb and for how long depends on where the drug is administered and how much of it. Local and regional anesthesia are pretty safe for the most part, but with general anesthesia, since your entire body is affected, a patient's vital signs are carefully monitored while they're "under." With all types of anesthesia, as long as you're healthy and young, you shouldn't have any complications.

Hopefully all that allays your fears a bit.

Source

How Does Novocaine Work?

FitSugar — Fri, 11 May 2007 07:30:00 -0700

When I have a cavity filled all I can say is praise to the Novocaine. When my dad was little, his dentist didn't use local anesthetics, and my poor dad had to sit in the chair knowing he was in for a whole lot of pain. My jaw hurts just thinking about it.

I just learned that prior to the invention of Novocaine, cocaine was used as a local anesthetic. Cocaine constricts blood cells, which reduces bleeding, but as we all know it's also highly addictive.

In the early 1900's scientists created a synthetic version of cocaine, but without the nasty side effects, and christened it Procaine. We know it by its trade name Novocaine, and I have no idea why my dad's dentist didn't use it since it was definitely available to the masses when he was a boy. Since its development, stronger local anesthetics have come along like Lidocaine, Septacaine, and Mepivocaine (most dentists still call the shot "Novocaine" though, so ask what they specifically use if you're interested).

These injectable local anesthetics prevent pain in a specific area by blocking the nerves that sense or transmit pain, so the area feels numb for up to 3-4 hours.

All I can say is that even though the shot stinks and can really pinch your gum (and make your mouth really sore for days after), it's still way better than how much it would hurt with NO shot at all.

Fit's Tip: Ask your dentist to apply a topical anesthesia to your gums to numb the area before the Novocaine shot. It makes getting a cavity filled just a little bit easier to bare.

Source

General anesthesia (Injection)

admin — Thu, 04 Sep 2008 20:03:21 -0700

Overview

Introduction
Brand Name(s)
When This Medicine Should Not Be Used
How to Use This Medicine
Drugs and Foods to Avoid
Warnings While Using This Medicine
Possible Side Effects While Using This Medicine

HEALTH GUIDE REFERENCE FROM A.D.A.M

Introduction

This medicine causes a person to relax or sleep (be unconscious) before and during a surgery. Also given to people in an intensive care unit (ICU).

Brand Name(s)

NovaPlus Diprivan, Amerinet Choice Propofol, Diprivan, Diprivan VHA Plus, Diprivan Novaplus, Amidate

There may be other brand names for this medicine.

When This Medicine Should Not Be Used

You should not receive this medicine if you have had an allergic reaction to any type of general anesthesia. You should not receive this medicine if you are breast feeding.

How to Use This Medicine

Injectable

Your doctor will prescribe your exact dose and tell you how often it should be given. This medicine is given through a needle placed in one of your veins.
You will receive this medicine in a hospital or surgery center. A nurse or other trained health professional will give you this medicine.

Drugs and Foods to Avoid

Ask your doctor or pharmacist before using any other medicine, including over-the-counter medicines, vitamins, and herbal products.

Tell your doctor if you are using any medicines that make you sleepy. These include sleeping pills, cold and allergy medicine, narcotic pain relievers, and sedatives.

Warnings While Using This Medicine

Make sure your doctor knows if you are pregnant or breast feeding. Tell your doctor if you have diabetes, kidney disease, pancreas problems, or high cholesterol. Make sure your doctor knows if you have ever had a head injury, stroke, or seizures, including epilepsy.
This medicine may make you dizzy or drowsy. Avoid driving, using machines, or doing anything else that could be dangerous if you are not alert.

Possible Side Effects While Using This Medicine

Call your doctor right away if you notice any of these side effects:

Allergic reaction: Itching or hives, swelling in your face or hands, swelling or tingling in your mouth or throat, chest tightness, trouble breathing.
Lightheadedness or fainting (after you awake from surgery).
Muscle stiffness.
Seizures.
Slow or uneven heartbeat.

If you notice these less serious side effects, talk with your doctor:

Blurred vision.
Cough, sore throat.
Headache, mood changes, unusual dreams.
Mild nausea or vomiting.
Mild skin rash.
Muscle pain, tightness, or weakness.
Pain, swelling, or skin changes where the needle is placed.
Shivering, shaking, or trembling.

Review Date: 8/4/2008

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

A.D.A.M. Copyright

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997-2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

adam.com

Source Doc: 45_4837

Anesthesia

admin — Thu, 04 Sep 2008 19:20:56 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

Anesthesia is the delivery of medicine to prevent you from feeling pain during surgery and other medical or dental procedures.

Information

Anesthesia may be given to you by a special doctor called an anesthesiologist or other health care provider. There are three main forms of anesthesia:

Local anesthesia
Regional anesthesia
General anesthesia

Local anesthesia numbs only the part of your body that is hurt or being worked on. You are awake, but won't feel any pain. Most of the time, a needle is used to inject the medicine under the skin. Sometimes it is delivered through a nasal spray.

You may receive local anesthesia when you get stitches, have a tooth pulled, or when your doctor removes a small piece of skin for a biopsy.

Regional anesthesia numbs a large area, such as an entire arm, leg, or the entire lower half of your body. An anesthesiologist injects the medicine into a group of nerves so you no longer feel pain. You are awake, but you may be given medicine called a sedative to make you feel sleepy and less anxious.

Two common types of regional anesthesia include:

Epidural anesthesia
Spinal anesthesia

Epidural anesthesia is commonly to prevent pain during childbirth. The anesthesiologist injects the medicine into the lower back in the area surrounding the spine. This type of anesthesia causes you to lose feeling in the lower half of the body.

Spinal anesthesia goes directly into the spinal canal. It also causes you to lose feeling in the lower part of your body. You may receive spinal anesthesia if you are having a hernia repair, certain prostate surgeries, or another medical procedure on the lower half of your body.

General anesthesia is used to temporarily put you into a deep sleep so you don't feel pain during surgery. You will not be aware of what is going on around you. A number of different medicines may be used. Sometimes, you breathe in the medicine through a gas mask or breathing tube. The anesthesiologist may also give you the medicine through a vein. During general anesthesia, the health care team carefully watches your vital signs and body functions, including your breathing and brain activity. After surgery is over, you will be given medicines to reverse the effects of the anesthesia, so you wake up.

HOW IT WORKS

When you hurt, pain signals travel up the spinal cord, through your nervous system, and to the brain. The medicines used during local and regional anesthesia temporarily blocks nerve signals in the area, so you don't feel the pain. General anesthesia shuts down the brain's pain-processing center, so your body doesn't recognize the pain signals.

RISKS

All types of anesthesia carry some risk. Local anesthesia is the safest. General anesthesia affects the entire body, so side effects are more common. However, the American Society of Anesthesiologists says that complications due to anesthesia have dropped dramatically over the last 25 years.

Risks from any type of anesthesia include:

Allergic reaction to the medicines used
Breathing problems

Risks from local and regional anesthesia include:

Long-term nerve damage (rare)
Temporary weakness or paralysis in the area that received the anesthesia

Risks from general anesthesia include:

Irregular heartbeat
Heart attack (rare)
Nausea and vomiting
Stroke (rare)
Temporary mental confusion (delirium)

Delirium is most common in older adults. Studies have linked general anesthesia to long-term problems in mental function in older adults who have certain types of surgery. The complication is called postoperative cognitive dysfunction (POCD).

Medicines can be given before or after anesthesia to help prevent nausea and vomiting.

SAFETY TIPS

Make sure you tell your health care providers about all the medicines you take. This includes over-the counter drugs, vitamins, and supplements.

Do not drink or smoke before surgery. Cigarettes and alcohol can change the way the anesthesia drugs work.

References

American Society of Anesthesiologists Task Force on Postanesthetic Care. Practice guidelines for postanesthetic care: a report by the American Society of Anesthesiologists Task Force on Postanesthetic Care. Anesthesiology. March 2002; 96(3): 742-52.

Miller RD. Miller's Anesthesia. 6th ed. Orlando, Fl: Churchill Livingstone; 2005.

Anesthetic management and one-year mortality after noncardiac surgery. Anesth Analg. 2005 Jan;100(1):4-10.

Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. N Engl J Med. 2001 Feb 8;344(6):395-402.

Review Date: 4/13/2007

Reviewed By: Seth Ian Kaufman, M.D., Pain Management Specialist, The West Clinic, Memphis, TN. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

adam.com

Source Doc: 1_007280

Redheads Feel More Pain?

FitSugar — Thu, 13 Aug 2009 03:00:41 -0700

Blondes may stereotypically have more fun, but some studies show those born with red locks might feel more pain. So we all need to treat our ginger-headed friends more gingerly since research shows they're more sensitive to hot and cold, and strangely, redheads also require more anesthesia to become numb.

For those with brown, black, and blond hair, the Melanocortin-1 receptor (MC1R) gene produces melanin, which gives our hair and skin color. In redheads, this gene is mutated and produces pheomelanin instead, causing pale skin, freckles, and strawberry tresses. MC1R mutations also affect carrot tops' perception of pain and the effectiveness of drugs that are used to block the sensation of pain.

Not only is this research interesting (and may explain why your friend screamed her red head off when she got her ears pierced), but it may also help scientists design drugs that are more person-specific based on an individual's genetic profile.

If you're a redhead, please share your thoughts on this hairy subject.

Breast biopsy

admin — Thu, 04 Sep 2008 19:17:47 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

A breast biopsy is the removal of breast tissue to examine it for signs of breast cancer or other disorders.

Alternative Names

Biopsy - breast

How the test is performed

Breast tissue samples may be obtained by a needle biopsy or open biopsy. The sample may consist of connective tissue, fat lobules, or milk ducts.

If the area of interest cannot be felt or is difficult to find, x-ray or ultrasound imaging may be used to help locate it. For an imaging-guided needle biopsy, imaging is used at the same time as the biopsy. For an open biopsy that requires imaging, the area of interest is marked with a needle or wire prior to surgery.

NEEDLE BIOPSY

The injection site is cleaned, then injected with a local anesthetic. Fluid or cells may be removed with a needle attached to a syringe (fine needle aspiration), but removal of a piece of tissue requires a special needle apparatus. Several samples may be taken from the same area. When imaging is used, a small metal clip may be placed into the breast in the area of the biopsy to mark it for future mammograms.

Once the tissue sample has been taken, the needle is removed, and pressure is applied to the site to stop any bleeding. A bandage will be applied to absorb any fluid.

OPEN BIOPSY

An open biopsy may remove part (incisional biopsy) or all (excisional biopsy) of the area of interest. If the entire lump or area of interest is removed, this method may also be called a lumpectomy.

Usually, you lie on your back for the procedure. Depending on the patient and the size of the lump, choices of anesthesia include local anesthesia, local anesthesia with sedation, or general anesthesia. An incision is made and breast tissue removed. Sometimes, testing is done for a preliminary diagnosis at the time of the procedure, but obtaining a final diagnosis requires more time.

After the tissue sample is taken, the incision is sutured, and a dressing and bandage are applied.

If general anesthesia is administered, vital signs (temperature, pulse, rate of breathing, blood pressure) will be monitored for at least an hour after completion of the procedure. Pain medication may be prescribed.

How to prepare for the test

Your medical history will be taken, and a manual breast exam performed.
An informed consent form must be signed. If you are going to have general anesthesia, you may be asked to fast for 8 to 12 hours before the test.
If you take medications (including aspirin or herbals), ask your doctor whether to discontinue these before the biopsy.

How the test will feel

There may be a sharp, stinging sensation when the local anesthetic is administered. During the procedure, you may feel slight discomfort or light pressure.

After the test, the breast may be sore and tender to the touch for several days. If an incision is made, pain medication will probably be prescribed. For needle biopsy, over-the-counter pain medication should be adequate.

Why the test is performed

A biopsy is the only way to determine if tissue is benign (non-cancerous) or malignant (cancerous).

Normal Values

A normal result means there is no sign of cancer.

What abnormal results mean

Benign tumors include:

Cancerous tumors include:

Adenocarcinoma
Colloid carcinoma
Cystosarcoma
Infiltrating carcinoma
Inflammatory carcinoma
Intraductal carcinoma
Lobular carcinoma
Medullary or circumscribed carcinoma
Sarcoma

Ask your doctor about your specific condition and how it applies to you.

What the risks are

There is a slight chance of infection at the injection or incision site.
Excessive bleeding is rare, but may require draining or re-bandaging. Bruising is common.
There will be a scar. Depending on the amount of tissue removed and how the breast heals, the appearance of the breast may be affected.
Depending on the results of the biopsy, further surgery or treatment may be needed.

Special considerations

Most breast lumps are detected during a manual breast exam or mammography. A discharge from the nipple may indicate the presence of a cancerous tumor. Even if the biopsy results are benign, discuss ongoing breast screening with your doctor.

References

Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, McKena WG. Clinical Oncology. 3rd ed. Orlando, Fl: Churchill Livingstone; 2004.

Whitman GJ. Ultrasound-guided breast biopsies. Ultrasound Clin. Dec 2006; 1(4); 603-615.

Review Date: 7/25/2007

Reviewed By: Robert A. Cowles, MD, Assistant Professor of Surgery, Columbia University College of Physicians and Surgeons, New York, NY. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

adam.com

Source Doc: 1_003920

Vasectomy and vasovasostomy

FitSugar — Wed, 08 Oct 2008 17:35:49 -0700

In This Report

Highlights
Introduction
Considerations
Male Contraception
Surgery
Complications
Unexpected Pregnancy
Long-Term Complications
Reversal Surgery
Assisted Reproductive Techn...
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Search Continues for the "Male Pill"

Research is progressing on a male contraceptive, but there have also been setbacks. The drug miglustat (Zavesca), which is used to treat a rare condition called Gaucher's disease, had shown success in animal studies but failed to work in a clinical trial, according to results published in 2007 in Human Reproduction. Researchers are now investigating an experimental drug, Adjudin (AF-2364), which disrupts sperm production.

Reversible Inhibition of Sperm Under Guidance

Reversible inhibition of sperm under guidance (RISUG) is one of the investigational male contraceptives furthest along in clinical trials. It is currently in phase III trials in India, but it is not yet known when or if clinical trials will be conducted in the United States. RISUG is a non-hormonal contraceptive method that uses an injectable polymer gel to stop sperm flow within the vas deferens.

No-Scalpel Vasectomy

The no-scalpel vasectomy is gaining in popularity as an alternative to standard vasectomy, but it requires a well-trained doctor to perform it. Performed correctly by an experienced doctor, no-scalpel vasectomy can result in shorter surgical time and less bleeding, infection, pain, and postoperative complications, according to a 2007 review published in the Cochrane Database. If you are considering a no-scalpel vasectomy, make sure that your doctor has performed at least 15 - 20 of these procedures.

Vasectomy Reversal

Vasectomy reversal may work better than assisted reproductive technologies (such as sperm retrieval) for men who have had a vasectomy but later decide to have children, according to research presented at the 2007 annual meeting of the American Urological Association.

Introduction

In the United States, vasectomy emerged as a popular method of permanent contraception during the 1960s. Within a decade, 750,000 men were undergoing vasectomies each year. Vasectomy rates markedly declined in the 1990s and have now plateaued at about 500,000 a year. Worldwide, an estimated 42 million couples use vasectomy as a method of birth control.

The procedure works by surgically interrupting the route that the sperm take from the testicles (where they are produced) to the penis. After vasectomy, the testicles still continue to generate sperm, but their movement is blocked at the site of the vasectomy. Eventually the sperm die, and the patient's body absorbs them. During sex, semen is produced in the same amount as before vasectomy, but this fluid does not contain sperm.

The testes are where sperm are manufactured in the scrotum. The epididymis is a tortuously coiled structure topping the testis, and it receives immature sperm from the testis and stores it several days. When ejaculation occurs, sperm is forcefully expelled from the tail of the epididymis into the deferent duct. Sperm then travels through the deferent duct through up the spermatic cord into the pelvic cavity, over the ureter to the prostate behind the bladder. Here, the vas deferens joins with the seminal vesicle to form the ejaculatory duct, which passes through the prostate and empties into the urethra. When ejaculation occurs, rhythmic muscle movements propel the sperm forward.

Click the icon to see an animation about vasectomy.

Vasectomy should not be confused with castration. It has no noticeable impact on a man's ability to perform sexually, or on his sensation of orgasm and pleasure. It does not affect the balance of male hormones, male sex characteristics, or sex drive. Testosterone continues to be produced in the testes and delivered into the bloodstream. Sperm form a very small portion of semen, so patients notice no difference in the amount of semen produced during orgasm.

The male reproductive tract performs three functions:

It enables a man to produce offspring.
It provides him with a supply of male hormones.
It enables him to experience sexual pleasure.

The Traveling Sperm. The sperm's journey through the male body -- from the testes (the testicles) to the final stage (the orgasm) -- is long and complex:

Sperm are produced in the testes at a rate of 50,000 an hour within tiny ducts called seminiferous tubules.
Sperm do not mature in the testes. They must first pass into the epididymis, a C-shaped storage chamber adjoining the testes composed of a 20-foot coiled tube. The sperms' journey through the epididymis takes about 2 - 3 weeks. They are held here until sexual activity forces them to move on.
When a man experiences sexual excitement, nerves stimulate the muscles in the epididymis to contract. This forces the sperm to pass into one of two rigid and wire-like muscular channels, called the vasa deferentia. (A single channel is called a vas deferens. It is the vas deferens that is cut during vasectomy.)
Muscle contractions in the vas deferens from sexual activity propel the sperm along past the seminal vesicles, which are clusters of tissue that contribute fluid, called seminal fluid, to the sperm. The vas deferens also collects fluid from the nearby prostate gland. This mixture of various fluids and sperm is the semen.
Each vas deferens then joins together to form the ejaculatory duct. This duct, which now contains the sperm-containing semen, passes down through the urethra. (The urethra is the same channel in the penis through which a man urinates. During orgasm, however, the prostate closes off the bladder so urine cannot enter the urethra.)
The semen is forced through the urethra during ejaculation, the final stage of orgasm when the sperm is literally thrown out of the penis.

Click the icon to see an image of sperm.

Considerations

Having a vasectomy is a serious decision. The surgery is intended to be permanent. The great majority of men who seek a vasectomy have been married for 10 years or more. Not all are good candidates, however. It is important that both the woman and the man completely agree that they no longer want to have children. They should also agree that permanent birth control is the right decision for them. Ideally, the couple should view the operation as a mutual commitment to an already successful marriage or relationship. Vasectomy generally is not a good idea if the couple's relationship is under great stress. It is not a cure for emotional or sexual problems between a man and woman.

After deciding that permanent birth control is the best solution, a couple still has the option of either vasectomy for the male or tubal ligation for the female.

Studies indicate that 5 -11% of men who have vasectomies regret the decision. In one study, 56% of men seeking treatment for fertility were hoping to reverse their vasectomies. Thirty years ago, this percentage was only 5%.

A reversal procedure called vasovasostomy is available, but it is a major operation that provides no guarantee of restored fertility. In a study of procedures performed between 1980 - 1996, vasectomy rates had leveled off but vasovasostomy rates had increased in men by nearly 70% in the most recent 5-year period compared to the earliest 5-year period.

Vasectomies may be right for:

Men in relationships in which both partners agree they have all the children they want and both do not want to use or are unable to use other methods of contraception
Men in relationships whose partners have health problems that make pregnancy unsafe
Men in relationships in which one or both have genetic disorders that they do not want to transmit

Vasectomies may not be right for:

Men in relationships in which one partner is unsure about his or her desire to have children in the future. (Couples in which the woman is working when they make the decision are at particular risk for regretting the decision later on.)
Men whose current relationships are unstable, going through a stressful phase, or are marked by substantial conflict
Men who are considering the operation just to please their partners
Men who are counting on having children later by storing sperm or by surgical reversal of the vasectomy
Young men, who still have many life changes ahead
Men who are single (including those divorced or separated) at the time of vasectomy
Men who are having the operation primarily for the sake of their partners and not wholly for their own reasons
Men or couples whose only motive is freedom from distraction imposed by other contraceptive methods during sexual activity

Vasectomy should not be undertaken in response to temporary stressful situations that might block the desire for children. Such conditions may include illness, temporary financial crisis, death in the family, or birth of a child. Couples should wait through such short-term stresses or seek counseling or psychotherapy to be sure that they are not making a decision they will later regret.

All Future Scenarios. Before deciding on a vasectomy, the couple should consider all future scenarios for their life together, such as the following examples:

If a couple already has children, how would they feel about a vasectomy if one of their children died?
If financial stress is triggering the decision for a vasectomy, would improved affluence increase their desire for children?
How would the man consider the vasectomy if his current relationship ended, either by divorce or the woman's death?

The word "sterilization" has a deep emotional connotation for many people. Even though a couple may rationally accept the idea of a vasectomy, it is extremely important for each partner to be as open as possible about any negative feelings they might associate with the procedure. Such feelings on the part of either partner can have devastating consequences on a relationship if they surface only after the procedure has been performed. Openness with each other is essential in order to make a decision that is clear of any hidden apprehensions. Neither partner should be too embarrassed to request counseling if the emotional aspects involved in making the decision are too difficult to solve between themselves.

What the man may be feeling:

A man may have a poor self image, including concerns for his own physical health or sexual ability. Such men are likely to have a difficult time adjusting psychologically to vasectomy.
A man may not actually really want the procedure but may not want to confront a partner he loves who wants him to have it.

What the woman may be feeling:

A woman might believe, incorrectly, that a vasectomy is emasculating, but she might not want to express this idea to her partner.
On the other hand, some women fear that vasectomy may make their partner more attractive and encourage outside affairs. (Research from the 1970s indicates that married men who have a vasectomy are no more likely to indulge in extramarital sex than fertile men.)

Storing frozen sperm in a sperm bank before vasectomy might enable men to have children later. Before the vasectomy, the man collects sperm, which are frozen and stored until he wants to have a child. In one study, 1.5% of men who had stored sperm later used it for conception and most were successful. Other studies have shown a lower success rate, however, and it is a very expensive process. Experts believe that a man who wants to bank sperm should probably reconsider his decision to have a vasectomy because such a concern may indicate doubts about giving up his ability to father a child.

Male Contraception

As many as 40% of couples seeking vasectomy have experienced a failure with their previous method of nonpermanent birth control. Such failures can occur from misplacement of a diaphragm, an incorrectly implanted intrauterine device (IUD), or noncompliance with an oral contraception regimen. Couples who are unsure about permanent sterility should still consider carefully all birth control options.

Withdrawal before ejaculation is a form of natural contraception, but it is extremely risky and most people find it unsatisfactory. If used on a regular basis, the average risk for pregnancy is 24%.

The only other form of male contraception currently available is the condom. However, the average rate of pregnancy for couples that rely only on condoms for protection is still 12%. In adolescents, the risk with condoms is even higher, 18%. Even for those who use a good-quality condom correctly, the annual risk for pregnancy is 3%.

The condom should be put on before intercourse when the penis is erect, long before ejaculation, since the male can discharge sufficient semen to cause pregnancy before ejaculation occurs. (Even after a vasectomy, men who are not in a monogamous relationship with an HIV-negative partner should always wear a condom during sex for protection against sexually transmitted diseases. Vasectomy is not protective.)

Click the icon to see an illustrated series detailing how to apply a condom.

Condom Materials.

Latex. Condoms made of latex rubber are the most common types. When they are contoured for better fit and contain a spermicide, they can provide fairly effective protection. Some people are allergic to latex, however, and in some cases the reaction can be very dangerous. The latex smell may also be unpleasant for some people.
Polyurethane. Polyurethane condoms (Avanti, eZ-on) are also available. At this point, they have good acceptance by couples but have a higher breakage rate (6 - 7.2%) compared to the latex condom (1.1 - 2%). Other synthetic materials are under investigation.
Animal Membranes. Condoms made from animal membrane can prevent pregnancy, but sexually transmitted infections can permeate them.
Lubricants. Lubricants can be used to prevent tearing. Petroleum-based products (such as Vaseline and baby oil) and vegetable oils should not be used because they can corrode the condom.

Spermicides. Some condoms come prelubricated with sperm-killing substances called spermicides. The standard active ingredient in spermicides in the U.S. is nonoxynol-9, which attacks the surface of the sperm cell. These spermicidal-coated condoms, however, are no longer recommended for a number of reasons. Side effects include irritation of the vagina or penis, particularly if used often or in large amounts. It can also promote yeast and urinary tract infections in women. Evidence now strongly suggests that nonoxynol-9 does not provide any additional protection against sexually-transmitted diseases. In fact, research indicates that it actually increases the risk for HIV in women, possibly by causing injury in the vaginal area. Spermicides are no longer recommended for use with male condoms.

Researchers are developing male hormonal contraceptives that reduce levels of sperm. Animal studies and clinical trials are progressing, and a "male pill" may become a reality in the not-so-distant future. Current trials are focusing on male hormonal contraceptives that combine testosterone (the primary male sex hormone) with progestin, a synthetic form of progesterone (one of the primary female sex hormones).

Testosterone suppresses levels of luteinizing hormone (LH) and follicle stimulating hormone (FSH). LH and FSH are hormones that stimulate ovulation in women and production of testosterone in men. Low levels of these hormones interfere with sperm production, but they do not completely stop it. For this reason, researchers are investigating combining testosterone with progestin. The addition of progestin further decreases LH and FSH levels, along with sperm counts. Researchers are also investigating combining testosterone with gonadotropin-releasing hormone (GnRH), another type of hormone that interferes with LH and FSH secretion.

Most of the male contraceptives currently in late-stage clinical trials deliver hormones through implant, injection, or both. The implant is surgically placed under the skin where it releases a steady stream of the hormone. The injection is given once every several months. Some of the investigational male hormonal contraceptives use a testosterone implant with progestin injections, while others use a progestin implant with testosterone injections. Forms taken by mouth are also being investigated. It generally takes around 3 - 4 months for the treatment to take effect, and for sperm production to be reduced. Research indicates that the male hormonal contraceptives are easily reversible. A 2006 study in the Lancet reported men regained their full fertility within 3 - 4 months after stopping hormonal treatment.

Side effects of male hormonal contraceptives include weight gain, acne, and changes in mood. These side effects are typical of hormone-based therapies.

Because of hormonal side effects, researchers are also investigating non-hormonal male contraceptives. Several initially promising drugs (such as miglustat) have performed well in animal studies, but have failed in human studies. Some non-hormonal research is now focusing on an experimental drug called Adjudin, which appears to work by disrupting sperm maturation in the testes. A 2006 animal study showed positive results, but it is still unknown if this drug will work in humans.

Researchers are investigating procedures that block sperm flow in the vas deferens using various drugs or materials that are reversible. One promising method is called Reversible Inhibition of Sperm Under Guidance (RISUG). RISUG is a non-hormonal contraceptive that uses a polymer gel. The gel is injected into the vas deferens, where it coats the vas deferens' inner walls and kills sperm. The gel can be injected through the skin through a needle or by using the no-scalpel vasectomy technique of making a tiny hole in the skin. The procedure takes around 10 - 15 minutes to perform, and men can resume sexual activity within a week.

The effects of RISUG are long-lasting. Studies indicate that a single injection can provide contraceptive effect for 10 years or more. It is also easily reversible. When a man wishes to discontinue the contraceptive, the gel is removed by flushing the vas deferens with a solvent. The major side effect so far has been a temporary swelling of the scrotum following the injection.

RISUG is mostly being investigated in human trials in India. American researchers are also interested in investigating RISUG, but animal studies need to be conducted first. It will be several years before any human trials are started in the U.S.

The intra vas device (IVD) is an investigational non-hormonal contraceptive that uses tiny silicone plugs to block sperm from traveling through the vas deferens. The plugs are surgically inserted into the vas using the no-scalpel vasectomy procedure. In 2006, the Food and Drug Administration granted approval to expand human trials of the IVD in several U.S. cities.

Unlike hormonal contraceptives, the IVD does not cause side effects like weight gain and acne. But researchers are still figuring out how to make this contraceptive method reversible.

Gossypol, a yellow pigment extracted from the roots, seeds, and stems of the cotton plant, has been used in China, Africa, and Brazil as a male contraceptive. Cotton root was also used as folk medicine in the American South to treat menstrual pain and to induce abortions. The chemical destroys the lining of tubules in the testicles where sperm are produced, thereby inhibiting their formation.

Gossypol does not appear to reduce sexual desire or frequency of intercourse. In about 20% of men, sperm production does not come back, so it should be considered as potentially permanent birth control. It also may not be effective in some men, since small numbers of sperm may survive. Researchers are investigating gossypol-derived compounds that may have less toxicity. No one should take any so-called natural gossypol product without consulting their doctors.

Surgery

Vasectomy is a minor operation that takes about 30 minutes and is usually performed in a doctor's office or a family planning clinic. If the operation is performed under local anesthesia, the cost ranges from about $500 - $1,000. Most insurance policies will cover vasectomies performed as a minor outpatient procedure, but will not cover vasectomies performed as major surgery in an operating room. If a Vasclip procedure is performed, there may be an additional cost of $400 - $500 for this device.

The Procedure.

To prevent increased risk of bleeding, patients should avoid taking aspirin or NSAIDs (Advil, Motrin) for 10 days prior to the procedure.
Before the operation, the patient's scrotum is shaved and cleaned.
A local anesthetic is injected into the scrotum. Patients should ask their doctor about applying an anesthetic cream (EMLA) before the injection to reduce its pain.
The surgeon makes a tiny incision on one side of the scrotum and locates one vas deferens. The vas deferens is isolated, drawn through the incision, and clamped at two sites close to each other.
The segment between the clamps (which should be more than 15 mm, or a little over 1/2 inch) is then removed.
The surgeon then seals off (ligates) the tube with surgical clips, sutures, or cauterization with an electric needle. Fascial interposition is an additional technique that may be used in combination with these methods to improve closure. With fascial interposition, the surgeon pulls the fibrous layer covering the vas (the fascia) over the cut end of the vas and sews it closed. This increases the barrier and further reduces residual sperm. Recent research suggests that fascial interposition combined with cauterization or ligation/excision is the best method for sealing off the vas.
The surgeon may choose to close off either one end of the vas (called an open-ended procedure) or both ends (closed-ended technique). In the open-ended procedure, the vas section connected to the testis is left open, and the one leading to the prostate is sealed. In the closed-ended approach, both are sealed. Many surgeons now prefer the open-ended version because it has lower complication and failure rates than the closed-ended method, and it results in fewer cases of chronic pain.
After closing off the tube, the vas deferens is gently placed back into the scrotum.
The procedure is then repeated on the other side.
After a short rest, usually about half an hour, the patient can leave the doctor's office or clinic. Arrangements should be made ahead of time for someone else to drive the patient home.

Click the icon to see an illustrated series detailing a vasectomy.

A method of vasectomy called no-scalpel vasectomy (NSV) that does not require the use of a scalpel was developed in China in 1974. NSV is now used in at least one-third of vasectomies.

The technique takes about 10 minutes and is performed in a doctor's office or a family planning clinic. The no-scalpel vasectomy differs from a conventional vasectomy in the method of accessing the vasa deferentia:

In NSV, the doctor feels for the vas deferens under the skin and holds them in place with a small ring clamp.
Instead of making two incisions, the doctor employs a sharp hemostat, a special instrument that makes one tiny puncture and then is used to gently stretch the opening until the vas deferens can be pulled through it. (The surgeon must rotate his wrist to pull the vas out -- called a supination maneuver -- which may be difficult to perform.)
The vas is then sealed off using the same methods (clips, sutures, cauterization using an electric needle, or some combination) as conventional vasectomy. As with standard vasectomy, the closures can be open- or closed-ended.
There is very little bleeding with the no-scalpel vasectomy. No stitches are needed to close the tiny opening, which heals quickly and leaves no scar.

When performed correctly, NSV works just as well as conventional vasectomy, takes less time, and (according to a 2007 review) causes less bleeding, infection, and pain. Current research indicates that NSV is the safest type of vasectomy procedure. NSV is difficult to perform, however, and most surgeons must do about 15 - 20 procedures in order to be proficient. NSV is becoming a popular alternative to standard vasectomy, but it is important to select a doctor who is experienced with this procedure.

A simpler method of NSV, called percutaneous vasectomy, is now being used. Recent research suggests that it works as well as standard NSV and is easier to perform. Percutaneous vasectomy uses the same instruments as no-scalpel vasectomy, but with a different surgical technique. The hemostat is used to first puncture the skin (instead of spearing the vas and lifting it out). The ringed clamp is then passed through the incision and used to enclose the section of the vas that is then pulled out for closure. This avoids the need for the difficult wrist maneuver in NSV.

Vasclip. The Vasclip is a recent alternative to standard vasectomy. This very small rice-sized plastic clip locks around the vas deferens and stops the flow of sperm. Some studies have reported fewer post-surgical complications than with standard vasectomy, including infection and swelling. It may be more easily reversible than a standard vasectomy.

Complications

Vasectomy is a low-risk procedure, and the complications, which occur in about 10% of patients, are usually easy to control. One study of no-scalpel vasectomy, for example, reported only 7 complications out of 4,255 procedures and they were mostly minor. Pain or soreness typically lingers for a few days after the procedure, but this is normal and usually does not require a return visit to the doctor. No deaths resulting from vasectomy have been reported in the United States.

Nearly all men recover completely in a few days. The following are some guidelines after the operation to help recovery:

The local anesthetic wears off about 1 - 2 hours after the procedure, and most patients then experience a dull ache in the testicles and groin. The doctor may prescribe a painkiller for the first few days, continuing with mild over-the-counter pain relievers if discomfort persists. Acetaminophen (Tylenol) with or without codeine is the primary choice for postoperative pain. Aspirin, ibuprofen (Advil, Medipren, Motrin, Nuprin), naproxen (Aleve), or other non-steroidal anti-inflammatory drugs (NSAIDs) can cause bleeding and should be avoided.
The patient should stay in bed on his back for at least one day and apply ice packs for 8 hours. The doctor may suggest that the patient wear an athletic supporter.
Some oozing of blood onto the gauze pads is normal during the first 2 days after the operation.
The patient should not perform any heavy physical labor for at least 2 days. Sports and heavy lifting may be resumed 2 - 3 weeks after surgery.
A semen analysis is done about 6 - 12 weeks after surgery to ensure that no live sperm remain in the semen. Many urologists recommend delaying a semen analysis until 2 months after a vasectomy or 12 ejaculations (whichever comes first). The semen is usually collected at home in a small jar and delivered to the doctor's office, where it is examined under a microscope. A second semen analysis is sometimes performed again about 4 months after the vasectomy, although many experts now believe that a second sample is unnecessary unless sperm found the first time were motile (still able to move). According to a 2006 study, 25% of men never bother to return for follow-up sperm testing. Without a follow-up test, men do not know whether the vasectomy was successful. Until test results verify that there are no sperm in the semen, men are at risk of fathering unwanted pregnancies.

All men experience some pain in the scrotum (the sac that contains the testes) after the operation. This pain generally disappears within two days, although the patient may feel sore for a few more days. In rare cases, pain can be persistent, which is known as post-vasectomy pain syndrome. The cause of this is unclear.

A few men may have an allergic reaction to the local anesthesia and develop itching and hives.

Frequently, blood may seep under the skin, so that the scrotum and penis appear to be bruised. If there is no dangerous swelling, this painless problem usually disappears without treatment within 1 - 2 weeks. If the patient bleeds excessively in the days after the operation and requires more than two or three gauze changes per day, he should call his doctor.

In 2 - 5% of cases, bleeding inside the scrotum can cause a painful swelling known as a hematoma. In these cases, the scrotum swells up shortly after vasectomy. The doctor should be called immediately.

Infections occur in 4 - 9% of men after vasectomy. The incision site may become infected, causing redness and swelling around the incision. Antibiotics, antimicrobial creams or ointments, or both, along with hot baths several times a day will usually clear the infection in a few days. There have been a few cases of infections in the lining of the heart (endocarditis) and severe gangrene of the scrotum, but they are extremely rare.

Unexpected Pregnancy

Pregnancy rates after a vasectomy are estimated to be very low, about 1 in 1,000. There are two main reasons for an unexpected pregnancy:

Residual sperm were still alive when the partners had unprotected sex. This is the most common reason for an unexpected pregnancy after a vasectomy. Men should make sure they have follow-up sperm analysis testing. They should also continue to use birth control until their doctor notifies them that the test results confirm sterility.
Failure of the procedure and recanalization. Failure in some cases is due to a technical error, but most often it is due to recanalization -- when the cut ends of the vas spontaneously reconnect. Success rates are best when an experienced surgeon performs the vasectomy.

Once the patient feels comfortable, he can resume sexual activity, usually in about a week. During ejaculation, the patient may experience some discomfort in the groin and testicles at first due to the contraction of the vas deferens. This almost always diminishes as the tissues heal.

However, after the operation there are always some active sperm left in the semen for several months so the risk for pregnancy persists. It is essential that the patient and his partner continue to use other methods of birth control until his sperm count is zero. The patient is considered sterile only when there are no live or moving (motile) sperm in his semen. It takes, on average, around 3 months or 20 ejaculations to clear the viable sperm from the reproductive system, but it may take some men as long as 6 months to become sterile.

About a third of men experience a recurrence or persistence of sperm that have no ability to move (immotile) 12 weeks after surgery and, in one study, about 7% had persistently immotile sperm. Immotile sperm, however, cannot swim up the vaginal canal and pose no danger for fertility. In rare cases, vasectomies have to be repeated because live sperm persisted in the semen. The risk for sperm surviving indefinitely is, however, very low.

The primary reason for vasectomy failure itself is recanalization-- when the cut ends of the vas deferens spontaneously reconnect. Recanalization in some cases may be due to sperm granulomas. These are tiny balls of debris that form from sperm, scar tissue, and white blood cells at the incision site. Cells lining the inside of the vas deferens grow through the scar tissue and form a new channel through which the sperm can now move. In general, surgeons can reduce the risk for recanalization by leaving a gap between the two cut ends.

This natural vasectomy reversal can occur after any vasectomy surgical procedure, but it is uncommon, with most studies reporting it occurring in less than 1% of cases. When recanalization does occur, sperm counts are almost always very low and pregnancies are still rare. Most cases of recanalization develop within several months after the operation. In very rare cases (about 0.6%), sperm have reappeared a year or even longer after vasectomy.

Long-Term Complications

Sperm Granulomas. After vasectomy, sperm often leak from the vasectomy site or from a rupture in the epididymis, the tightly coiled, thin tube that connects the testicle to the vas deferens. Sperm elicit a very strong response from the immune system, which views them as foreign substances and attacks them. Sperm leakage therefore provokes an inflammatory reaction. The body forms pockets to trap the sperm in scar tissue and inflammatory cells. Firm balls of tissue about 1/2 inch in diameter then form; these are known as sperm granulomas. They occur in about 60% of vasectomy patients.

Although they rarely cause serious problems, one study reported that sperm granulomas were troublesome in 15% of patients. In about 3 - 5% of cases, sperm granulomas obstruct the already blocked ends of the vas deferens and generate pressure build-up in the epididymis. This can cause a rupture from the pressure of the fluid. In such cases, the testicles may become enlarged and painful. A damaged epididymis can be repaired, but if the patient later wishes a reversal of the vasectomy, disruption of this tiny tube makes success much less likely.

Epididymitis. Epididymitis occurs when an inflammation at the site of the vasectomy causes swelling of the epididymis. This condition may occur within the first year and can be treated with heat and anti-inflammatory medications. It usually clears up within a week.

The male reproductive structures include the penis, the scrotum, the seminal vesicles and the prostate.

Positive Effects. Surveys indicate that about 90% of men are satisfied with vasectomy and that the feeling persists. One study reported even higher satisfaction in the partners, with more than 95% of wives reporting satisfaction with the procedure. Younger and older couples, with or without children, were all equally likely to have favorable reactions to vasectomies. Most men who have vasectomies feel relieved that the worry about pregnancy is over, and most couples respond well to their new-found contraceptive freedom.

Negative Effects. Some men go through a brief period of self-consciousness, wondering whether others notice some difference in their masculinity. About half of vasectomy patients keep their operations a secret. They may believe that vasectomy is tainted by the stigma of emasculation and that knowledge of it would degrade them in the eyes of their friends and family. For most men, this tentativeness passes quickly.

In a few men, however, problems of poor self-image persist and require counseling. Some may experience depressed and angry emotions. They may actually require a mourning period over the loss of their reproductive ability (similar to what some women go through during menopause). These negative feelings usually resolve over time as the patient moves on to the next stage of his life.

A small percentage of couples experience serious difficulties with the adjustment. Their emotional distress most often manifests itself in sexual dysfunction, such as impotence, premature ejaculation, or painful intercourse. In such cases, however, the vasectomy is probably the catalyst but not the cause of such extreme reactions. Studies have indicated that men who experience erectile dysfunction after vasectomy are more likely to have female partners who are unable to accept the operation.

Research indicates that up to a third of men have some pain in or around the testes that lasts longer than 3 months. In a study of 700,000 patients with vasectomies, up to 10% reported long-term chronic pain around the testicles. In one survey, 19% of subjects reported chronic pain that was simply a nuisance, and 12% reported more severe pain. Another study that followed men for an average of 19 months reported that 27% had some pain in the testicles, although, in the great majority, the pain was brief.

Causes of Chronic Pain. In many cases the source of the pain after vasectomy is not known, although some of the following conditions may be a source of pain:

Scarring from the surgery
Obstruction of part of the epididymis that causes swelling in another section
Pinched nerves
In about 1% of all vasectomies, the epididymis becomes so congested with dead sperm and fluid that the patient feels a dull ache in his testicles. This condition, called chronic orchialgia, usually disappears within 6 months.
Some doctors believe that granulomas may cause more chronic pain than generally believed. Others point out, however, that open-ended procedures, which increase the risk for granuloma production, result in less pain than closed-ended techniques that produce fewer granulomas.

Treatments for Chronic Pain. Surgery may be required if time or more conservative measures fail to relieve pain. Procedures may include:

Removal of the epididymis and surrounding tissue tends to be effective if the pain is in the scrotum (the sac that contains the testes) and if abnormalities in the epididymis can be observed using ultrasound.
A surgical procedure that blocks nerves in the sperm cord can bring relief in severe cases.
Surgery to reverse vasectomy (vasovasostomy) may relieve chronic pain. In one study, nearly 70% of men became pain free, although researchers were unable to discover any biologic differences after the procedure that might explain such relief.

Prostate Cancer. Prostate cancer is the second most common cause of cancer death among American men. About 30% of all American men will develop at least localized prostate cancer at some time in their lives. Long-term high-normal levels of testosterone may be associated with an increased risk for prostate cancer. Because testosterone levels remain higher for a longer period in men who had vasectomy, experts have been concerned that such men have a greater chance for developing the cancer.

Click the icon to see an image of prostate cancer.

A 2002 review indicated a 10% increase in risk for every 10 years after the procedure. The authors of the study reported, however, that such increased risk may not be caused by vasectomy since the association was small and could be due to bias. Most recent studies report no higher danger. A rigorous 2002 study from New Zealand, which has the highest vasectomy rates in the world, found no increased risk of prostate cancer from the procedure, even 25 years after the operation. Another 2002 study, in fact, reported a lower risk for prostate cancer in men who had had vasectomies.

It is possible that the higher rates reported in the early studies may simply be due to earlier prostate screening in men who have had vasectomies. One study reported that about 25% of doctors screened men with vasectomies earlier for prostate cancer than those without the operation.

An expert panel has recommended that vasectomy reversal is not warranted to prevent prostate cancer and that screening criteria for prostate cancer should be the same for men with and without vasectomies. Men with a family history of prostate cancer can discuss the risks and benefits of vasectomy with their doctors, although the weight of evidence to date indicates there is no link between vasectomy and prostate cancer.

Testicular Cancer. There have also been some concerns that vasectomy could increase the risk of testicular cancer. However, studies show there is no association between the two.

Vasectomy is known to provoke immune system changes.

Anti-sperm Antibodies. Sperm continue to be produced after vasectomy but are disposed of in the body. In some men the immune system mistakes these sperm as foreign proteins (antigens) and produces anti-sperm antibodies that are designed to target and interfere with sperm's motility (ability to move). Up to two thirds of vasectomized men develop such anti-sperm antibodies. Infections in the genital tract, such as orchitis or sexually transmitted diseases, increase the risk for anti-sperm antibodies. The anti-sperm response itself appears to be a problem only if a man wishes to reverse the vasectomy.

Heart Disease and Other Changes. Some researchers are concerned that changes in the immune system might cause damage in other parts of the body, including contributing to heart disease. However, a large 2002 follow-up study of men who had vasectomies found no increase in risk for heart disease, stroke, or peripheral artery disease, even after more than 20 years. Nor did researchers find any evidence of greater risk for hardening of the arteries (atherosclerosis) or inflammation, which play a role in cardiovascular disease.

Click the icon to see an image of atherosclerosis.

Some experts have voiced concern that vasectomy may increase the risk for the bone-thinning condition known as osteoporosis. However, evidence to date does not support an association.

Studies suggest that men younger than their mid-40s who have vasectomies have twice the risk for kidney stones as their peers who have not had vasectomies. The increased risk persists for up to 14 years after the operation. Kidney stones are not life threatening, but they can be extremely painful. Drinking plenty of fluids is the best way to prevent kidney stones.

Click the icon to see an image of kidney stones.

Reversal Surgery

Although men should consider vasectomy a permanent decision, vasovasostomy is a reversal procedure that may restore fertility in men who change their minds. Vasovasostomies are also effective in relieving chronic pain from vasectomies in the rare case that this occurs.

One Australian study suggested that although the rate of vasectomies has not changed over the past few decades, the desire for reversal surgery increased by over 70% in the late 1990s compared to the early 1980s. Men who had vasectomies in their 20s are more likely to seek reversal later on than older men. The main reasons for requesting a reversal are remarriage, the death of a child, or an improvement in finances. Reversal may also be performed to relieve post-vasectomy pain, which occurs in a small percentage of men. However, fewer than 10% of patients who request reversals do so because of physical or psychological problems following vasectomy.

Standard Procedure. Vasovasostomy reconnects the severed ends of the vas deferens to reestablish the flow of sperm. The procedure is difficult:

It involves sewing together the two tiny ends of both tubes, each with pinhead-sized openings.
If the vas deferens is blocked, the surgeon may try to connect the epididymis to an area in the vas deferens that bypasses the blockage.

Vasovasostomy can usually be done on an outpatient basis, and patients can usually return to work within 1 - 2 weeks. It is far more difficult and expensive than vasectomy itself, however, and is even costlier if the procedure involves connecting the vas to the epididymis, which takes about 3 hours. It should be noted that reversal surgery is usually not reimbursed by insurance companies, and that the results may not be known for some time.

Microscopic versus Magnification Techniques. The surgeon may view the surgical site using either magnification instruments (called macroscopic vasovasostomy) or microscopic techniques. Advanced microscopic techniques are proving to increase the chances of a reversal's success. Although macroscopic vasovasostomy has a slightly lower success rate, pregnancy rates can still be over 50%, and it is less expensive and has a shorter operating time than microscopic procedures. Still, a 2003 study suggested the microscopic approach is preferable for repeat vasovasostomies when the initial procedure failed.

Laser Techniques. Laser surgery is being investigated and may prove to require less surgical expertise, reduce operating time, and result in fewer complications. At this time, however, results vary widely.

An Australian study reported that the pregnancy rates in the late 1990s after reversal surgery were nearly four times higher than they were in the early 1980s. Pregnancy rates of over 50% are now being reported after vasovasostomy. One study indicated that when successful conception occurs, it does so at an average of 1 year after the surgery.

A successful reversal is more likely if the following conditions are present:

The section removed during vasectomy was not long.
The original procedure was performed on straight sections of the vas deferens.
The pieces joined during the vasovasostomy are of equal size.

The closer in time the vasovasostomy is to the original vasectomy, the better. In one large study, the pregnancy rates were 76% for those who had vasectomy less than 3 years before reversal surgery, but decreased to 30% for those men who had a vasectomy more than 15 years earlier. The decrease in rates as time goes by is probably due to an increase in the chance for obstruction of the epididymis and the development of anti-sperm antibodies. Success rates, according to some studies, are slightly better if the male partner does not change female partners after the procedure. Other studies suggest that it makes no difference if the man has a new female partner. The age of the woman is an important factor, and the chances of achieving pregnancy are best for women younger than age 35. Some research suggests that men who have a vasectomy reversal may have a greater rate of sperm chromosomal abnormalities than normal fertile men.

Even though tubes are re-opened and sperm is restored in as many as 85% of men who undergo vasovasostomy, pregnancy is not guaranteed. Several factors may play a role in the failure of reversal surgery.

Epididymis Obstruction. If the sperm count does not recover within a reasonable period after vasovasostomy, it is often due to blockage from scarring that has occurred in the epididymis. This sometimes can be corrected with a second procedure. The doctor may be able to detect obstruction before the vasovasostomy by pressing and manipulating (palpating) the epididymis. If any part seems swollen or larger than other parts, an obstruction is very likely to be present and the patient is likely to need a vasoepididymostomy, which creates a bypass around the obstruction.

Antisperm Antibodies. In many cases in which vasovasostomy fails, the reversal procedure reopens the tubes but fertility is impaired because of a process called autoimmunity. With this condition, important immune factors called antibodies attack the body's own cells, mistaking them for antigens (any foreign microinvader that the immune system perceives as a threat).

In the case of vasectomy, the autoantibodies attack the sperm, and so are called antisperm antibodies. Such antibodies develop when sperm continue to be produced after vasectomy, but, instead of being confined to the reproductive passages, they leak out into the body. Once out of their natural habitat, the immune system perceives them as foreign invaders and develops antibodies to attack them.

Antigens are large molecules (usually proteins) on the surface of cells, viruses, fungi, bacteria, and some non-living substances such as toxins, chemicals, drugs, and foreign particles. The immune system recognizes antigens and produces antibodies that destroy substances containing antigens.

The antisperm antibodies bind to specific parts of the sperm (the head or tail) and cause problems depending on the site of attachment. Sperm may stick together (agglutinate), fail to interact with the woman's cervix, or fail to penetrate the egg. Even after vasovasostomy, such antibodies often persist.

Oxidation. The immune factors that trigger the autoimmune process may have other harmful effects as well. In a process called oxidation, they can trigger the release of particles called free radicals, highly reactive oxygen molecules that, in excess, can do considerable damage to cells and genetic material. When high levels of free radicals persist after a vasectomy, they may, in theory at least, injure sperm DNA, contributing to infertility.

Repeat Vasovasostomy. If pregnancy fails, in some cases a repeat vasovasostomy may be effective. Success rates depend on several factors:

The doctor's skill
Complications from the original operation
Effects of anti-sperm antibodies
Time elapsed since vasectomy (the shorter the better)
History of previous children. In one study, conception rates after reoperations were highest (80%) in couples who had had previous children. The pregnancy rate was only 17% when men had remarried.

A 2003 study indicated that the microscopic approach may be preferable for many repeat vasovasostomies.

Vasoepididymostomy. Vasoepididymostomy is a microsurgical technique that is useful when a vasovasostomy has failed because of damage to the epididymis. This procedure creates a bypass around the obstruction. It may be done on one or both sides of the testes.

To appreciate the difficulty of this operation, one should realize that the epididymis is 1/300th of an inch wide with a wall thickness of 1/1000th of an inch. Microscopic techniques are critical for the success of this procedure and require a surgeon who specializes in them. Refinements in vasoepididymostomy techniques are showing promising results, opening tubes in 77 - 85% of cases.

Success rates are higher for repairing obstructions closer to the testicles, because the epididymis is wider in this area. In general, pregnancy rates are around 25%, but higher rates have been reported. In one study of men who had vasectomy reversal more than 15 years after the original procedure, 62% required vasoepididymostomy, and the overall pregnancy rate was 43%. Pregnancy rates ranged from 49% in those who had had their vasectomy 15 - 19 years earlier to 25% in those who had the surgery 25 or more years before, with the highest rates occurring, not surprisingly, in those with the youngest wives.

Damage in other ducts and small tubes are a major reason for vasoepididymostomy failure. Ultrasound before the operation may be valuable to determine if these abnormalities exist, which would make it unlikely that the procedure would be successful.

If an initial vasoepididymostomy fails but conditions are favorable, a repeat procedure may still succeed.

If the patient did not contribute sperm for freezing and banking before vasectomy, some doctors suggest freezing sperm obtained during vasovasostomy as insurance against failure. Such sperm can be used in assisted reproductive methods later on if natural intercourse fails to achieve pregnancy.

There is some controversy, however, surrounding routine use of frozen sperm before a vasovasostomy. One study reported that so many sperm were non-motile at the time of the reversal surgery that freezing sperm obtained during the procedure provided little benefit. Nevertheless, new fertilization techniques are using even non-motile sperm with some success. Studies report successful pregnancies with frozen sperm. Some experts recommend routine sperm retrieval only for men undergoing bilateral vasovasostomy (those performed on both sides) and possibly for men who are having vasovasostomy with vasoepididymostomy. Men should discuss these options with their doctor.

Even though newer techniques such as intracytoplasmic sperm injection (ICSI) are improving pregnancy rates after vasectomy, vasovasostomy is still a better choice than assisted reproductive technologies (ART) for most men who want children.

Success rates with reversal surgeries are improving, and the costs are lower than with ART. In addition, a vasovasostomy does not pose a risk for multiple births. In one study, the pregnancy rate for vasovasostomy was 52%, whereas success after intracytoplasmic sperm injection (ICSI) was between 25 - 30%. (ICSI is the ART treatment of choice for men who have had vasectomy.) Even for men who have failed vasovasostomy, a repeat procedure appears to be less expensive than embarking on fertility treatments at that time.

ART may, however, be a better approach than reversal for men with evidence of anti-sperm autoantibodies due to vasectomy. ICSI may also be more effective than reversal surgeries in men whose vasectomy was conducted at least 15 years earlier.

Assisted Reproductive Technologies

Assisted reproductive technologies (ART) are available for men who want to conceive children after a vasectomy. The shorter the period since the vasectomy the better the chances of success. In one study, success rates after ART were highest (34%) when it was performed within 10 years of the vasectomy and lowest (8%) when ART occurred more than 20 years after vasectomy. Of course, the couples would be older as the duration between procedures increased, so pregnancy rates would be lower in any case. However, time elapsed after vasectomy appears to have an effect independent of a couple's age. Debate is ongoing about its advantages versus reversal surgeries for men who have had vasectomies and want children. Research presented at the 2007 American Urological Association annual meeting suggested that vasectomy reversal may work better than sperm retrieval or other ART.

The best assisted reproductive technology procedure for men who have had vasectomies or failed reversal surgery is intracytoplasmic sperm injection (ICSI). In this procedure, sperm are taken from the epididymis or testes using needles or microsurgical techniques.

The procedure itself injects a single sperm into an egg with the aid of powerful microscopic and robotic instruments. The fertilized egg is then implanted in the woman. [See In-Depth Report #67: Infertility in men.]

If a reversal surgery is not successful, a doctor may be able to retrieve sperm from the testes or the epididymis for use in assisted reproductive technologies (ART). Various techniques are now available for retrieval. The procedure may be done under local or general anesthesia, using a spring-loaded biopsy device, a thin needle, incisions, or microsurgical techniques. Rigorous trials on the best technique are lacking, although all can be successful. The choice will depend on the experience of the clinic and any underlying problems.

Testicular Fine Needle Aspiration. Testicular fine needle aspiration (TFNA) employs a fine needle to remove sperm. This can be performed with local anesthetic and by surgeons who do not have to be experienced in microsurgeries.

Microsurgical Epididymal Sperm Aspiration. Microsurgical epididymal sperm aspiration (MESA) uses microsurgical techniques to collect sperm that are close to blocked portions of the epididymis. It involves an open incision and may be done under general or spinal anesthesia in a hospital setting, although the patient can often go home the same day. The doctor accesses the epididymis and retrieves sperm with an extremely fine needle-like device. It has the advantage that it can retrieve the largest number of sperm compared to other procedures. However, as with any invasive procedure, it carries some risk of complications, such as bleeding or infection.

Percutaneous Epididymal Sperm Aspiration. Percutaneous epididymal sperm aspiration (PESA( uses a needle to obtain mature sperm from areas in the upper parts of the epididymis (the coiled tube where sperm are stored before ejaculation). It is done under local anesthesia, sometimes in the doctor's office, is less expensive than other techniques, and recovery is fairly painless. However, it has less of a chance of achieving sufficient sperm than MESA, and there is also a chance of hitting a blood vessel, causing bleeding.

Testicular Sperm Extraction. Testicular sperm extraction (TESE) is a microsurgery that removes a small amount of tissue from one or more areas of the testes using incisions and microsurgery techniques. The tissue is placed in a culture and chopped into tiny pieces. Sperm are liberated from the tiny tubes and extracted. It is a complex process, however. This is the second best method for men with vasectomies, according to some experts. It is more painful than PESA, however. In addition, if the procedure is repeated too often it can cause permanent alterations in testicular function that may reduce male hormone levels.

Testicular Sperm Aspiration. Testicular sperm aspiration (TESA) uses a needle-like biopsy device to draw a small sample of testicular tissue. Multiple attempts are sometimes required to retrieve sperm, and it is not as effective or as safe as TESE, although imaging techniques using ultrasound may improve results.

Resources

www.engenderhealth.org -- EngenderHealth
www.nichd.nih.gov -- National Institute of Child Health and Human Development
www.plannedparenthood.org -- Planned Parenthood
www.fhi.org -- Family Health International
www.auanet.org -- American Urological Association
www.urologyhealth.org -- Urology Health
www.newmalecontraception.org -- Male Contraception Information Center
www.imccoalition.org -- International Male Contraception Information Coalition
www.vasectomy.com -- Information on vasectomy

References

Amory JK, Muller CH, Page ST, Leifke E, Pagel ER, Bhandari A, et al. Miglustat has no apparent effect on spermatogenesis in normal men. Hum Reprod. 2007 Mar;22(3):702-7. Epub 2006 Oct 25.

Cook LA, Pun A, van Vliet H, Gallo MF, Lopez LM. Scalpel versus no-scalpel incision for vasectomy. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004112.

Mruk DD, Wong CH, Silvestrini B, Cheng CY. A male contraceptive targeting germ cell adhesion. Nat Med. 2006 Nov;12(11):1323-8. Epub 2006 Oct 29.

Review Date:
10/17/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

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Transjugular intrahepatic portosystemic shunt (TIPS)

admin — Thu, 04 Sep 2008 19:19:48 -0700

Overview

Alternative Names
Definition
Description
Indications
Risks
Expectations after surgery
Convalescence

HEALTH GUIDE REFERENCE FROM A.D.A.M

Alternative Names

TIPS

Definition

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure to treat complications of severe liver disease. Such complications include bleeding from the esophagus or stomach and the accumulation of fluid in the abdomen. The cause of these complications is high pressure in blood vessels of the liver called portal veins.

The procedure involves inserting a stent (tube) to connect the portal veins to adjacent blood vessels that have lower pressure. This relieves the pressure of blood flowing through the diseased liver and can help stop bleeding and fluid back up.

Description

The procedure is typically performed by radiologists. Many patients receive a local anesthesia to numb a small area of the skin plus sedative and pain medications. In certain cases, general anesthesia may be used, where the patient goes to sleep.

A needle is initially placed in the jugular vein in the right side of the neck to make a small hole. Needles and long, thin tubes called catheters can then be advanced down to the veins in the liver.

A needle is inserted to make a connection between an adjacent vein and a branch of the portal vein. This channel is then expanded, and a tube called a stent is inserted to allow blood to flow more easily through the liver. This tube is left in place.

Indications

This procedure is used to treat complications of severe liver disease, when the patient has not responded to less invasive treatments (such as salt restriction in the diet and medications called diuretics to remove fluid).

Risks

At the time of the procedure, the risks include:

A reaction to the anesthesia
Bleeding into the abdomen
Cardiac arrhythmia (irregular heart beat)

Because people with severe liver disease are also at risk for encephalopathy (deterioration of brain function), this is another common complication after the TIPS has been inserted and it may require treatment. A patient who has had significant encephalopathy may not be a good candidate for TIPS.

Blockage of the TIPS occurs in most patients within the first year of placement of the TIPS. This may lead to recurrent bleeding or reaccumulation of fluid. If this occurs, the TIPS can be expanded, or a new TIPS may be created.

Death has been reported after TIPS placement. The risk is associated with the complications listed above at the time of the procedure. In addition, deaths have been reported due to worsening liver failure that occurs in the days and weeks after TIPS placement. Patients with more advanced liver disease are at greater risk for worsening liver failure after TIPS placement.

Expectations after surgery

The patient is typically monitored after the procedure, as he or she wakes up from the anesthesia. An ultrasound is commonly performed the morning after the procedure to document that the TIPS is open and functioning well.

Convalescence

The main goal during the recovery period is to watch for signs of complications. Anesthesia helps prevent pain at the time of the procedure, and there is often little, if any, discomfort after the procedure.

Review Date: 7/25/2006

Reviewed By: Jenifer K. Lehrer, MD, Department of Gastroenterology, Frankford-TorresdaleHospital, Jefferson Health System, Philadelphia, PA. Review provided by VeriMed Healthcare Network.

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Intracranial pressure monitoring

admin — Thu, 04 Sep 2008 19:09:57 -0700

Overview

Definition
Alternative Names
How the test is performed
How to prepare for the test
How the test will feel
Why the test is performed
Normal Values
What abnormal results mean
What the risks are

Illustrations

Intracranial pressure monitoring

HEALTH GUIDE REFERENCE FROM A.D.A.M

Definition

Intracranial pressure monitoring is a device, placed inside the head, which senses the pressure inside the brain cavity and sends its measurements to a recording device.

Alternative Names

ICP monitoring

How the test is performed

There are three ways to monitor pressure in the brain cavity (intracranial pressure):

A thin, flexible tube threaded into one of the two cavities, called lateral ventricles, of the brain (intraventricular catheter)
A screw or bolt placed just through the skull in the space between the arachnoid membrane and cerebral cortex (subarachnoid screw or bolt)
A sensor placed into the epidural space beneath the skull (epidural sensor)

The intraventricular catheter is thought to be the most accurate method, but if immediate access is needed, a subarachnoid bolt is typically used. If no qualified brain surgeon (neurosurgeon) is available to place a bolt, then an epidural sensor will probably be used.

To insert an intraventricular catheter, a burr hole is drilled through the skull and the catheter is inserted through the brain matter into the lateral ventricle, which normally contains liquid that protects the brain and spinal cord (cerebrospinal fluid). Not only can the intracranial pressure (ICP) be monitored, but it can be lowered by draining cerebral spinal fluid (CSF) out through the catheter.

This catheter may be difficult to place with increased intracranial pressure, since the ventricles change shape under increased pressure and are often quite small because the brain expands around them from injury and swelling.

A subarachnoid screw or bolt is a hollow screw that is inserted through a hole drilled in the skull and through a hole cut in the outermost membrane protecting the brain and spinal cord (dura mater).

The epidural sensor is placed through a burr hole drilled in the skull, just over the epidural covering. Since no hole is made in the epidural lining, this procedure is less invasive than other methods, but it cannot remove excess CSF.

Lidocaine or another local anesthetic will be injected at the site where the incision will be made. You will most likely get a sedative to help you relax. First the area is shaved and cleansed with Betadine and alcohol. After the area is dry, an incision is made and the skin is pulled back until the skull is visible. A drill is then used to cut through the bone to expose the epidural tissue.

If an epidural sensor is used, it is then inserted between the skull and epidural tissue. If a bolt is used, an incision is made to expose the subarachnoid space and the bolt is screwed into the bone. This allows the sensor to record from the subdural/subarachnoid space.

If an intraventricular catheter is used, it is threaded through the brain matter into one of the lateral ventricles. This type of catheter is effective and accurate at sensing intracranial pressure measurements.

How to prepare for the test

If you need this procedure done, you will be in the hospital and most likely in an intensive care unit. If you are conscious, your health care provider will explain the procedure and the risks, and you will have to sign a consent form.

How the test will feel

If the procedure is done while you are under general anesthesia, you will feel nothing until you wake from the anesthesia. At that time you will feel the normal side effects of anesthesia, plus the discomfort of the incision made in your skull.

If the procedure is performed under local anesthesia, you will fell a prick on your scalp like a bee sting as the local anesthetic is injected. You may feel a tugging sensation as the skin is cut and pulled back to expose the bone. You will hear a drill sound as it cuts through the skull bone. The amount of time this takes will depend on the type of drill that is used. You will also feel a tugging sensation as the surgeon sutures the skin back together after the procedure.

Your health care provider may prescribe mild pain medications for relief. You will not receive strong pain medications, so that your doctor can check for brain (neurologic) signs. With increased intracranial pressure, neurologic problems are common.

Why the test is performed

This test or procedure is done to measure the intracranial pressure and to learn if you are at risk for injury from increased intracranial pressure. It also provides a sterile access for draining excess CSF.

Normal Values

Normally, the ICP ranges from 1 to 15 mm Hg.

Note: mm Hg = millimeters of mercury

What abnormal results mean

Intracranial pressure monitoring is usually done in cases of severe head injury. It also may be done after surgery to remove a tumor or repair damage to a blood vessel (vascular lesion) if the surgical team is concerned about brain swelling.

Elevated intracranial pressure can be treated by draining CSF through the catheter. It also may be treated by changing ventilator settings (for people who are in critical condition and on a respirator) or by giving certain medications through a vein (intravenous).

Intracranial pressure monitoring is crucial to identify the problem and treat it right away. Raised intracranial pressure means that both nervous system (neural) and blood vessel (vascular) tissues are being compressed. If left untreated, it can result in permanent neurologic damage. In some cases, it can be fatal.

What the risks are

Infection
Bleeding
Damage to the brain tissue with continued neurologic effects
Risks of general anesthesia
Inability to find the ventricle and accurately place catheter

Review Date: 5/3/2007

Reviewed By: Robert A. Cowles, M.D., Assistant Professor of Surgery, Columbia University College of Physicians and Surgeons, New York, NY. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

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