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This picture compares the incision size of the In-Line Vasectomy in millimeters with the actual size of several common objects: A) a dime, B) a raisin, C) a kernel of corn, D) a grain of rice, E) the 4mm opening of an In-Line Vasectomy. |
Each year, more than 500,000 American men receive vasectomies for permanent birth control. Most local medical centers offer minimally invasive vasectomies, but only Cooper University Hospital performs the in-line vasectomy.
“This is perhaps the most minimally invasive procedure available,” said Joel L. Marmar, M.D., Head of Cooper’s Division of Urology and the creator of the in-line vasectomy. “The in-line vasectomy is faster and less invasive than other procedures. It also requires less local anesthetic.”
In a typical vasectomy, the doctor cuts the tubes (vas deferens) that carry sperm from the testicles to the urinary tract so that sperm can’t get into the semen. Most of these procedures involve making incisions on each side of the scrotum to do this. The doctor then brings the entire tube to the skin level to remove a small section and seals the ends. The office-based or outpatient procedure takes about 30 minutes.
Dr. Marmar performs the in-line vasectomy through an incision smaller than a grain of rice, using special scissors he designed. He only brings the upper part of the tube to the skin level and then completes the procedure. Each side takes about five minutes.
After a vasectomy, up to 5 percent of men decide they want to have children. These men have two options: surgical reversal or sperm extraction. Dr. Marmar has performed more than 1,000 outpatient microsurgical vasectomy reversals and office-based sperm aspirations for in-vitro fertilization.
With meticulous microsurgery it is possible to restore the continuity of the vas deferens so that sperm may reappear within the ejaculate. The surgery may be performed with local anesthesia or light general anesthesia depending upon the patient's preference.
The success of Vasectomy reversals can be linked to the length of time between the vasectomy and the reversal. Those men who seek reversals within 10 years of vasectomies typically undergo a direct vasovasostomy with consistently good results.
In cases of reproductive tract obstruction such as prior vasectomy or trauma, there are no sperm in the ejaculate, but spermatozoa are continuously produced within the testicle. These sperm may be removed via sperm aspirations and then used for IVF/ICSI. In these cases, the female partner is stimulated for ovulation induction. When her eggs are removed by ultrasound guidance, a single sperm is microinjected into each egg for fertilization.
Dr. Marmar has developed new techniques that do not require open surgery conducted in an operating room. Using percutaneous methods, Dr. Marmar performs sperm acquisition procedures in an office setting and the patient receives just a single injection of local anesthetic to the spermatic cord. The sperm are extracted by needles (percutaneous methods)instead of open incisions.
Data suggests that percutaneous procedures performed in the office have a low level of complications. The birth rate for one cycle was 27%. If the patients persist through four cycles then the birth rate can reach 52%. These new procedures offer options and hope for some men who were previously considered untreatable.
According to the World Health Organization, approximately 40% of men with male infertility are found to have varicoceles and these lesions may be correctable.
When varicoceles are present, the veins are large and lack internal valves. As a result, the blood flow goes backward into the testicles in the venous system causing a buildup of heat, pressure and poor oxygenation of the sperm producing tissue. The net effect of the backflow may be manifested as a low sperm count in the semen, poor motility, or abnormal sperm morphology.
To correct these lesions, Dr. Marmar introduced outpatient, subinguinal microsurgical varicocelectomy with sedation and local anesthesia. These procedures have gained wide acceptance and to date, Dr. Marmar has performed over 2000 of these procedures. Patients typically undergo surgery on Friday and are able to return to work on Monday.
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| The anatomic relationship between the internal (Inc.) inguinal ring, the external (Ext.) ring, and the pubic symphsis. A 2-cm mini-incision was made just over the external inguinal ring. (From Marmar JL, DeBenedictis TJ, Praiss D. Fertil Steril. 1985;43:583-588.) |
The index finger is introduced via the scrotum in the direction of the Ext. inguinal ring. The anesthetic is delivered through a skin wheal just over the Ext. inguinal ring. (Fertil Steril. 1985;43:583-588.) |
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| The incision is separated by small band retractors. Xylocaine is injected under the cremasteric fascia under direct vision to block a segment of the spermatic cord. |
The anesthetized segment of the spermatic cord is then grasped with a Babcock clamp and brought to the surface through the inguinal incision. |
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| The spermatic cord is draped over two Penrose drains. The distal Penrose drain is held taught in order to stabilize the cord, whereas the proximal drain is allowed to remain loose. The cremasteric fascia is examined under the operating microscope and opened in two layers to avoid the lymphatics. |
The fascia of the cord is spread widely to identify the artery and vas deferens. The cord is sprayed with papaverine hydrochloride to augment the arterial beat prior to dissection of the varicosites. |
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| The varicose veins are clipped with hemoclips and transected. |
The incision is closed with absorbable suture and covered with a band-aid. |
Statistical data on 606 procedures suggest that the semen parameters improved in 63-75% of the patients and that the pregnancy rates were 37.5% within the first year of the surgery. If pregnancies do not occur naturally, artificial insemination may be utilized after surgery.
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For more information about vasectomies and male reproductive health at the Cooper Urological Institute, please call 1-800-8-COOPER (800-826-6737) to speak with a member of our physician referral and information service. |