What would you do? (#1)
After trying for 45 minutes to locate a vas on one side, you give up. Your suspicion is that the patient may have unilateral absence of vas deferens. (UAVD) What would you do next?
How vasectomy providers responded:
Dr. #1 – Advised him to request a scan by his GP to rule out renal agenesis on that side. Patient’s response was, “Oh sorry I forgot to mention I only have one kidney “.
Have done some literature search, it is not uncommon 0.76-1% have UAVD and 76% of those have renal agenesis on the ipsilateral side.
Dr. #2 – Always ask the patient before procedure.
Dr. #3 – A lesson learned here is that if you cannot feel al dente pasta through the skin, whether it’s as thick as spaghetti or as thin as angel-hair pasta, “exploring” the spermatic cord with instruments is not usually productive. You cannot see anything through that tiny hole. Exploring is done with the fingers and if they don’t “find” (feel) anything that stands out as slightly thicker and denser that other cord elements, using instruments is not helpful (at least in my hands) and risks injury to other cord structures (nerves, arteries, veins, lymphatics).
In fact, unless you routinely provide a cord block for vasectomy, you administer anesthesia (whether by needle or spray applicator) directly to the vas and surrounding fascia. So, if you cannot feel a vas, you cannot administer anesthesia with any precision.
The outcome may have been the same had you not applied anesthesia or used instruments on the right side, but it is more difficult to imagine a mechanism for loss of flow to the testis after palpation (even prolonged or aggressive palpation) only.
What would you do? (#2)
One of my patients had a bladder neck incision 10 years ago. He was warned by the surgeon of the risk of dry ejaculations. Since his vasectomy his ejaculation amount has reduced slowly and steadily and he is now completely dry ejaculating with good evidence of the ejaculate being pumped into the bladder.
I have told him that with my failure rate of 1:1000 or better he is very unlikely to ever father a child anyway, but I cannot prove success to him unless he starts ejaculating again.
Is there anything else you would tell him? Any experience with this?
Dr. #1 – You can obtain a post ejaculate urine and check the specimen for sperm. Easy and cheap.
Will give him a peace of mind.
Specialist #2 – On a technical perspective, many fertility labs including mine would just ask the patient to collect a first sample of urine and stop during miction (as a control sample), then orgasm by masturbation and collect whatever comes out (if no ejaculate is produced, it’s fine), then collect another sample of urine.
Urine samples are checked under the microscope before and after centrifugation.
If sperm cells are detected, one could technically do the test again using a collection tube that already contains bicarbonate to increase the pH of urine at miction and allow for motility detection if present. Some protocols for ICSI in retro-ejaculation cases also involve giving the patient bicarbonate solutions to drink so his urine is less acid and chances of recovering motile sperm is better.
But this is all technical. You would do all this to protect the couple from a possible/eventual normal ejaculation during coïtus and in case your vasectomy has not worked. I’m not a physician etc. but I would say chances of conception are already really small.
