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Eric Seaman
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A Specialist in Vasectomy and Vasectomy Reversals
A Specialist in Vasectomy and Vasectomy Reversals

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New Technology for Growing Sperm from Stem Cells

In the Journal Cell Stem Cell (Volume 18, Issue 3, p330–340, 3 March 2016), scientists in China report growing (mouse) sperm –like cells from (mouse) embryonic stem cells. Those cells were then able to be injected into (mouse) eggs and create normal adults that in turn were able to mate and produce healthy offspring.

The potential application of this new technology for people is for use in men who cannot produce sperm, either because they have a condition called sertoli cell only where there are no sperm making cells at all, or in the setting of maturation arrest, where sperm progenitors fail to mature into sperm. This condition can happen due to a genetic abnormality, due to exposure to toxic agents and or chemotherapy, as well as for unknown reasons. These types of problems affect at least one percent of men with fertility issues.
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Shockwave Therapy to Treat Erectile Dysfunction has come to New Jersey!

Low-intensity shock wave therapy to the penis is a new alternative for the treatment of erectile dysfunction or difficulty with erections. It has been shown to help men with erectile dysfunction (ED) that is unresponsive to conventional medications: phosphodiesterase type 5 (PDE-5) inhibitor treatments such as viagra, levitra, cialis, stendra,or staxyn. It is also been shown to improve function in patients who are partially responsive to medication.

The key to LISWT appears to be its effect on blood flow. Previously, Low-energy shock wave therapy had been shown to induce the regeneration of small coronary vessels in patients with angina who were not suitable for coronary surgery or angioplasty. Based on the finding that therapy can improve the blood flow of vessels in the heart, the potential for use in erectile dysfunction was explored.

Read more by visiting the link below.
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Evaluation of the Male infertility Patient. Which physician is the right one to see?  The Role of the Urologist.

When someone needs to be evaluated for problems with male fertility, they are often referred to a urologist.  What are urologists and why are they the doctor frequently recommended to see?    Who else is involved in fertility care?

Urology

Urology is a surgical subspecialty within medicine.  Urologists are physicians whose focus is the urinary and male genital system.     That means beyond an internship in general surgery, urologists spend several years in residency training acquiring knowledge and skills used in treatment of disorders of the genitourinary system. 

 The Urinary system includes whatever is involved in the production and transport of urine.  This includes the kidneys which filter the blood to actually produce the urine,  the ureters which carry the urine to the bladder, the bladder itself and the urethra.     With respect to  males, urologists also receive residency training in  disorders of the male genital system.    This includes the accessory sex organs such as the prostate, and seminal vesicles as well as the penis and testicles, all of which are involved with reproduction.  

 Male Reproductive Medicine

Some Urologists may undertake additional training known as a  Fellowship in Male Reproductive Medicine or Male infertility.   Fellowship training may give a urologist more exposure and experience with disorders related to male infertility as well as with surgical procedures often used in the treatment of men with fertility issues such as varicocelectomy, vasectomy reversal and surgical sperm retrieval.  Fellowships usually provide extensive microsurgical training and experience to maximize surgical skills in this area.

Obstetrician / Gynecologists

However, infertility is, in reality, a couple’s issue.   Obstetrician/Gynecologists have residency training in the female genital system and are often the first doctor the infertile couple will see in the evaluation process.   Reproductive endocrinologists are gynecologists who have undertaken fellowship training in female fertility  and have additional expertise including extensive training and experience with in vitro fertilization.    Nurses often play a large role in reproductive care, especially in the setting of a reproductive endocrinology practice.

Other Health Professionals

Still other health professionals may be involved with the treatment of individuals with fertility issues.  It is not uncommon for couples to seek nutritional counseling.   Acupuncturists sometimes also attend to couples with fertility issues.    Less commonly, genetic counselors may play a role.

At  the end of the day,  the patient should see the physician or health care professional who is best trained and best able to address their particular problem.   For male infertility issues, particularly surgically treated problems, Urologists, may be the most appropriate physician to see, especially those with additional training and or an interest in male infertility. 
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A ‘How to’ Guide. What a man can do to maximize his chances of successful Vasectomy Reversal.  

Vasectomy reversal is a surgical procedure which essentially allows a man with a vasectomy to change his mind.  Although vasectomy itself is readily accomplished in an office setting in about twenty minutes to a half hour,  a vasectomy reversal is far more difficult, takes more time and requires microsurgical techniques for the best chances of success.     Still, no matter how good the surgeon,  the patient plays a major role in the success of the surgery.  The following are some suggestions as to how to maximize the chance of success of the surgery from the patient side. 

1) General health

The body simply works better if it is healthy.    High blood pressure, coronary artery disease,  diabetes,  and any systemic disease can work against efficient body function.  If a man has any of these conditions, it is important that he get them maximally controlled prior to reversal.    The fertility of some diabetics is exquisitely sensitive to their blood sugar levels.    If it’s chronically elevated, their sperm production and quality of ejaculate will simply be worse.    Although being a tri-athlete is unnecessary, good physical conditioning can count, so, if you are able, stay in shape.   Finally, age can impact as well.  No one grows younger and, on average, men’s sperm production will decrease as age advances;  interestingly, up to about age 45, sperm count will stay relatively constant for most men, but there can still be some deterioration in motility and morphology as time passes.    That is not to say men over 45 should not have reversals.  I have reversed men in their fifties and a few in their sixties who subsequently conceived children, but a younger age tends to go with a better prognosis.   

      Weight counts.   Elevated body mass index is associated with metabolic syndrome, sleep apnea and low testosterone levels, all of which can be contributory to poor testicular function.     Try to stay a healthy weight.

      Finally, mental health is a part of overall health.    Depression, anxiety, and other mental illness can affect results.   Although not a mental illness, grief can have an impact.  I reversed a patient who lost a loved one shortly after his procedure.  His first analysis showed no sperm.   Months later, after he was coping better, his semen parameters became normal and he and his wife conceived. 

2) Recreational substance use 

   Some men are more sensitive to certain recreational substances  than others, but beyond some level of use, we are all affected.   I have a patient who smokes a lot of marijuana.   He appears to be very  happy, but he is not very fertile;  the smoking several times a day has impacted his sperm production.  I have similarly seen people indulge after their reversal with the same results.  

a.   Use of other recreational substance like alcohol can also impact on fertility.   Although most men can have a couple of drinks a few times a week without significant consequence, at some level of alcohol ingestion, there will be an impact.  Chronic alcohol use can take its toll on sperm production through several mechanisms and effects can be long lasting or even permanent.    Narcotics can also take their toll, especially in patients who suffer from chronic pain.

b.  One substance often indulged in by men that is often overlooked with respect to impact on fertility is supplemental testosterone use.   I have seen patients for reversal with sky high testosterone levels and suppressed pituitary hormones due to taking testosterone.  The problem is that by suppressing production of pituitary hormones, these men are also suppressing their sperm production and their reversal will fail if the situation is not corrected.

c.   Finally smoking is a bad idea in general and bad for your results.   The micro vasculature (blood supply) that enables healing requires enough oxygen to work properly.  The carbon monoxide in cigarette smoke will starve those healing tissues of the oxygen they need.   With that said, however, don’t abruptly stop smoking right before the surgery.  The reactive cough that you get can also be damaging to your healing.   Best if you quit several weeks prior to your  procedure, or, it it’s right before the procedure, cut down by half.

3) Time since vasectomy 

There is a fair amount of literature on this issue.   Every year that passes after the vasectomy is associated with a lower chance of reversal success.  When it comes to reversal, sooner is better than later.   Success rates within 5 years of reversal are very good,  within in 10 years, good, and so on.

4) The woman;   It takes two to tango.

   If you are going through a procedure to reverse your vasectomy, then it only makes sense that your partner is proactive in getting checked out as well.   Her health is also important to enable conception and to carry a child.   She should see her gynecologist  to make certain there are no significant fertility roadblocks on her side.  

5) Post operative

Post op care and consideration is very important for a good result.  The surgery uses suture finer than human hair to accomplish the reconnection.  Tissue has to heal under good conditions for a good result.    No sex, sports or strenuous activity is advised for a few weeks as well as wearing support.  But even after sex is permitted,  use your head.  No full contact aerobics, no extreme mud wrestling, in short, no activity that is excessively strenuous for  a few months.

Combine these behaviors with good surgical skills and you will have the best results possible for your surgery.
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What is the Best Way to Undergo a Permanent Method of Birth Control?  

Vasectomy is considered to be a minimally invasive, safe and reliable method of effecting birth control.  Although vasectomy reversal surgery is feasible, vasectomy is considered to be a permanent means of eliminating sperm from the ejaculate.    

The vasectomy procedure has been performed for several decades in the US and seems to keep gaining in popularity.   Incentives for men to undergo a vasectomy include: taking control of one’s financial future, a man taking responsibility for his role in family planning,  and the fact that tubal ligation, the female equivalent of vasectomy, is considered to be a major surgical procedure as it requires invading a major body cavity.   

So what prevents more men who have decided that they do not wish to father any more children from taking that next step?

For some men it is simply anxiety.   Previous experience with soccer or softball injuries to the family jewels as well as years of safeguarding what’s between one’s legs naturally gives men some pause before undertaking an alteration to the reproductive plumbing.    For many men, the conviction to get their vasectomy done is enough to get them through, but for some, a little more help may be needed.

It is therefore interesting to know that different urologists take different approaches to addressing this problem.    Most urologists will take efforts to education patients as to the process of vasectomy, how the procedure works and what to expect afterwards and in so doing, address patient questions and concerns.   However there is a variation among doctors who perform vasectomy as to what to offer in terms of addressing patient anxiety through medication.

Sedation prior to Vasectomy

Many physicians prefer to only perform office vasectomy with their patient awake, under straight local and without any form of sedation.   Some don’t even want their patients listening to music.   They feel that they can calm and if necessary, distract their patient with conversation.   By speaking to the patient, they feel the can also ensure patient cooperation if it is needed.    

In contrast, some urologists routinely offer their patients the opportunity to take a sedative such as an Ativan , a Xanax or a Valium pill before hand, while others only offer it upon patient request.   Less commonly, physicians will also offer the patient the option of going to sleep for their vasectomy with the help of an anesthesiologist, while some doctors prefer to limit performing the procedure to being performed completely awake in their office.

In my practice I recognize that not all men are created equal.     Some men are simply more anxious than others.   I generally review information about the procedure,  instructions for preparation before the procedure and post procedure instructions with all patients.  Patients are then engaged on whether they want to have the procedure with straight local, take a pill to help manage their anxiety or even go to sleep with the help of an anesthesiologist.    I find men to be very capable of deciding for themselves what their needs are.    One caveat, however:  in my practice, any patient that takes any medication beyond straight local must have someone drive them home. 
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Vasectomy: A way to help take control of your future.
Although there may be several reasons why a man might consider a vasectomy, the most common setting occurs after a man has conceived one or more children with his partner. Concerns regarding the future of one’s family can be the driving force in the decision to take control of one’s reproductive potential.
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Vasectomy Reversal means a man can change his mind.

Vasectomy is intended to be a permanent method of birth control.

It is an office based or sometimes an outpatient minor surgical procedure.  It generally only requires fifteen to thirty minutes to accomplished and is most commonly performed on men who have decided that they no longer desire to have additional children with their partner. 

But can a man change his mind about that last part?   The answer is “yes”.   
Vasectomy reversal surgery exists and often can offer a high chance of restoring a man’s fertility potential.    It is performed as an outpatient surgical procedure with the goal of restoring flow of sperm into the ejaculate.

How is it performed?  

To understand that, first you must understand what is accomplished in a vasectomy. A vasectomy is a procedure that disrupts flow of sperm through the vasa (men generally have one vas on each side), into the ejaculate.  Typically a small piece of the vas is removed and the ends are sealed and cauterized.

A vasectomy reversal typically involves removing the sealed ends and joining the pieces of vas back together.

  This is a bit more complicated that it sounds.   The vas is a thick muscular tube as it has to be, in order to propel the sperm into the ejaculate.  The lumen or hollow central portion of the vas is very small in relation to that muscular wall and also very small in general.  In fact, it is  often smaller than a millimeter, unless dilated or stretched open.  So, in order to perform a vasovasostomy , the procedure to put the tubes back together, microsurgical techniques are required in order to get the best result.   This requires a higher level of surgical skill on the part of the surgeon, as well as more time, often taking a few hours.

There are also additional considerations.
  If it has been a long time since vasectomy, there may be additional blockage at the level of the “epididymis”, the tubules that receive the sperm from the testes before they pass into the vas.   In this case of a secondary blockage beyond the vasectomy, connecting one end of the vas to the other end will not accomplish much and instead a vas to epididymis connection would be required.  This is called an epididymovasostomy and requires even more microsurgical skill and time. 

If vasovasostomy is accomplished the success rate of returning sperm to the ejaculate is very good, generally above ninety percent.

  If epididymovasostomy is required, success rates are somewhat lower, occurring about two thirds of the time.   If the surgery is not successful at restoring sperm into the ejaculate, there still remains another option which is surgical sperm retrieval combined with in vitro fertilization.    In fact, I sometimes perform this procedure for my patients at the same time as vasectomy reversal so that a back up plan is available without requiring an additional procedure.
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