Vasectomy

Vasectomy represents the most definitive form of male contraception.  This 10-15 minute procedure is usually completed in the office under local anesthesia without the need for a scalpel incision.  This "no-scalpel" technique permits access to each vas deferens-the tube carrying sperm from the epididymis/testis to the urethra-through a single puncture in the scrotum. Sterility is confirmed with a semen analysis at 6 and 12 weeks, at which time no sperm should be found in the ejaculate.
Vasectomy is safe, highly effective and is not associated with any increased risk of erectile dysfunction or prostate cancer.  Mild scrotal discomfort is usually manageable with anti-inflammatories, ice pack application and scrotal support for only a couple of days.  It is recommended that one avoid heavy lifting or vigorous exercise for one week, but return to work and to normal daily activities is common in one to two days.  For more information, visit Vasectomy.com (place link here).

Hypogonadism

Hypogonadism is a condition of testicular hormone (testosterone) underproduction, also known as low testosterone or Low T. Testosterone is commonly known as the male hormone, responsible for male sexual development, libido and instrumental in the cascade of events that produce a normal erection. Testosterone is produced by specific cells of the testis, called Leydig cells. Testosterone produced here is critical to proper sperm production by the Sertoli cells of the testis.

Hypogonadism can have broad-ranging effects that include poor libido, fatigue, muscle loss, increased abdominal fat, impaired sleep, difficulty concentrating and memory loss, depression, irritability, early diabetes and heart disease, as well as infertility, erectile dysfunction, loss of bone mass, hot flashes, and potentially reduced life expectancy after age 50.

Free testosterone levels decline by slightly over 1% each year in men over 45 years of age. This gradual decline is often undiagnosed, but exists in nearly 40% of middle-aged men. A simple blood test of total testosterone is used to establish a diagnosis, with normal levels ranging between 300 – 1,000 ng/dl.

Hypogonadism may be the result of andropause, or male menopause, where the testicles over time fail to produce adequate levels of testosterone. Adropause represents primary hypogonadism, where the problem exists with the testicles themselves failing to produce adequate hormone levels. Other causes of primary hypogonadism are varicocele, where dilation of scrotal veins leads to testicular atrophy and/or abnormal sperm production, and specific endocrinologic conditions like Klinefelter Syndrome. Mumps infection after puberty can also lead to testicular failure and primary hypogonadism within several months to several years after infection.

Hypogonadism can also result from abnormalities with hormone production necessary for adequate testicular function. Deficient production of hypothalamic or anterior pituitary hormones necessary to stimulate testicular hormone production is termed secondary or central hypogonadism, as the underlying disorder exists outside the testicle in the brain. Measurement of pituitary hormones LH and FSH are used to distinguish primary from secondary hypogonadism. Exogenous steroid use (usually anabolic steroid abuse) is another cause of secondary hypogonadism. In this condition, the administered anabolic steroid is detected by the hypothalamus and anterior pituitary in the brain, leading to reduced levels of stimulatory hormones produced by these glands, thereby turning off testicular hormone production and causing testicular atrophy.

Treatment of hypogonadism is accomplished by safely replacing the deficient hormone. Testosterone replacement therapies (TRT) include daily transdermal patches, gels or creams and can be administered by once- or twice-monthly testosterone injection. TRT does not cause prostate cancer; however, because the progression of existing prostate cancer is usually testosterone-dependent, prostate cancer screening with PSA measurement and digital rectal examination every 6 months instead of annually is recommended during TRT.

Varicocele Repair

Varicocele is an abnormal enlargement of the network of veins draining the testicle. It is usually caused by failure of valves in these veins to accommodate the back pressure of blood within the venous column that spans the distance from the testicle to the inferior vena cava and renal vein in the upper torso. Compression of the veins by a nearby structure can also cause a varicocele. Dilatation of these scrotal veins greater than 2 mm represents a varicocele. The increased temperature surrounding the testicle caused by this pooling of venous blood is thought to disrupt normal sperm production and sperm maturation and can lead to male infertility. In over 90% of male infertility cases, bilateral varicoceles can be identified.

Varicocele is a condition of young men, presenting usually between the ages of 15-25 years, and rarely after the age of 40. 98% of varicoceles caused simply by incompetence of venous valves (primary varicocele) occur on the left side, as the insertion of the left gonadal vein into the left renal vein creates a longer and straighter column of venous blood leading to greater vascular back pressure. Isolated right sided varicoceles are rare and should prompt an evaluation for a source of extrinsic compression (secondary varicocele).

Symptoms of a varicocele may include a dull aching within the scrotum, feeling of heaviness in the testicle, shrinkage (atrophy) of the testicle or visible or palpable enlargement of scrotal veins, likened to feeling “a bag of worms”. Varicoceles are reliably diagnosed with scrotal ultrasound, documenting dilatation of the scrotal vessels greater than 2 mm and/or reversal of blood flow within the scrotal vessels during an increase in abdominal pressure.

Surgical correction of a varicocele is termed varicocelectomy. This procedure is performed in the operating room as an out-patient procedure through a small inguinal (groin) incision resembling that of an inguinal hernia repair. The procedure is performed with the assistance of optical loupes or under a microscope, permitting identification of the small scrotal veins within the spermatic cord. Intra-operative ultrasound is also performed permitting identification and preservation of the testicular artery carrying blood to the testicle. The individual enlarged veins are simply looped with silk suture and occluded, preventing pooling of venous blood below the suture and allowing the arterial blood flowing to the testicle to cool before reaching the testicle.

Approximately 70% of men diagnosed with abnormal sperm production or maturation who undergo varicocelectomy will respond with improvement in their semen analysis. 50% of these men will go on to father a pregnancy, assuming the female evaluation is normal.

Possible complications of this procedure include bleeding, infection and injury to the testicular artery, which can lead to testicular damage or loss. These complications are uncommon.