Urologic Consultants, P.C.

Pursue Fatherhood Once Again

Due to the increased success of modern surgical techniques, vasectomy reversals are now more common than ever. Whether you remarried, suffered the loss of a child, are fulfilling a religious obligation, or simply changed your mind, you can pursue fatherhood once again by having an outpatient-performed vasectomy reversal.

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Vasectomy Reversal Defined

Vasovasostomy involves a surgical reversal of a previous vasectomy with the goal of obtaining sperm in the ejaculate of sufficient quantity and quality to achieve a pregnancy. The patient usually takes an oral narcotic and muscle relaxant one half an hour prior to arriving at the office. Then after the surgical area has been washed with betadine, a long acting local anesthesia is injected. Then, depending on the length of time since the vasectomy, or the presence of a sperm granuloma, a small incision is made just over the area of the vasectomy. The proximal end (the end that comes from the testicle) is opened and the fluid is checked for sperm under the high power microscope. The distal end (the end that goes to the prostate and out) is flushed to make sure it is open. The vas is connected to the vas if 1) there is sperm found or 2) if the inside diameter is wide open and abundant fluid runs out. This connection or “anastomosis” is called a vaso-vasostomy. The operating microscope is used during the entire procedure. I use 10-0 nylon for the inside diameter to connect the mucosal lining of the vas, and 9-0 nylon to reinforce the muscular layers of the wall. After placement of the sutures, the skin is closed with absorbable suture. Then attention is turned to the other side. After both sides are anastomosed, dressings are placed and the patient is dismissed.

If during the course of surgery, no sperm are seen at the level of the vasectomy and the inside diameter is small and no fluid is expressed, then a search for sperm ensues. Generally, the incision will be lengthened and the epididymis is exposed. The next step is to find sperm at the epididymis. Outcomes are better the further away from the testicle sperm are encountered. When sperm are identified then the vas is connected to the epididymis in a procedure called a “vaso-epididymostomy” or “epididymo-vasostomy”, I just call it a VE.

Our Process - Why Choose Us

Professional, Courteous, Experienced… Serving You Is Our First Priority

We understand that visiting a medical specialist can be an uneasy experience if you don't know what to expect, so our entire staff is committed to making you as comfortable as possible during your initial appointment and all the way through recovery.

The Consultation

Before Treatment

Most patients are seen several days to weeks before surgery and we get to know each other. I review the historical details and proceed with a physical examination to get an idea of how long the surgery will last and what the expected outcome will be. We can also review my personal results since I have been in Michigan. Usually the couple will take a tour of the room where the reversals are done.
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Safe and Convenient

The Procedure

I generally plan on three hours of surgery, a little more or a little less. The operating room table is firm so the patient will need to understand he will need to hold still for that amount of time. Some patients fall asleep. I sit to the right of the patient, my assistant sits to the left and there is an attendant to take the vital signs and deliver the supplies as needed. We almost always play some music.
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Recovery

Healing should be rather quick and fairly easy. Pain after surgery is most often controlled with pills. About 50 out of 100 men say the pain after the reversal is like after their vasectomy. Another 25 out of 100 say the pain is less than after the vasectomy, and 25 out of 100 say it’s greater. Pain bad enough to need medications rarely lasts longer than a few days to a week.

Most men can return to their normal routine and light work within a week. We recommend an ice pack to the scrotum for 24 hours, a scrotal support for ten days, weight restriction for ten days and ten days of sexual abstinence.

Dr. Phillip G. Wise, M.D., F.A.C.S

Board Certified in Urology  |  Adult & Pediatric Urology  |  Male Infertility

Dr. Phillip Wise was raised in Southern California and graduated from the University of Southern California with a Bachelor's degree in physics. Immediately after college, he pursued his interest in medicine by studying the effects of laser therapy on bleeding stomach ulcers. Following this research, he continued his studies and traveled extensively in Europe, perfecting his French while studying at L'Universite de l'Etat Liege, Belgium.

In 1982, Dr. Wise graduated from the University of Southern California School of Medicine, where he received his M.D. At USC, he was exposed to enough of the local population to be able to communicate in Spanish. From there, he went to Baylor College of Medicine in Houston to study the field of urology, where he became interested in male infertility and went on to complete a fellowship with a world-renowned professor.

Dr. Wise has published book chapters on the surgical therapy of cancers, and was among the first to treat patients with the extracorporeal shock wave lithotripsy (ESWL). He keeps abreast of new treatments by attending conferences, frequently in foreign countries. In addition, he is active in the local medical, urological and infertility societies.

We are ready to help expand your family.

Focus and patience is the real key to success. Keep your eyes on the goal, and just keep taking the next step towards completing it.

Frequently Asked Questions / Articles

In Sickness and in Health... and Infertility?
Remember how you felt when you were first married, the feeling that you and your love could handle anything? That there was nothing out there big enough to come between you? And then came infertility... and everything seemed different.

Infertility is a force in marriage unlike any other, because it does not come as much from "outside" as from "inside". It is not so much an outer force, as an inner one that nibbles away at areas hard to talk about: individual self-image, sexuality, and the sexual relationship, as well as emotional well-being and ways of responding to a crisis--every area of a marriage from the inside out. And though two people may want to cope with the crisis in a united way, it just may not be possible at first.

The average couple will go through a scenario something like this: He will cope by keeping his feelings to himself and focusing on her... She will cope by expressing over and over how awful and unfair and frustrating everything is... She pushes more and more; he retreats more and more... He feels overwhelmed by her need because he feels powerless to take away the pain; she feels abandoned when she needs him the most...

And the scene goes on night after night. The issue is so personal. A couple cannot help looking at their marriage differently and at themselves differently. And as the crisis forces a spotlight on the marital relationship, the easiest thing to do is to keep dodging the light. But that is not possible. Boston psychiatrist Miriam Mazor sees the point clearly: "Infertility makes couples take a harder look at each other... They begin to assess the marriage at a stage when other couples are too busy with child care to do so". The health of a relationship must stand the glare of that spotlight and must keep standing the glare for the whole infertility crisis -- no matter how extended it may be.

What's the answer? Communication.

There is a trick to communication, however. The trick is to listen without criticism and advice, and with acceptance and understanding. It is hard to assimilate such a serious life situation. Even following a decision to change, coping patterns will be slow in transition.

However, as a couple talk they find themselves growing together. Slowly they grasp what is happening to them. And they may begin thinking of ways to cope together. The husband might decide to be with his wife through as much of her part of the medical work-up as possible. They may decide together that there are ways to soften the tension of temperature charts, the husband keeping the chart or picking between the two or three pivotal nights for instance. Maybe they can explore other ways to share, working toward coping in a healthy partnership way.

Sometimes, though, it takes more than just "one-on-one" talking. What may be needed is a chance to bounce ideas off of other couples, to learn that other couples have similar problems and to hear how they are responding. Many, many couples cannot get past their denial without sharing with other couples having similar experiences. A couple might share with another going through the same crisis, or they might want to seek support from a group such as one listed below.

Keeping a marriage healthy through this crisis may mean communicating in a new way, in a deeper way than before. If may man looking painfully deep into oneself, into long-held understanding of one's own sexuality, beliefs about marriage, and one's own priority system. And then it may mean listening closely to that someone held dearest as he or she works through all the painfully deep examinations too. The united front is possible. And surviving the emotional, mental and physical stress of infertility can forge a marital bond that can stand any stress.

Adapted from Give Us A Child: Coping with the Personal Crisis of Infertility By Lynda Rutledge Stephenson

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Varicocele

Male infertility has been found to be the major cause of a couple's inability to conceive in 50% of childless marriages. There are many causes of male infertility including: deficiencies in sperm production; blockage of the conducting system; antibodies against sperm; injury to the testicle; hormone problems; poor descent of one or both testicles; and finally the presence of a Varicocele.

In order to understand what a varicocele is, one must be aware of some basic anatomy and physiology. The testicles are the paired male genital organs that contain not only sperm but also cells that produce and nourish the sperm. These organs are located in a sac called the scrotum. The epididymis is a small, tubular structure attached to the testicle. It is a reservoir where the sperm mature and are stored. The vas deferens connects the epididymis to the prostate gland and is the tube through which sperm travel during ejaculation. The vas deferens is not situated by itself but is a part of a larger tissue bundle called the spermatic cord. The spermatic cord contains many blood vessels as well as the vas deferens, nerves, and lymphatic channels. The vein of the spermatic cord are known as the pampiniform plexus. These veins drain blood from the testes, epididymis and vas deferens, eventually becoming the spermatic veins that drain into the main circulation at the level of the kidneys. The pampiniform plexus of veins may at some time become tortuous and dilated much like a varicose vein of the leg. In fact, a scrotal varicocele is simply a varicose enlargement of the pampiniform plexus around the testicle.

The scrotal varicocele is a well-recognized cause of decreased testicular function and is present in about 40% on infertile males. In order to understand the significance of this abnormality in the infertile patient, a brief review of the historical background, current concepts of its anatomy and function, and methods and results of surgical repair must be considered.

History

Varicoceles have been recognized as a clinical problem since the 16th century. Ambroise Pare (1500-1590), the most celebrated surgeon of the Renaissance, described this vascular abnormality as containing "melancholic blood." It was not until the late 19th century that the relationship between infertility and varicocele was first proposed by the British surgeon Barfield. Shortly thereafter, other surgeons reported an association with "an arrest of sperm secretion" and subsequent restoration of fertility following varicocele repair. Through the early 1900's reports by other surgeons continued to describe the association of infertility with a varicocele. It was not until the 1950's, after a report of fertility following varicocele repair in an individual known to be azospermic (i.e. without sperm), however, that the concept gained support as a clinical entity among American surgeons. Research then continued with studies characterizing semen of men with varicoceles having degrees of impaired sperm quality. From these studies a pattern of low sperm count, poor motility, and a predominance of abnormal sperm forms was documented. This became known as the "stress pattern" of semen. Although not synonymous or specific for a varicocele, it consistently suggests early evidence of testicular damage. Clinically, urologists evaluate male infertility through the study of sperm. The sperm are evaluated for their number (sperm count), the percentage of motile forms, their forward movement and their morphology (shape and form). Although varicoceles do appear in about 25% of normal, fertile men, their presence is significantly higher in the subfertile population. In fact, scrotal varicoceles have been found to be the most common identifiable and surgically correctable factor contributing to poor testicular function and decreased semen quality.

Anatomy of the Varicocele and Mechanism of Effect Varicoceles are more common on the left than on the right for multiple anatomic reasons. They may vary in size and can be classified into three groups: 1) large - easily identified by inspection alone, 2) moderate - identified by palpation without bearing down or straining, and 3) small - identification only by bearing down which increases the intraabdominal pressure, further impeding drainage and thus increasing the size of the varicocele. It is important to remember, however, that the size of the varicocele is not related to the degree of changes in the sperm. Several theories have been proposed to explain the deleterious effect of the varicocele on sperm quality. These include possible effects of oxygen deprivation, heat injury or toxins. Despite considerable research, none of these theories have been unquestionably proven although an elevated heat effect caused by impaired circulation appears to be the most reproducible defect. The fact that creation of a varicocele in the experimental animal can lead to poor sperm function with elevated intratesticular temperature does give support to this concept. Regardless of the mechanism of action, varicocele indisputably is a significant factor in decreasing testicular function and changing the semen quality in a large percentage of men seen for infertility.

Diagnosis Because of its potential role in causing significant testicular damage, it is important to identify the varicocele on physical examination. Reasons for surgical correction include the presence of significant testicular pain, impairment of testicular function, as evidenced by decreased semen quality, and loss of testicular size (atrophy). The mere presence of a varicocele does not mean that surgical correction is necessary. Usually, the varicocele is asymptomatic and the patient is seen primarily for evaluation of a possible male factor in an infertile marriage. However, the patient may sometimes complain of pain or heaviness in the scrotum. Careful physical examination remains the primary method of varicocele detection. It is important to examine the patient in the standing position, having him perform the Valsalva maneuver, i.e., take in a deep breath and bear down to magnify a small varicocele. When small varicoceles are difficult to diagnose, more objective means can be used such as the Doppler Stethoscope and venography. The Doppler technique is painless and evaluates the motion of blood in the peritesticular veins using soundwaves. Venography requires a small incision in the groin, insertion of a needle into a groin vein and injection of "dye" (contrast solution) which will flow into the spermatic vein. This technique is relatively pain-free, performed on an outpatient basis and allows direct visualization of the varicocele by x-ray.

Surgery and its Results Once a varicocele is diagnosed, reasons for surgical correction include: testicular discomfort or pain unrelieved by routine, symptomatic treatment; testicular atrophy (loss of size); or the possible contribution to unexplained male infertility. There are four commonly used surgical approaches for the correction of a scrotal varicocele. These are the transinguinal (groin), the retroperitoneal (abdominal), laparoscopic and microscopic approach. The transinguinal and retroperitoneal approaches were the operations of choice for many years. Recent advances in surgical techniques and equipment have brought newer ways to remove the varicoceles. With the laparoscopic approach a small incision is made under the belly button and two small holes on either side of the abdomen are created. Through these ports, instruments are placed to tie off the offending veins. The advantage of the laparoscopic method is that there is much less pain involved. The disadvantage is that there is a small risk of injury to the intra-abdominal organs. With the microscopic approach, the abdomen is not entered, but a larger incision in required and placed over the top part of the scrotum. This seems to cause more pain, but there is no risk of damage to the abdominal contents. Although the mechanisms whereby varicoceles cause impairment in sperm production and semen quality remain theoretical, the statistical association between varicocele and male infertility is unquestionable. Furthermore, improvement in semen quality after varicocele correction has been repeatedly demonstrated. The resultant improvement seen in sperm motility rather than in sperm count. The pregnancy rate is as high as 40% with the average pregnancy occurring 6 to 9 months following surgery.

The scrotal varicocele remains the most correctable factor when treating poor semen quality. Therefore, when present in the infertile male with abnormalities of semen quality, surgical correction should strongly be considered. The side effects following varicocele repair are remarkably low, and successful surgery will often increase the incidence of eventual pregnancy in the infertile couple.

Questions? If you or a relative would like more information please ask or make an appointment for a private consultation.

We believe communication is an essential part of any doctor-patient relationship. You are encouraged to discuss any aspect of your healthcare with us.

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We believe that everyone should have access to affordable healthcare services, and we are dedicated to keeping our fees as low as possible. Our physicians participate in the Medicare program and accept assignment of payment so you can avoid having to wait for reimbursement of out-of-pocket expenses. In addition, we accept most major health plans and work with a number of HMO and PPO products.

Vasovasostomy costs around $4,300.00. This fee includes the procedure, a local anesthesia, and operating room. Dr. Wise performs approximately 123 procedures a year.

A $500 deposit is required at the time the procedure is scheduled. Patients that cancel the week of or do not show up to their appointment will forfeit their deposit. Patients that reschedule at the time of cancellation will apply the deposit to the new date of service.

As a courtesy, our office staff will verify our participation in your insurance plan prior to your appointment, and will file your insurance forms for you after you come in. We will bill you for any remaining charges not covered by your insurance policy.

Urologic Consultants, P.C.
25 Michigan Street, Suite 3300
Grand Rapids, MI 49503