U of M
Section of
Urology

Erectile Dysfunction (Impotence) and Male Infertility

Erectile Dysfunction Treatment

Dr. Dana Ohl's clinic performs a comprehensive evaluation of male erectile dysfunction, including evaluation of those men with hormonal, neurologic and vascular problems. Specific testing modalities include cavernosometry and cavernosography, duplex Doppler ultrasound and penile angiography in conjunction with his colleagues in radiology. A full range of impotence treatments is provided, including hormonal therapy, oral agents, penile injection therapy, vacuum erection devices and penile prostheses. Microsurgical penile revascularization is performed in selected individuals.

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Male Fertility Assessment & Treatment

Dr. Dana Ohl directs the Male Fertility Clinic within the Department of Urology. This full-service fertility clinic is operated in close conjunction with the Gynecology/Reproductive Endocrinology department. Medical and anatomic evaluation of couples presenting with infertility is performed. Dr. Ohl performs microsurgical reconstructions of the vas deferens for those individuals seeking vasectomy reversal, as well as reconstruction of blocked ejaculatory ducts as indicated. Men with antisperm antibodies following vasectomy reversal receive pharmaceutical treatment. Varicoceles which severely impair sperm function are removed surgically using the most up-to-date techniques. This affords improvement in recovery time without compromising the results of improved male fertility. Other fertility problems are treated as well.

For those individuals who require higher level assisted reproductive techniques, Dr. Ohl works in close coordination with female fertility specialists. The Assisted Reproductive Technologies laboratory at the U. of M. offers comprehensive sperm assessment, as well as sperm processing for programs in artificial insemination. Couples are evaluated and assisted with intrauterine insemination, in-vitro fertilization and intracytoplasmic sperm injection (ICSI) as needed.

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More About Vasectomy Reversal

Vasectomy Reversal Information

It is possible to reverse a vasectomy, although the procedure is more complicated than having the vasectomy itself. During the vasectomy, the doctor made one or two incisions in the scrotal sac, then cut and blocked the tubes which carry sperm cells from where they are made in the testicles to where they enter the semen. Following the vasectomy, the tubes are in the sac, separated and blocked. To reverse the vasectomy, two incisions are made in the sac, and the blocked areas are removed. The tubes are then sewn together again under an operating microscope. The reason for using a microscope is because the channels in the tubes are quite small - slightly smaller than a period on a typewritten page. Using very fine suture material, the tubes can be sewn together accurately using the microscope.

Results

The results for returning sperm to the semen are fairly good using this method. 80% - 90% of the time sperm cells will return to the semen. Unfortunately, the pregnancy rates are not that good. The overall pregnancy rate is about 50%. The reason for the difference between the positive sperm count rate and the pregnancy rate is not definitely known. In addition, the pregnancy rate decreases as time goes on since the vasectomy. This rate of decrease is known and is shown below.


Years since Vasectomy

2
5
10
15
% Pregnancy

77
49
43
30


Reversal Surgery

Vasectomy reversals are done as an outpatient under general or local anesthesia. The patient reports to the outpatient surgery unit, has the reversal, and leaves for home after a brief (10 minute) recovery period if local anesthesia is given. There is a 1 - 2 hour recovery period if general anesthesia is used. Because sedation and/or anesthesia is used, it is necessary to have someone drive the patient to surgery and back home again. The reversal itself takes about 2-1/2 to 3 hours.

Recovery

Recovery from reversal surgery is similar to recovery after an uncomplicated vasectomy. There may be slightly more swelling and discomfort. The activity restriction is quite different, however. In order to protect the delicate surgery, patients are instructed to avoid heavy lifting over 30 lbs., and sports-type physical activity such as jogging, swimming, golf, bowling, etc. for 6 weeks following surgery. Walking and driving are all right when comfort permits. Stairs are okay if taken one at a time. Intercourse may be resumed after two weeks, but care must be taken to avoid significant injury to the testes. Patients may return to work when comfort permits, but the physical restrictions must be observed. After 6 weeks, there are no further restrictions and normal physical activity may be resumed.

Follow-up

There is a regular follow-up program following vasectomy reversal. A clinic visit is scheduled 10 - 14 days after surgery to make sure healing is progressing properly. Then a series of sperm counts is done to assess the success of the procedure, beginning at 8 weeks following surgery, with tests at roughly 3 month intervals thereafter until stable. The first count is sometimes low, but counts usually increase up to a year following surgery, and then stay at that level. The average time for a pregnancy, if it occurs, is 18 - 24 months, but pregnancies have occurred as early as 8 weeks, and as late as 5 years after surgery.

Cost and Payment

The total fee for the surgery should come to about $6,500 under local anesthesia and about $7,500 under general anesthesia. Most insurance does not pay for any of these costs and charges. It is worthwhile checking with your insurance company to see if any charges are covered by your policy. Please note that these fees are subject to change in the future, to offset increased costs.

How to Schedule Reversal Surgery

A consultation and physical examination is arranged in the clinic before surgery to go over the procedure, determine fitness for surgery, and to answer any questions. This may be scheduled through the Urology Clinic at (734) 936-7030. Be sure to tell the clerk that the appointment is for vasectomy reversal consultation with Dr. Ohl.  Following the consultation, an appointment for reversal surgery may be made at the consultation visit, or by calling back anytime in the future. The schedule for surgery is usually booked 2 - 4 weeks in advance.

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Spinal Cord Injury & Fertility

A major achievement in the field of male infertility was the establishment of a fully equipped program for the treatment of ejaculatory disorders. Most of the men attending this clinic are spinal cord injured, but men with absence of ejaculation from previous surgery, diabetes, multiple sclerosis and other ejaculatory disorders are also treated. The pregnancy rate in Dr. Ohl's program is 45% with the majority of these pregnancies occurring by ejaculation induction procedures coupled with artificial insemination. Dr. Ohl's clinic offers state-of-the-art ejaculation induction procedures, including penile vibratory stimulation (PVS), electroejaculation (EEJ) and sperm aspiration (direct surgical extraction of sperm).

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More Information about the EEJ Program

The electroejaculation project began in January 1985, through a grant funded by the Eastern Paralyzed Veterans of America. The study involved evaluation of fertility potential in the SCI male using either vibratory penile stimulation or electroejaculation. Clinical trials involving artificial insemination of partners of the SCI males desiring pregnancy are currently underway. Basically, vibratory penile stimulation consists of application of a vibrator to the penis to produce ejaculation. This method has been successful in those men with high T level or C level injuries. Alternatively, electroejaculation may be used. This procedure consists of insertion of a probe into the rectum of the SCI patient. A current is then applied and erection, followed by ejaculation, is produced. Pain has not been a problem in most patients evaluated thus far. A slight cramping or tightening in the stomach is noted by many. Blood pressure is continuously monitored. All episodes of high blood pressure have responded to stopping the stimulation and/or medication.

The following are some important facts about the SCI Males Project:

1. A commitment of at least 4 trials (1 day a month for 4 months) is required to adequately assess and/or treat the majority of patients.

2. The spouse or significant other should begin daily temperature charts prior to or on entry into the program.

3. Reports and x-rays of the SCI patient's most recent urological work (within 1 year) including IVP, cystoscopy and CMG should be brought for our review on the day of the initial examination.

4. The SCI patient's fertility history is required, including previous pregnancies, ejaculations and the ability to achieve erections.

5. Results cannot be guaranteed. It often takes at least 2 to 3 trials to "learn the patient" and produce an ejaculate. Not all ejaculates are sufficient for insemination. Not all patients produce an ejaculate.

6. Insurance will be billed for the procedure. Any fees not covered are the responsibility of the patient. All female evaluations, including ultrasound, examination by gynecologists, etc., must be covered either by the patient or by private insurance.

7. We unfortunately are unable to reimburse you for your travel expenses.

8. A female fertility team, led by Dr. John Randolph, will see all female partners to assess temperature charts, perform ultrasounds and prescribe medication. Fertility drugs may be used, but in most cases these are not necessary. Clomid, for example, is a drug which is taken to make the development of the egg more predictable. An injection of HCG is given on the day of insemination to assure that ovulation occurs. This sequence of events, summarized below, begins when the husband's ejaculate has adequate numbers of sperm.

Month #1

Eval. by UM Gynecologist,
Review female temperature chart (FTC)
Month #2

FTC + Clomid days 5-9 of cycle
Ultrasound, then
Month #3

FTC + Clomid days 5-9 of cycle
+ HCG + potential insemination



We hope this information is of benefit to you. If you have any questions or want to enroll in the study, please contact Marcy McCabe, R.N., at (734) 936-5770.

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Electroejaculation for Non-Spinal Cord Injured Men

Although originally used exclusively in spinal cord injured males, we have expanded the program to treat individuals unable to ejaculate because of testicular cancer surgery, diabetes, multiple sclerosis or other neurologic impairments. Clinical trials involving artificial insemination of partners of these men desiring pregnancy are currently underway.

Basically, the procedure consists of insertion of a probe into the rectum of the patient. A current is then applied and erection, potentially followed by ejaculation, is produced. Either a general or spinal anesthetic is administered in order to avoid discomfort during the brief procedure.

The preoperative evaluation consists of a history and physical exam, blood tests and signing of an operative permit.

The following are some important facts about the electroejaculation program:

1. A commitment of at least 4 trials (1 day a month for 4 months) may be necessary.

2. The spouse or significant other should begin daily temperature charts on entry into the program.

3. The male patient must be checked for retrograde ejaculation (sperm that goes back into the bladder at the time of orgasm), and have been given a 1 month trial of Ephedrine, Sudafed and/or Imipramine, if not hypertensive or allergic, prior to the initial visit here. If either of these manipulations results in an ejaculate, electroejaculation may not be necessary.

4. A fertility history of patients, including previous pregnancies, ejaculations, ability to achieve erections, is necessary. We also require copies of records detailing previous operations and chemotherapy when applicable.

5. Results cannot be guaranteed. It often takes at least 2 - 3 trials to "learn the patient" and produce an ejaculate. Not all ejaculates are sufficient for insemination. Not all patients produce an ejaculate.

6. Insurance will be billed for this procedure. Any fees not covered are the responsibility of the patient. All female evaluations, including ultrasound, exams by gynecologists, etc., must be covered by the patient or private insurance.

7. A female fertility specialist, Dr. John Randolph, will see all female partners to assess temperature charts, perform ultrasounds and prescribe medication. Clomid is a drug which is taken make the development of the egg more predictable. An injection of HCG is given on the day of insemination to assure that ovulation occurs. This sequence of events, summarized below, begins when the husband's ejaculate has adequate numbers of sperm.

If you have any questions or want to enroll in the study, please contact Dr. Ohl office., at (734) 936-5770.

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