Male infertility: Procedure done, recovery underway

NOTE: You may want to start at the beginning of this series. All posts can be found here.

We are a week out of my varicocele embolization procedure, and we're almost back to normal. Astonishing.

Everyone at Candler was wonderful. I'm not going to name any names, though, because I'm going to talk about drugs and wimps and what we expect from comfort.

Before the procedure, my wife thought to ask what we should do about pain relief. A physician's assistant told her ibuprofen or acetaminophen, as they would not send us home with narcotics.

I've heard the Bell brothers say ibuprofen and acetaminophen together work as well as or better than opioids and are not addictive, so that was my plan going in. I had some 500mg and 200mg ibuprofen tablets in the house, and I picked up some 500mg acetaminophen tabs as well.

Otherwise, I planned, per the PA's orders, to wear comfortable clothing, not eat or drink anything after midnight and to come in at 8am.

I stopped with the food and drink at 11:30 Tuesday night, finished working at 3 a.m. Wednesday, went to bed, woke up a few hours later to take the dog out and grab a quick shower.

At the hospital, I put on the lovely open-backed gown, got my prep talk, signed my waivers and a nurse offered me a Xanax to keep me calm until they got the Fentanyl into my veins.

Quick aside: I was journalistically curious about Fentanyl. It kills a lot of people, including Prince, Tom Petty, Slipknot's Paul Gray, Jay Bennett of Wilco, pro wrestler Anthony Durante (Pitbull #2) and a whole bunch of other people.

I declined the Xanax; I was already tired and pretty chill and, frankly, the fewer drugs they can give me the better.

The doctor stopped by to say hello, give a quick overview of what was going to happen and he promised to swing back and let my wife know when all was good.

The short version of what was going to happen: Give me an IV, stick a catheter in a vein in my neck, drop in springs to block blood flow in the wrong direction in the affected vein, let the blood find another way to get to my testicle that didn't involve a varicose vein and send me on my way.

They stuck the IV into my hand (not connected to anything), wheeled me into the operating room, had me scoot from the cot to the table, and then they did some stuff like shave part of my chest, put a tent over my face and tell me to turn my head to the left (I was all good with that stuff, but I guess some people at that point are freaked out, which is why the Xanax). Then they started the Fentanyl drip.

And let me tell you: I get it. I was aware of everything that was going on and I did not give a shit. And I guess it doesn't take much to kill you. I vaguely remember the doctor really liking the length of the springs so he didn't have to send too many in.

Apparently the doctor then left, told my wife he wished he could relax as well and as quickly as I did (I don't think anyone told him I'd had maybe three hours of sleep), and pretty soon I was awake and they were asking me to scoot from the table back to the cot.

They wheeled me back to hang with my wife. I had the IV in my hand, still, with nothing attached to it, and I was hooked to a machine reading my vitals. They told me they'd need to keep me two hours; after 10 minutes I was (in my head anyway) ready to go.

And then I had to pee.

They handed me a pitcher, and then began what might be the longest 45 minutes of my adult life to date.

The nurse told me I was supposed to lie flat, but that she would prop my head up a little because men typically have a lot of trouble urinating while lying flat.

That was 20 minutes of my life until a different nurse came by and took the thing measuring my pulse off my left hand and told me I could try rolling on my side.

And that was 20 minutes of my life until my wife figured out how to pull down the rails on the bed so I could get a foot on the floor

She's a life-saver, that one.

After about an hour and a half, my vitals had settled. My pulse was back at 54, which is a little higher than my normal resting rate, and my blood pressure was a high-normal 130/68, but considering I'd just had a procedure and was resting uncomfortably in a hospital bed, let's call that normal-normal.

They offered me the opportunity to walk myself the 15 feet to the restroom rather than take a wheelchair ride. I handled it just fine. Afterward, they sat me in a wheelchair, pulled out the IV, handed me a prescription for Percocet (despite the fact the PA mentioned they wouldn't give me narcotics) and wheeled me to my wife's car.

I was left with some gauze on my hand where the IV was, to come off in an hour, and a patch on my neck where the catheter had been, to come off in 24 hours.

Well that’s not my fave way to spend Wednesday morning but home and doing fine.

A post shared by Josh Shear (@joshuanshear) on


Now, unlike the Fentanyl, I had no curiosity about Percocet. I know it makes my mother vomit, and I know that codeine makes both my mother and me vomit, so there was a good chance that Percocet would make me ill as well. I also know it's highly addictive, and I have the sort of personality who totally got Fentanyl in under three minutes.

I spent the rest of the day just hanging out. My neck was a little stiff, like I'd slept funny, and I didn't have a lot of mobility thanks to the patch, but otherwise, I felt pretty good.

I took some ibuprofen and acetaminophen before bed, and then again when I woke up.


Thursday, my first full day out of the procedure, was a day of alternately relaxing and pacing. I took the dressing off my neck at about the 24-hour mark as prescribed, and I was moving slowly but I was moving.

Friday, I was moving a little better for a while, but I usually have the family over for dinner on Fridays and sitting in our wooden-seated kitchen chair for a while proved to be a mistake; Saturday I woke up with some soreness in my groin.

I worked both Saturday and Sunday, sitting on the recliner rather than at my desk, getting up every 20-30 minutes to move around, sometimes working from a standing position for 10 minutes or so at a time.


Monday came with no pain for the first time. I took the dog for a long walk, and when that was done, I drove downtown (the first time I'd driven more than about 50 yards), and walked for another couple of hours. I felt great.

Yesterday, I got to the gym for the first time, but took it easy. After taking the dog on a nice long walk before it got hot (you try being a black dog in 85-degree heat), I hopped on the elliptical for 15 minutes, lifted a bit (much lighter than I normally would lift) and walked on the treadmill for another 15 minutes. I managed to sit at my desk for work, with no pain other than a 13-inning Red Sox loss.


What's Next?

Now, we wait. Over the next few days, I should get back to normal; hopefully by the weekend I'll be able to get a short run in; I may have to take another week off racquetball and it'll take some time to get back to lifting full strength, I'm sure.

Since it takes about three months for new sperm to generate, I'll schedule a new seed test in late August, maybe early September.

Onward!

Male infertility: The procedure is upcoming

I'm right about 24 hours from my scheduled varicocele embolization. [If you're new here and don't know what I'm talking about, read the rest of this series here.]

I'm spending the day being more or less normal. I'll go for a long run, which, while it's normally something I do the second half of the week, is par for the course when I'm going to undertake something that's a bit different for me. Then I'll have breakfast, take a nap, walk the dog and go to work.

I'll stop eating and drinking before midnight, finish work at 3, get a couple of hours of sleep and get to the outpatient surgery center by 8, tired from a short sleep and no liquids for eight hours.

The recovery is supposed to be something on the order of 2-3 days. I imagine Thursday morning will find me somewhat groggy as the last of the anesthetics wears off; they're doing that thing where they put you mostly out, but they kind of expect you to fall asleep anyway (which, given my lack of sleep at that point, won't be an issue).

Since sperm take about three months to generate, we'll expect to do another seed test in mid-late August.

We'll check back in here when we're upright and thinking.

Male infertility: Varicocele embolization scheduled

Well, we didn't need the CT scan we discussed after all. The radiologist got the information he needed from the ultrasound I detailed in part one.

Short story short, I have a procedure scheduled for April 25. They're so certain in the effectiveness of this procedure for clearing varicoceles (not always a fertility problem), that when they're happy you're conscious enough after the anesthesia, they just send you home and don't contact you again (apart from billing, of course).

I'm sure I'll have a post up in the couple of days before, and another in the day or two after.

Male infertility: Varicocele embolization consultation, with CT scan

This is an ongoing series about my journey with infertility. I was diagnosed with a varicocele, which is likely responsible for poor sperm quality. It's something present in around 15% of all men, but in upwards of 40% of all infertility cases. Start here for the background and what we've done so far.

Varicoceles don't only affect fertility (and don't always lead to infertility). Apparently, they can be very painful; mine doesn't hurt at all. I have, over the past few weeks, noticed occasional soreness in my left testicle, but that's really only been since the urologist told me varicoceles are often painful, so it may be primarily in my head. Who knows how long I've had this issue, with no pain?

When a physician's assistant asked, "On a scale of 1-10 (10 being excruciating), what's the pain like?"

"Two to three," I said.

"What do you do when you feel the pain?"

"Nothing. When you get older your knee just hurts a little bit sometimes? It's kinda like that."

Anyway.

I had a consultation with the physician's assistant for an interventional radiologist who would perform a varicocele embolization.

This is a non-surgical, outpatient procedure. They're so confident in the procedure not producing issues that they don't even follow up with patients to see how they're doing a few days later.

I have a CT scan scheduled. This will show a map of my arteries and veins, give the doctor an idea of whether he'd go in through my neck or my leg (more in a minute) and whether for some reason I might not be a candidate for the procedure.

The alternative is a surgical fix, called a varicocelectomy, performed by a urologist, which comes with as much as six weeks of recovery time.

Now, some of this is recap from the first installment, but here's the skinny. We don't know why varicoceles occur (we know how they occur, but not the underlying cause). After being corrected, they can return. Once detected, we have no idea how long they've been there (we might assume mine's been there at least 19 months, since that's how long we've been trying to have a child). The urologist told me both the varicocelectomy and the embolization have a success rate of around 90% (that's success in eliminating the varicocele), and in case that the varicocele is eliminated for fertility purposes, about half of couples conceive naturally.

Sperm take about three to four months to develop; sperm I might ejaculate today started forming sometime between Thanksgiving and Christmas 2017. That means we won't find out if my sperm quality improves until four months or so after the procedure. We do that by a seed test, which is essentially me masturbating in a cup in someone else's bathroom (again, see the first installation for a deeper description).

Back to my consultation.

The procedure goes like this. You get an IV with an anesthetic (a name I wouldn't know) and a pain killer (fentanyl). In theory, just enough to keep you sedated, but a lot of people fall asleep. Then they take a catheter, put it into a vein in either your neck or your leg (you're facing away from the procedure, with a nurse monitoring vitals in your field of vision, if you're awake). Once the catheter is in, you get either some tiny metal balls or some tiny metal coils to break up the varicocele and hopefully prevent from happening again.

They pull the catheter out, remove the IV, monitor you for a couple of hours, put you in a car (preferably one driven by someone you know), and send you a bill at some point.

My next step is the CT scan. Results from that usually take about two days, so unless something comes up, that'll be the next installation.

Male infertility: A journey begins

There don't seem to be many stories of male infertility online. If you want to know anything about any complications for women, there are lots of stories available. Some of those stories are self-authored, some are reported in magazines or newspapers, and some of them are from the husband's perspective.

That's not to say there's nothing out there. Most of the reader comments about male infertility here are from women, but here's a story from a guy who felt guilty about his infertility, but he and his wife got pregnant after a couple rounds of in vitro fertilization (IVF). Then there's a story from a man who didn't want to use a sperm donor for IVF, so his girlfriend broke up with him.

There's a book written by a woman about how there's just not that much out there on male infertility.

I did find one story detailing several types of male infertility.

There is a forum for male infertility, though a lot of posts in there are from women.

I decided to start writing about my journey for two reasons: (1) It's how I work through things, and (2) maybe it will help others share, or at least feel better.

Before we get going, you should be aware of a couple of things. Links (none of those above, but going forward) might have instructive images. By that, I mean pictures of penises and testicles. Also, I'm going to be me here, which means that I'll use both correct language and slang (read: I'll write both "scrotum" and "ball sack" and I might drop a cuss word or twelve). I'm not going to pull punches. I won't be gratuitously graphic, but if something's pertinent, it'll be here (if you're my mother or my sister, you might want to stop reading, since this might get uncomfortable for you). Finally, we're in a discovery phase at this writing, so this really will be an ongoing story, perhaps for months or a year or however long it takes.

For those of you who don't know me, I'm 41 years old, a few pounds overweight but a regular exerciser and distance runner. I live in Savannah, Georgia. My parents call me "Mr. Excitement" because it's typically difficult to read my emotions. I'm an introvert, which means not that I'm shy or afraid of sharing, it just means I charge my energy by being alone, which makes writing a great outlet for me.

Anyway.

I have what's called a varicocele. It's reasonably common; about 15 percent of men have them. They don't always lead to infertility, but in cases of infertility or subfertility (which I guess is what I have, technically), they appear in upwards of 40 percent of cases. It's probably hard to nail down a good number on who actually has them, since most people don't just go get tested for them.

Essentially, it's a varicose vein in a testicle. It's most common on the left side, which is where mine is.

The way my urologist explained it to me, we don't know why it happens, but we do know how. Veins have a flap that acts something like a railroad switch in them, which allowing blood to flow online in one direction. When that flap fails, blood pools and the veins become swollen, which means the veins leading to my left testicle are too big, and it's harming my sperm (more on that later).

Now, let's get into how we got here.


In August of 2016, my wife and I decided to start trying to have children. We started off "normally," just having sex as often as we were up to it. Over the ensuing months, that turned into an ovulation thermometer and ovulation strips. Her periods are slightly irregular, varying by a few days each month, so it was difficult to track any other way.

A year later, we decided it's been a year, let's get checked out. My wife is "mostly fine;" one of her tubes is blocked but that doesn't stop her from releasing an egg each month, and her ob/gyn says that's not going to impede pregnancy at all.

I scheduled my first seed test around the same time. Read: they test semen.

A seed test goes like this.

First, you're abstinent for a minimum of three days and a maximum of five. They want you rested, but not dusty.

I went to a an office in a local hospital's "professional building" and sat in a chair in a waiting room. It appears that most of the patients are couples; one woman was there with someone I assumed to be her mother.

Eventually, someone came to lead me out the door and down the hall. She handed me a piece of paper, a pen, and a cup, then told me to mark the time when I'm done, put everything in the carousel, spin it, ring the doorbell, and leave.

In other words, please don't check in again. We all know you're in here masturbating and we don't want to see you right after you finish.

The bathroom they sent me into was bizarre. There's a toilet, of course, and a sink. And a chair with one of those pads on it people leave on the floor and hope their dogs pee on. There's a TV/DVD player combo above the toilet and a pile of magazines hidden inside blue folders that probably haven't been updated since 1996.

There's a note to not use lube or soap or anything, since that can taint your sample.

I provided my sample, put the cover on the cup and put it in basically a bank safety deposit box, rang a doorbell and got out of there.


Since the order for the test had come through my wife's ob/gyn, they called her first with the results. "Low sperm count, low motility and little chance of pregnancy."

No details, no explanation of what that translated to, no next steps. So, we basically tried to figure out what we could do and how.

We knew some of the risk factors. Tight underwear. Bicycles. Saunas. Hot tubs. Alcohol. Caffeine. Being 40 years old. Being overweight.

I maintain that boxer briefs are fine. My wife wanted me to wear boxers. I refused, but as a compromise I mostly stopped wearing underwear except when I'm working out or running. I've stayed off my bike, out of the sauna and out of the hot tub. I cut back from 5-6 drinks a week to 3-4. I cut back from a pot and a half of coffee a day to a cup every couple of days, with a cup or two of tea every day replacing all the coffee. I couldn't do anything about my age (in fact, I had another birthday, making it worse), and I didn't manage to lose any weight — that's really difficult when you're cutting back on stimulants.

I asked my physician for an order to get another test. He gave me one, I went back in December to jerk off in a cup again, and waited. I got a call a couple of weeks later from my doctor's office with just the information that the test was abnormal, and I should go see a urologist (he sent over a referral). Again, no details.

So I went to the urologist, and he spelled everything out for me.

All sorts of things get tested, but he was looking for three things:

1. Sperm count: About 50 million per milliliter is average, but 20 million is considered a minimum threshold for normal.
2. Motility: About 35% is normal.
3. Appearance: Average is 14% of sperm in one ejaculation appearing "normal," with 4% being a minimum threshold for effective.

In my first test, my sperm count was 19 million/mL. He said that might as well be 20 million. My motility was 27%, which means they were generally lazy. A big fat goose egg on appearance, though. Zero percent appeared normal.

My second test — the one for which I tried to eliminate as many risk factors as I could — looked somewhat better. My sperm count was 74 million/mL (overachiever!). My motility was 67% (ditto!). The appearance, though, had only approved to 1% appearing normal (yeah, I know that's an increase of infinity, but it's still not good enough to give me a good shot at getting my wife pregnant).

Now that we had an idea of what the problem was, the next step was to figure out why.


He ordered some blood work and an ultrasound. The blood work was easy. I have good veins for needles. I don't have a fear of them and the sight of blood doesn't bother me.

The ultrasound, on the other hand, was pretty awkward. And yes, it's the same procedure used to show pregnant women their babies.

I sat down in the waiting room, and a woman came out to get me. We got to her room, which consisted of an exam table, a chair, a sink and a computer desk. She handed me a rolled-up washcloth and a hand towel folded in thirds.

"You're going to lie down on the table," she said. "You can leave your shirt and shoes on, but pull your pants and underwear down to your knees. Put the washcloth between your legs to prop your scrotum up, and use the other towel to cover yourself. I'll be back in a few minutes.

You know how you don't take a toddler's pants all the way off to change a diaper? Like you just let the pants keep the feet together well enough to move everything around as needed? I was in that position, but squeezing a washcloth between my thighs. Of course, a toddler can look up at you and all that. She wasn't in the room, so I was just staring at the HVAC.

Finally, after what seemed like 90 minutes but was probably more like four, she came in and asked if I was ready.

Uh, ready? Sure. I'm lying on an exam table doing kegels with a washcloth and wearing the shortest skirt a grown man should ever wear.

She sat down, put on some gloves, jellied up her sound-camera-thingy, and reached up my towel-skirt.

"I know this isn't your whole day," I said, "but what's the conversation like when you get home? How was your day, honey?"

She smiled politely and said she'd been at this for ten years and didn't even think about it anymore, it's just part of the job. "At least I'm not starting catheters," she said.

After 10 minutes of drawing abstract art on the computer screen with sound waves, she told me she was all done, when she left I could get dressed and head on out, and they'd call me when the lab came back with results.


This freed me up to start doing some research.

It turned out there were two likely culprits: hormone levels and varicoceles.

Hormone levels could be adjusted with Clomid, which we think of as a thing they give women.

Varicoceles, on the other hand...

I didn't want to Google image search varicoceles, because, frankly, I didn't want a pile of dick pics in my face. Turns out they're all illustrations anyway, since the varicocele is inside the scrotum.

"Want to know what the surgery's like?" my wife asked.

"That depends," I said. "Do they cut open my ball sack and fix something, then leave me stitched up and bruised?"

"Yeah, pretty much."

"I'll pass, thanks."

My hormone levels came back basically fine; he could find an excuse to give me Clomid if I wanted to, but really, the varicocele is most likely the problem.


It turns out there are two fixes for varicoceles. One is surgical, the other nonsurgical. They have roughly the same success rate (close to 90%), my urologist said, and successful correction typically leads to pregnancy about half the time, which is probably not that much different from "normal" couples.

In either case, there's a long waiting period to figure out if it worked. Sperm production takes about three months from genesis to ejaculation (so, sperm you ejaculate today started forming three months ago). They wait four months and then send me back for a seed test.

I've spoken to the urologist about the surgical version. He makes about a two-inch incision in the abdomen, goes in and drains the varicose veins, then fixes that little broken railroad switch. The recovery is 2-3 weeks of rest, then 2-3 weeks of light duty after that.

He also described the nonsurgical version, which is called an embolization, though I have an appointment set for next week with the interventional radiologist who would perform that, should I go that route. It involves going through my groin with a catheter, and putting a balloon up beyond the kidney (or something like that). The recovery is more like 2-3 days.

I'm assuming there's a cost difference, since that second one sounds more difficult, but the recovery time is so much better.

I've called the insurance company, and they'll cover both equally.


What's Next

I have an appointment with the radiologist next week, to learn a little more about the procedure, hopefully figure out costs, preparation and recovery, and work toward making a decision.

After that, it'll be recovering, waiting for that next seed test, and seeing what happens from there.

I'll check back in sometime next week.