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Child had bilateral inguinal hernia surgery. Should I be concerned for fertility issue?

Answered by
Dr. Anand Sinha

Pediatrician, Surgery

Practicing since :2003

Answered : 246 Questions

Posted on Sat, 4 May 2013 in Medicines and Side Effects
Question: Hi Doctor,

My elder son is 4 and half years old and my younger son is 2 years old. My elder son had bilateral inguinal hernia surgery when he was 6 months old (done by a experienced pediatric surgeon in India). I'm not from medical field. I'm scared about his fertility after reading articles about pediatric hernia surgery in the internet (Article Reference: WWW.WWWW.WW . Even though the surgeon said the surgery was successful, I want a second opinion and clear up my mind.

The above article says that there are several complications associated with Hernia surgery. I have questions on these complications.

1. Regarding vas injury, if vas is injured in pediatric hernia surgery in one side and not injured in other side, does it impact someone to father a child when they become adult?

2. I don't understand when they say about the complication - 'development of sperm-agglutinating antibodies'. What does this mean? Do I have to be concerned about it? Does it affect fertility when the kid becomes adult?

3. They are saying that around 20% of the patients will experience decreased testicular size due to pediatric hernia surgery. Is it true? Will it impact someone to father a child when they become adult? My son goes to pediatric visit every year and pediatrician checks testicles and never said anything about testicle size.

4. I read in another article that if one sibling has hernia there is a possibility for other to get it. My younger son is 2 and he is healthy, Full term baby. I read in the below article that processus vaginalis is completely closed by 2 years (Reference: WWW.WWWW.WW ). Does this mean that the risk of getting indirect inguinal hernia is minimal or none for my younger son? Does he still have the risk of getting indirect inguinal hernia? Should I be concerned about it?

5. Is there any reason to be concerned about the fertility of my elder son due to this Pediatric Hernia surgery?

I apologize for asking these questions. I thought a lot about whether to ask these questions or not. I want to clear up for my peace of mind. Thanks a lot for answering these questions.

Answered by Dr. Anand Sinha 11 hours later
Thank you for posting your query on Health Care Magic,
I can understand your concern. At the same time I may say that you are worrying a bit too much and relying too much on statistics. I will answer your questions one by one. And I will try to provide you explanations for them.

1. If vas was injured on one side only, then it would not affect the fertility in future. One normal side is enough.

2. Normally our sperms are never exposed to our blood. It is called a blood testis barrier. It has been designed so because if sperm ever comes in contact with blood, our blood starts making antibodies against the sperms (our body considers our sperms as foreign elements and hence forms antibodies). If any surgery damages the testis in any way and sperms come in contact with blood, our body starts making antibodies called sperm agglutinating antibodies. These antibodies will destroy the sperms and can cause infertility.

3. Testicular size is not an indicator of fertility. Very small testis are unlikely to produce sperms but other than that minor size variations don't make any difference. It is the sperm quantity and quality in the semen which matters. And 4 years is not the age to comment on testicular size. Its at puberty anyone will judge it. So your pediatrician does not comment on it. If it were too small, he would have mentioned it.

4. (a)Yes the processus vaginalis closes by two years but there is no way to know whether it has closed or not. The processus may be open but hernia may not develop for a long time. A child may experience an indirect hernia even at 10-12 years age due to an open processus vaginalis. However the chances of developing a hernia late in childhood is definitely lesser. So although your younger son has crossed 2 years, we can only say that his risk for developing hernia is decreasing; however we can not say for sure that he will not have a hernia.
(b) On an average any child has a risk of 1-5% of developing a hernia. If one brother already has a hernia, the risk is only minimally higher. So you should not worry any more than any other normal child.

5. I don't think you should be worried about your elder son's fertility.


I will first quote some sentences from well established books of pediatric surgery to allay your fears
PEDIATRIC SURGERY (6th ed, XXXXXXX L Grosfeld, Mosby Elvesier publications): considered to be a Gold standard book for pediatric (children) surgery
>>"Patrick et al found only a 0.13% incidence of vas injury in an analysis of 1494 sacs and that the incidence is so low.. XXXXXXX
>>"Fisher and Mumenthaler and Fahstrom have each reported an incidence of 1% testicular atrophy"
>>"The rate of infertility varies from 6 to 14% but details of surgery and experience of surgeon were not noted"

COMPLICATIONS IN PEDIATRIC SURGERY (1st ed, XXXXXXX G Caty, Informa Healthcare publications): Book dealing with only complications in pediatric surgery
>>"The blood supply of the testis is very delicate, and damage to the vessels can lead to testicular atrophy. The rate of testicular atrophy in one large series was 0.3%"
>>"The need for a gentle dissection is well known and accordingly the rate of vas deferens injury is low, 0.06% XXXXXXX

So you can see the risks of these complications is really low. Complications are higher in cases where emergency surgery is done for a obstructed hernia and far lesser in routine cases (like yours) and when it is done by an experienced surgeon.

Vas injuries are very rare (<0.5%). The surgeon would have told you if there was any such injury. And even if it occurs on one side, your son will be fine with one normal side. So stop worrying about that.
Chances of Testicular atrophy is also very low. And your pediatrician does not say anything. That means its normal. Its unlikely it will be any different from now on.
Chances of developing anti sperm antibodies after a hernia surgery is also very very low.
Infertility can occur with bilateral hernias. But again risks are too low. Moreover, with evolving surgical skills, fine instruments and fine sutures, the risks are declining even more. In addition you say it was an experienced surgeon. The risk is even lower. Even if you want to check, forget it now. Get his semen analysed when he gets to 16-18 years age. I am sure he will be alright.
Your other son has as much risk of developing hernia as any other child. Probably just marginally higher and nothing more. So you should not think it will happen.

I hope I have been able to put a rest to all your anxieties.
You should stop worrying. God bless you
Dr Anand Sinha
MS General Surgery
MCh Pediatric Surgery
Above answer was peer-reviewed by : Dr. Prasad
Follow up: Dr. Anand Sinha 2 hours later
THANKS A LOT Dr XXXXXXX XXXXXXX I can't express in words how much I appreciate your response. Thanks a lot again. Thanks for explaining in detail. I have one last question based on your response.

I understand from your response that injury to Vas or testicles are extremely rare. Based on your response, I'm feeling very good and not going to worry about it here after. I have only one thing bothering me in your response.

In the quote from the book (Pediatric Surgery) you mentioned above, it states that - the rate of infertility varies from 6% to 14%. Is the quote for pediatric hernia surgery? What is causing this high percentage (It seems a high number to me since the risk of complications in this surgery is rare like less than 1%)? Is the rate due to emergency surgeries or complicated cases?

Do I have to be worried about it? If you say I don't need to be worried about the fertility of my sons then I'm good. THANK YOU!!!!!

Answered by Dr. Anand Sinha 6 hours later
Thank you for writing on Health Care Magic.
I am glad that you feel reassured.
1. Now let me tell you some details about infertility (quoted from Campbell's Urology textbook: again a gold standard textbook in urology). The rate of infertility in couples in today’s world is 12-32%. One fourth of them are due to male factors, one fourth due to female factors and another half due to factors in both. So in almost half of these patients males are responsible. In short, the incidence of male infertility is 5-15%. So you can understand that even with this hernia surgery, your child would not be at a much higher risk. I agree that there is a slightly higher chance but it is meagre really.

2. These figures also include surgeries, which are done in emergencies for obstructed hernias where the blood vessels to testis are likely to be blocked. And rates of infertility is higher in them. It’s not the case with your son.

3. I am sure if any complication like vas injury or testis injury had happened, the surgeon would have informed you. We always do. So grossly, no such problem occurred in your child's case.

4. However even in uncomplicated cases with smooth surgery, sometimes the vas or cord may be stretched during the surgery and can cause some problems in future. That cannot be picked up or be noticed during the surgery. But the surgical skills and steps have evolved over time and now we take even more care that such things don't happen and hence we absolutely don't touch the cord (includes vas) or stretch it at all. The fertility rates quoted are from adults now, so they must have been operated a good twenty thirty years back. I am sure if we follow today's children who have been operated recently, the fertility will be much higher. So you need not worry.

I hope this puts a rest to your anxiety. You should not worry. Your son will do absolutely fine.
God bless you.
Dr Anand Sinha
MS General Surgery
MCh Pediatric Surgery

Above answer was peer-reviewed by : Dr. Shanthi.E
Follow up: Dr. Anand Sinha 2 hours later
Thanks a lot Dr XXXXXXX XXXXXXX You explanations are reassuring to me. Thanks again for the help!

Based on your response I assume that even if the vas or cord is stretched in one side, the fertility will be normal since the other side will work normally. Is this assumption correct or wrong? Is stretching the cord or vas in one side affect the other side too? I apologize for this question. I wanted to be clear before closing this discussion.

I'm not sure I will be allowed to Thank You after your next response or not. I hope you realize the happiness you brought us. God Bless You. Thanks again for taking time in answering my questions. THANK YOU DOCTOR!

Answered by Dr. Anand Sinha 2 hours later
Thank you for being in touch with Health Care Magic
In addition, I thank you for your appreciation.
I can understand your concern. If cord is stretched a little bit, it does not affect the fertility potential of the same side too. And that is what an experienced pediatric surgeon would have done: gentle handling of the vas and cord. So mild stretching does not pose any threat. And even maximum stretching or even injury to the vas or cord on one side will never hamper the other side. It will have no effect on the other side. Therefore, you need not worry at all. I am sure it will have no bearing on your son's fertility potential.
I am glad I could be of any help
God bless you.
Dr Anand Sinha
MS General Surgery
MCh Pediatric Surgery

Above answer was peer-reviewed by : Dr. Shanthi.E
Follow up: Dr. Anand Sinha 2 days later
I forgot to ask one question. This is regarding to my younger son. While he is taking bath in the hot water (He cries usually also tries to hold his breath for a second or two), we observed that his testicles or middle portion of scrotum go back for a couple of seconds and then comes back to the normal position.Is it normal? Thanks a lot Dr XXXXXXX Sinha!!!
Answered by Dr. Anand Sinha 1 hour later
Hello again,
Thank you for being in touch through Health Care Magic
I can understand your concern.
But it is an absolutely normal phenomenon. Temperature changes can cause the testis to re-enter towards the abdominal cavity. As long testes remain in the scrotum most of times, it is all right. At times it can happen in adulthood too. So don't worry about it.
Wish your family the very best of health.
God bless you
Dr Anand Sinha
MS General Surgery
MCh Pediatric Surgery
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
Follow up: Dr. Anand Sinha 8 days later
Thanks a lot Dr XXXXXXX XXXXXXX I forgot to ask you one question last week. I also have one question on my health. I thought I will clarify with you on these questions.

1. I read a couple of articles last year that stated that in hernia surgery for one side, the doctor will explore the other side to check whether the other side also requires a fix (has hernia). The article said that this exploration of other side in hernia surgery causes infertility. I'm not sure how much of it is true. In the case of my elder son, when he was diagnosed with inguinal hernia, the doctor initially told us (before the surgery) that the hernia is definitely there on one side and he strongly suspected it is present in other side too. After the surgery the doctor told us that the hernia was present in both the sides and surgery was done on both the sides. When I read this article, I was not sure whether the doctor would have explored the other side or not in my son's case to figure out if the other side had hernia? If he has done that does this really affect his fertility? I wanted to check with you on this one.

2. The doctor also told us that the intestine was slightly pasted together with the gap on the side where hernia was initially identified and he had to carefully take it and put it in. He told overall it is a simple and successful surgery. It was a scheduled surgery. Does these things are normal in these surgeries? Does these require stretching Vas or cord? Just wanted to make sure that this doesn't affect fertility.

3. I'm 33 years old. These days when I exercise heavily, I'm getting pain in the lower end of my ribs on the left side. But if I stop exercise for 2 mins, the pain goes off. I'm getting the pain only during running. If I do moderate exercises like elliptical or walking, I'm not getting any pain at all even if I do it continuously for one hour. Also If I have lot of food then I get a kind of tingling or numbness feeling in the upper part of the stomach. I went for a master checkup last year. Everything came out as normal. The doctor said he is not sure what is causing the first issue. For the second issue he told me that it might be due to acidity and I need to have food at regular intervals and have the acid reducer. Do you think I need to consult any specialist on the first issue? If so what specialist should I go to?

Answered by Dr. Anand Sinha 1 hour later
Thank for being in touch through Health care Magic
1. Normally when there is hernia on one side, there is a 10% chance that the other side will have a hernia. Earlier there used to be a concept of contralateral exploration (opening the other side and check whether the hernia is present and to fix it). It was done especially in females as it was believed that chances were higher in females. However the recent concept is that when you have hernia on one side, then we operate only on one side and operate on the other side only if and when it develops hernia on the other side (10% chance). But this is only applicable when there is no suspicion of hernia on the other side and it looks absolutely normal from the outside. In your case as you say, the doctor said that there was a strong suspicion of hernia on the other side, then it was justified exploring the other side.And as it turned out, he was right and hernia was present on both sides and he repaired it. It is actually fortunate that he diagnosed hernia on the other side, so that now we can be assured that your son will not develop hernia on the other side and its related complications. As far as the fertility potential is concerned, I think I have laid enough stress, that you should not be concerned about it.

2. Intestines within the sac is a pretty normal finding. It does not make the surgery any more prone to long term complications. It does not cause any additional stretch to be worried about.

3. Now for your problem. As for the slight pain on the left side while vigorous exercise, there may be various causes for it. The common ones are
a) Stretching of the muscles in that region. It is the most likely cause at your age. I think you can ignore it. Try stopping a bit before you develop such a pain. And from there you gradually increase your exercise tolerance. I mean, stay at that level of exercise for a few days and then just gradually increase a little bit, but not till the level you develop pain. So gradually build your exercise tolerance.
b) Angina: Pain due to inadequate blood supply to heart. It happens due to clogged arteries. Very unlikely in your case because of various reasons. You exercise regularly. You are young. The pain is not very severe and especially does not radiate any where else. And it stops pretty soon when you stop exercise. Lastly all your tests turned normal. So I would not worry about that much. But yes, a cardiologist is the person to consult if it were the suspicion.
c) Intestinal colic: It is due to gaseous distension of the intestine. But it should not have any relation with your exercise. So that too is unlikely.
In short, it seems to be muscular in origin only.

For your second problem, it seems to be acidity as told by your doctor. Treatment measures include small frequent meals (avoid heavy meals), avoid too much spice and oil in diet, good night's sleep and yes also importantly reduce anxiety. I think you should worry less about so many issues and relax a bit. Stress also increases acidity. Some drugs like antacids can be used if it is more severe. The person to go to is a gastro-enterologist.
However I believe if you take of the simple measures that I have told you, you should do well. Even your exercise pain should go away with that.

I can understand your concerns, but I believe you are having a lot of stress with all the concerns. You should try a little bit of meditation with your exercise. As for your son's fertility is concerned I hope that I have been able to get that out of your mind.
Hope that helped.
God bless you
Dr Anand Sinha
MS General Surgery
MCh Pediatric Surgery
Above answer was peer-reviewed by : Dr. Mohammed Kappan

The User accepted the expert's answer

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