Ask Dr. Stephan Moll

These questions have been submitted by folks on the mailing list and answered by Dr. Moll, Director of the Thrombophilia Program at the Carolina Cardiovascular Biology Center, Department of Medicine, Division of Hematology-Oncology, UNC Chapel Hill (North Carolina, USA). Why am I doing this?

74. Vasectomy and warfarin

Q: “Both my husband and I have heterozygous factor V Leiden. He has had clots and is on coumadin® and very stable with it. I have not had clots. It's time for us to be out of the baby-making business. Because of my FVL, the pill is out. We are currently exploring the surgical alternatives, either tubal ligation or vasectomy. Because a tubal is more invasive we are leaning toward the vasectomy. My question is: is there any major reason to avoid vasectomy if one is on coumadin?”

A: There is no major reason to avoid vasectomy in the man on warfarin (=coumadin®). Unfortunately, there are no formal published recommendations as to how to manage anticoagulation around the time of vasectomy; the American Urological Association, for example, does not have official guidelines on this topic.

Any treatment needs to take an individual patient’s special circumstances into consideration (his/her risk of clotting, risk of bleeding). Because of the increased risk of bleeding on warfarin during vasectomy a reasonable approach is to discontinue warfarin a few days before the surgery (7 days, for example). Whether to bridge the patient with low molecular weight heparin (LMWH, such as Lovenox®, Fragmin®, of Innohep®) depends on how high the individual's risk for thrombosis is; if the risk is assessed as low I would not bridge with LMWH. If the risk for thrombosis is high, however, one could bridge with

• Lovenox® 1.5 mg/kg qd or
  
• Fragmin® 200 U/kg qd or
  
• Innohep® 175 U/kg qd
  

Last LMWH dose should be given the morning of the day before the surgery.

After the surgery: it depends on the patient’s risk of thrombosis as to whether one should start blood thinning medication immediately, or wait for a few days. Because of the risk of bleeding after vasectomy, the urologist may recommend to wait for up to 7 days before restarting blood thinners. However, if the patient’s risk for thrombosis is high, then one would want to start blood thinners earlier.

When restarting warfarin, I would restart at the previous maintenance dose. In the patient who has had a previous blood clot I typically use LMWH bridging for the first 5 days of warfarin therapy, until the INR is therapeutic again, i.e. typically > 2.0.

In patients not on warfarin, but on anti-platelet drugs (Aspirin, Plavix®, Ibuprofen, Motrin®): the urologist may tell the patient to stop these drugs about a week ahead of time. Once again, an individual assessment as to how high the patient’s risk for thrombosis is if off these drugs needs to be made before giving the recommendation to stop these drugs 7 days before the vasectomy.

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