This chapter should be cited as follows: This chapter was last updated:
Barone, M, Pollack, A, Glob. libr. women's med.,
(ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10407
August 2008

Sterilization

Male Sterilization

Mark A. Barone, DVM, MS
EngenderHealth, New York, New York, USA
Amy E. Pollack, MD, MPH
Columbia University, New York, New York, USA

INTRODUCTION

Vasectomy is now well recognized worldwide as one of the safest and most effective contraceptive methods. It is estimated that more than 43 million men are currently vasectomized.1 Although most are concentrated in a small number of countries, the distribution of users is becoming increasingly widespread. In comparison, an estimated 180 million women have been sterilized worldwide; however, in several countries, vasectomy incidence approaches that of female sterilization.1 In 2002, an estimated 526,501 vasectomies were performed in the United States, for a rate of 10.2 procedures per 1000 men aged 25–49 years,2 compared with approximately 684,000 tubal sterilizations, for a rate of 11.5 per 1000 women aged 20–49 years.3

Some predicted that men would not accept the vasectomy procedure because they fear loss of masculinity or because they mistakenly equate vasectomy with castration. However, when vasectomy is properly presented, men in all societies can welcome the procedure. Several conditions appear to be of critical importance. Men's desire to limit family size and their concern for economic and educational advancement must outweigh their desire for more children, and their concerns about maternal morbidity and the failure of female contraceptive methods must be an overriding consideration.

Most couples seeking vasectomy are dissatisfied users of other forms of contraception. Many couples find barrier methods inconvenient. Women using hormonal methods may have suffered from related side-effects or experienced user difficulties such as limited access to pill supplies or trained providers for implants. Intra-uterine devices also have associated side-effects.

As is true with many other contraceptive methods in which popularity and acceptance preceded thorough scientific understanding of effects on body systems and long-term sequelae, the effects of vasectomy have come under scrutiny by investigators. In the past 30 years, immunologic response and effects on lipid metabolism, spermatogenesis, epididymal function, and hormone levels have been studied. Long-term complications following vasectomy, including increased risk for heart disease, testicular cancer, immune complex disorders, and a host of other conditions, have not been supported by long-term, well-designed epidemiologic studies. The relation between vasectomy and prostate cancer has been studied intensely and, taken as a whole, these studies provide little evidence for a causal association between vasectomy and prostate cancer.

HISTORY

The clinical use of vasectomy is historically linked with the course of experimental investigation. The first reference to the occluded vas was made by Hunter during his dissections in 1775. The first experiment in tying of the vas was reported as early as 1785, but it was not until the 19th century that several investigations into the effects of vasectomy were undertaken. In 1830, Cooper initiated the first systematic experimental work when he demonstrated that closing the duct of the testis had no effect on the production of sperm by the testis for as long as six years after the operation. In 1921, Simmonds noted that even in cases in which the vasa deferentia had been occluded for many years, there was no apparent injury to the sperm-producing functions of the testicles. Gosselin confirmed this finding in 1947.

In the late 1890s, an investigation of the clinical uses of vasectomy was begun by surgeons in conjunction with therapeutic operations on the prostate gland. Ochsner performed such operations and reported that no change was noted in the sexual function of his patients following successful vasectomies.

In the 1920s, Rolnick studied the regenerative power of the vas and its ability to resist trauma and restore continuity of its lumen. He emphasized the importance of the blood supply and the sheath of the vas acting as a splint making a path of epithelialization during recanalization and after vas ligation. This classic work still has pertinence today in our efforts to achieve successful vas occlusion and to reduce the chance of failure, and informs us about the potential for successful vasectomy reversal when indicated.

ANATOMY

The male reproductive organs include the testicles, the ducts, and the accessory glands (Fig. 1). The testicles produce sperm and the male sex hormone testosterone. After vasectomy, the testes continue to produce both sperm and hormones.

Fig. 1. Male reproductive organs. (From EngenderHealth. No-Scalpel Vasectomy Curriculum, 2nd Edition. New York, EngenderHealth, 2007.)

The second group of organs is a series of connected ducts: the epididymides, the vasa deferentia, and the urethra. Each of the two epididymides (which begin at and are connected to the testes) are connected to one of the vasa deferentia. Sperm pass through the epididymis to get from the testis to the vas and are also stored in the most distal portion, or tail, of the epididymis. Sperm become motile and acquire the ability to fertilize ova during transport through the epididymides. The vasa begin at the epididymides and end at the base of the prostate, where they come together and are connected to the urethra and the accessory glands. Here, the sperm, which were carried by the vasa deferentia, mix with secretions from the accessory glands. The urethra carries the semen (i.e. sperm contained in the secretions from the accessory glands) out of the body during ejaculation. The urethra also carries urine.

The third group of internal organs are the accessory glands. These include the seminal vesicles, the prostate, and the bulbourethral glands. These glands secrete the seminal fluid that carries sperm through the urethra during ejaculation.

The vas deferens is a firm, tubular structure approximately 34 mm in diameter and approximately 35 cm in length. It extends from the tail of the epididymis to the prostate, where, together with the duct of the seminal vesicle, it forms the ejaculatory duct.

The vas deferens may be divided into five portions: the sheathless epididymal vas, the scrotal vas, the inguinal vas, the retroperitoneal or pelvic vas, and the ampulla (Fig. 2). The portion of the vas of clinical interest in relation to vasectomy is the scrotal vas in the midscrotal area. Here the vas is located within the spermatic cord, which is made up of fascia, arteries, veins, and nerves and which suspends the testis in the scrotum (Fig. 3). The firm, thick structure of the vas can be easily palpated and differentiated from other structures in the spermatic cord. Also in the spermatic cord is the testicular artery, which supplies blood to the testis and epididymis, and the testicular veins, which form the pampiniform plexus that returns blood from the testis and epididymis.

Fig. 2. Anatomy of the vas. (Copyright AVSC International, 1999.)

 Fig. 3. Cross-section of the spermatic cord. (From EngenderHealth. No-Scalpel Vasectomy Curriculum, 2nd Edition. New York, EngenderHealth, 2007.)






 

The vas deferens is composed of three layers of smooth muscle: the outer and inner longitudinal layers and the middle circular layer. It is capable of powerful peristaltic motion. There is a thick sheet of connective tissue exterior to the muscle layer. The lumen of the vas, like that of the epididymis, is lined with pseudostratified epithelium and contains longitudinal folds lined with microvilli.

The blood supply of the vas deferens is from the artery of the vas deferens (deferential artery), a branch of the superior vesical artery that is also important in collateral circulation for the testicle. This artery is easily separated from the vas during vasectomy; however, it may be a source of hemorrhage during vasectomy if it is not separated or ligated.

The nerves of the testes (the superior spermatic nerves) arise from the renal plexus and intermesenteric nerves and travel in association with the testicular arteries, whereas the inferior spermatic nerves arise from the hypogastric plexus and course around and along the vas deferens to innervate the epididymides. At the junction of the epididymis and vas deferens, the amount of adrenergic innervation increases, with innervation of the vas consisting of short, postganglionic neurons. Adrenergic fibers, which are found in all three smooth muscle layers, are most likely the motor supply of the vas muscle. The sheath of the vas in the scrotal portion contains pain nerves. Careful infiltration of the sheath with local anesthetic agents is effective in reducing pain during the procedure.

Blood vessels and nerves involved in erection and ejaculation, including the internal pudendal artery, dorsal and cavernous veins, pudendal nerves (sensory nerves to the penis), and nerves from the pelvic plexus arising from sacral nerves S2S4 (nerves involved in erection), are located well away from the procedure site and are therefore unaffected by vasectomy.

COUNSELING FOR VASECTOMY

The patient's request for vasectomy must be made voluntarily. Good counseling for men interested in vasectomy is critical for two reasons: vasectomy is permanent, and vasectomy is a surgical procedure that carries with it the risks inherent in any surgery. Because men's greatest fears about vasectomy are related to pain of the procedure, impact on sexual functioning, and potential for adverse effects,4 these topics should be thoroughly covered during counseling. Counseling should involve both partners if possible and include the following steps:5, 6, 7

  1. Discuss vasectomy in conjunction with an explanation of all other available contraceptive options.
  2. Discuss the patient's readiness to end his fertility and screen for indicators of poststerilization regret. Factors shown to predispose to poststerilization regret include young age (less than 31 years), quick or economically motivated decision or decision related to pregnancy, marital instability, and no children or children very young at the time of sterilization.8, 9, 10 The provider should explore with the individual whether he would feel differently if his marital situation changed or if he lost his spouse or a child. Identifying regret risks should not be a reason for denying vasectomy but should be an indicator that more careful counseling and discussion of other contraceptive methods are necessary.
  3. Emphasize that vasectomy should be regarded as a permanent procedure, and inform the client of failure rates associated with vasectomy. Despite what the client may have heard about vasectomy reversal, it is expensive, and success cannot be guaranteed. If a client considering vasectomy is seriously thinking about reversal, a vasectomy may not be the best procedure for him at this time. Likewise, if a man asks to have his sperm stored in a sperm bank for the future, mention to him that this is costly and viable long-term storage is not without risk and that he may want to reconsider vasectomy.
  4. Using diagrams, briefly describe the vasectomy procedure and how a vasectomy works. Describe to the patient the surgical site, time the procedure usually takes, type of anesthesia, length of recovery, and resumption of sexual activity. Discuss general surgical risks. Emphasize that vasectomy is not effective immediately and that the client should use an alternate method of contraception until his semen is tested and found to be free of sperm.
  5. Describe all medical benefits and risks. Fears and myths regarding the long-term health effects of vasectomy often lead to eventual dissatisfaction with the procedure. Although the body of research suggests that vasectomized men are no more likely than nonvasectomized men to develop heart disease and cancer, preventive lifestyle and screening should be addressed. Emphasize that vasectomy provides no protection against sexually transmitted diseases, including human immunodeficiency virus (HIV) infection.
  6. Point out that vasectomy does not cause a loss in physical strength, development of a high pitched voice, a loss or change in sexual function, weight gain, or a loss of masculinity. Inform the client that he will still ejaculate after surgery and in the same amount. The semen will not, however, contain any sperm after successful vasectomy. Some studies have indicated that sexuality may improve because couples do not worry about accidental pregnancy.
  7. Tell the patient about any fees he is expected to pay. Ensure compliance with local, state, and institutional restrictions regarding age, waiting periods, and second opinions.

Throughout the discussion, answer client questions and concerns. Use diagrams and pictures of instruments to reduce patient anxiety. Emphasize that vasectomy is a safe, moderately priced, simple, and highly effective procedure.

Provide printed educational materials that the client and his partner can review privately, as well as oral and written preoperative instructions. Preoperative vasectomy patients must avoid aspirin-containing drugs for two weeks before and one week after surgery.11 The client must also undergo a limited physical examination; in specific cases, laboratory workup is required (blood count, bleeding and clotting time, urinalysis, and semen analysis), but this is not routinely done. On the day of surgery, the client should bathe or shower and wear loose-fitting clothing. If necessary, hair on the scrotum should be clipped immediately before the procedure and not by the client at home. The client should bring an athletic supporter or briefs to wear after the surgery.

DOCUMENTING INFORMED DECISION MAKING

The client signs an informed consent form on the day of surgery to indicate that he has reviewed the information given him and discussed his decision with the vasectomy provider. The client must understand the seven points of informed decision making listed below and know what he is signing. The provider should encourage the client to ask questions. The seven points of informed decision making are:12

  1. Temporary contraceptive methods are available to the client and his partner.
  2. Vasectomy is a surgical procedure.
  3. There are certain benefits and risks associated with vasectomy, including the small risk of failure, both of which must be explained.
  4. The effect of vasectomy is to be considered permanent.
  5. If successful, vasectomy will prevent the client from having any more children.
  6. Vasectomy does not protect the client or his partner from infection with sexually transmitted infections, including  HIV.
  7. The client can decide against the operation at any time before the procedure without losing the right to other medical, health, or other services or benefits.

With a witness present, the client's signature or mark should be obtained. If the client is illiterate, the provider should obtain a witness's signature attesting that the client has affixed his mark or thumbprint on the informed consent form.

PREOPERATIVE SCREENING AND EVALUATION

There should be no rigid guidelines concerning waiting periods between the prevasectomy medical history and physical examination and the performance of the vasectomy. Generally, a 23 week period gives the client or couple sufficient time to consider any possible concerns about effects on sexuality or health. Table 1 lists the required and recommended components of a prevasectomy medical history and physical examination and explains the reason each component is included.

Table 1. Components of a prevasectomy medical history and physical examination


Component

Reason

Medical History

 

Existence of bleeding disorders

Can indicate the potential for hemorrhage

Previous scrotal or inguinal surgery or trauma

Scarring or adhesions that could complicate a vasectomy procedure may exist

Current or past genitourinary infections, including sexually transmitted disease

Past infections could have caused scarring and adhesions; current infection could lead to acute postvasectomy infection

History of sexual impairment

Can indicate pre-existing psychological or physiologic problems that could later be incorrectly attributed to the vasectomy

Current and recent medications

Can indicate medical problems that the vasectomist should be aware of before surgery

Allergy to medications

Can help prevent complications by determining whether the client has ever had an allergic reaction to any of the medications or antiseptics used before, during, or after surgery

Physical Examination

 

Genitals

Can rule out the presence of infections or masses that the vasectomist should be aware of before surgery

Lungsa (auscultation and respiratory rate)

Can rule out infections and other lung disease that the vasectomist should be aware of before surgery

Abdomena (palpation)

Can rule out the presence of infections, organ enlargements, or masses that the vasectomist should be aware of before surgery

Hearta (auscultation, pulse, and blood pressure)

Can rule out hypertension, heart murmurs, and other cardiovascular disease that the vasectomist should be aware of before surgery


a Recommended but not essential.

GENITAL EXAMINATION

After the client's heart, lungs, and abdomen have been examined, a genital examination should be performed. Before beginning the examination, the surgeon should tell the client what will be done and why it is done. The man is assured that he will feel minimal pain. During the genital examination, penile and scrotal examination is conducted. Unless lesions are observed, gloves are unnecessary during a genital examination, but the doctor should wash his or her hands thoroughly before and after the examination.

PENILE EXAMINATION

Visual Inspection

The penis is visually inspected, and any lesions or scarring are noted. The penis, including the underside, is gently lifted and examined. The urethral opening is examined. Any abnormalities such as discharge, reddening, or irritation are noted and assessed.

Potential Abnormalities

Potential abnormalities include rash, cyst, discharge, and skin cancer (rare).

SCROTAL EXAMINATION

Visual Inspection

The scrotal skin is visually inspected. The scrotum is lifted to examine the posterior side. Coloring, size, and contour are observed. Any swelling or masses are noted and assessed.

Potential Abnormalities

Potential abnormalities include rash, cysts, poorly developed scrotum (possible cryptorchidism), and swelling (possible inguinal hernia, torsion of spermatic cord, strangulated inguinal hernia).

PALPATION OF THE TESTIS AND EPIDIDYMIS

Using the thumb and first two fingers, the doctor palpates each testis and epididymis (Fig. 4). He or she avoids putting pressure on the testis during the palpation so as not to cause pain. The size, shape, and consistency of each testis and epididymis are noted. Any nodules or tenderness are noted.

Fig. 4. Palpation of the testis and epididymis. (From EngenderHealth. No-Scalpel Vasectomy Curriculum, 2nd Edition. New York, EngenderHealth, 2007.)

Potential Abnormalities

Painless nodules in the testes may indicate testicular cancer. Nodules in the epididymis may indicate an epididymal cyst (seminoma).

PALPATION OF THE SPERMATIC CORD AND VAS DEFERENS

Each spermatic cord and its vas deferens are palpated (Fig. 5). The doctor moves his or her thumb and fingers along its length. Any nodules or swellings are noted.

Fig. 5. Palpation of the spermatic cord and vas deferens. (From EngenderHealth. No-Scalpel Vasectomy Curriculum, 2nd Edition. New York, EngenderHealth, 2007.)

Potential Abnormalities

Potential abnormalities include thickened vas (suggests chronic infection), tortuous veins (suggests varicocele), and cyst in the cord (suggests hydrocele).

PRECAUTIONS

Although vasectomy is a simple operation that can be performed almost anywhere, the more removed the setting is from medical back-up, the more important it is to screen out men who are likely to develop complications.

The major physical precautions to performing vasectomy are local skin infection and systemic blood disorder. Local skin infection, which can prevent normal healing or increase risk of postoperative infections, is easily recognized and should be treated and the condition resolved before the operation is performed. Other local conditions that make vasectomy more difficult to perform include inguinal hernia, previous surgery for hernia or orchiopexy, hydrocele, varicocele, pre-existing scrotal lesions, and a thick, tough scrotum.

Systemic blood disorders that call for special precautions include any disease that interferes with normal blood clotting (e.g. hemophilia). In such cases, the vasectomy technique used should minimize tissue trauma, and emergency equipment should be available. If the patient is taking anticoagulants, the same precautions may be required. Other systemic diseases, such as diabetes, hypertension, or other cardiac disease, are not contraindications to vasectomy, but hospitalization and intraoperative monitoring with prolonged close observation and follow-up are advisable in case emergencies arise. Table 2 presents the World Health Organization's (WHO) eligibility criteria for vasectomy procedures,13 which include standard vasectomy precautions.

Table 2. WHO eligibility criteria for vasectomy procedures


There is no medical reason that would absolutely restrict a person's eligibility for sterilization. There may be conditions and circumstances that indicate that certain precautions should be taken.

The classification of the conditions into the different categories is based on an in-depth review of the epidemiologic and clinical evidence relevant to medical eligibility.

Definitions

 

A (Accept):

There is no medical reason to deny sterilization to a person with this condition.

C (Caution):

The procedure is normally conducted in a routine setting, but with extra preparation and precautions.

D (Delay):

The procedure is delayed until the condition is evaluated and/or corrected. Alternative temporary methods of contraception should be provided.

S (Special):

The procedure should be undertaken in a setting with an experienced surgeon and staff, equipment needed to provide general anesthesia, and other back-up medical support. For these conditions, the capacity to decide on the most appropriate procedure and anesthesia regimen is also needed. Alternative temporary methods of contraception should be provided if referral is required or there is otherwise any delay.

Condition

Category

Rationale/Comments

Young ageCYoung men are more likely to request vasectomy reversal.
Depressive disorders CDecision making may be affected.
High risk of HIVA

No routine screening is needed. Appropriate infection procedures must be carefully observed with all surgical procedures.


HIV-positive ANo routine screening is needed. Appropriate infection procedures must be carefully observed with all surgical procedures.
AIDSSThe presence of an AIDS-related illness may require a delay in the procedure.

Local infections (scrotal skin infection, active STI, balanitis, epididymitis or orchitis)

D

There is an increased risk of postoperative infection.

Previous scrotal injury

C

 

Systemic infection or gastroenteritis

D

There is an increased risk of postoperative infection, complications from dehydration, and anaesthesia-related complications.

 

Large varicocele

C

The vas may be difficult or impossible to locate; a single procedure to repair the varicocele and perform a vasectomy decreases the risk of complications.

Large hydrocele

C

The vas may be difficult or impossible to locate; a single procedure to repair the hydrocele and perform a vasectomy decreases the risk of complications.


Filariasis; elephantiasis

D

If elephantiasis involves the scrotum, it may be impossible to palpate the spermatic cord and testis.

Intrascrotal mass

D

This may indicate an underlying disease.

Cryptorchidism

C

If cryptorchidism is bilateral, and fertility has been demonstrated, this will require extensive surgery to locate the vas, making the condition category S. If cryptorchidism is unilateral and fertility has been demonstrated, vasectomy may be performed on the normal side and sperm analysis performed, as per routine. If sperm continue to be persistently present, more extensive surgery may be required to locate the other vas, and the condition becomes category S.

Inguinal hernia

S

Vasectomy can be performed concurrent with hernia repair.

Sickle-cell disease

A

 

Coagulation disorders

S

Bleeding disorders lead to an increased risk of postoperative hematoma formation which, in turn, leads to an increased risk of infection.

Diabetes

C

Diabetics are more likely to get post-operative wound infections. If signs of infection appear, treatment with antibiotics needs to be given.


(Adapted from World Health Organization (WHO): Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use. Third edition. Geneva: WHO, 2004.)

VERIFYING INFORMED CONSENT

Just prior to surgery, the surgeon should verify that the patient has signed an informed consent form. The guide presented in Fig. 6 can be used in making a final assessment of the patient's informed decision to have a vasectomy.

Fig. 6. Assessing a client's decision for vasectomy. (From EngenderHealth. No-Scalpel Vasectomy Curriculum, 2nd Edition. New York, EngenderHealth, 2007.)

TECHNIQUES

Approaches to the Vas

Conventional vasectomy is performed under local anesthesia. A scalpel is used to make either one midline incision or two incisions overlying each vas deferens; these incision or incisions are 12 cm long (Fig. 7). After occlusion of the vasa using the surgeon's preferred technique, the incision or incisions are closed with sutures.

Fig. 7. Conventional vasectomy technique. (Copyright AVSC International, 1999.)

No-scalpel vasectomy (NSV) is a method of delivering the vasa deferentia under local anesthesia that was developed and has been used in China since 1974.14, 15 It has been introduced in many developed and developing countries. In 2002, the most recent year for which data are available, nearly 40% of physicians surveyed in the US reported they were currently using NSV and almost one half of all vasectomies performed in the US were no-scalpel vasectomies.2 Most vasectomies performed in Bangladesh, India and Nepal are with the NSV technique.16 This technique eliminates the need for use of a scalpel and instead utilizes two specialized instruments: a ringed clamp (Fig. 8) and dissecting forceps (Fig. 9). No-scalpel vasectomy involves a deep injection of local anesthetic applied alongside each vas, creating a vasal nerve block (Fig. 10). In conventional vasectomy techniques, only the area around the skin entry site is anesthetized. Recently, a jet injection technique has been described to deliver a high pressure spray of local anesthetic for vasectomy that minimized the amount of anesthetic needed and results in almost immediate onset of anesthesia.17, 18 Use of this no-needle approach significantly reduced pain of administration of anesthesia and was equally as effective in reducing pain during NSV, compared to injection of local anesthetic.18 

Fig. 8. Ringed clamp used for no-scalpel vasectomy. (From EngenderHealth. No-Scalpel Vasectomy: An Illustrated Guide for Surgeons, Third ed. New York, EngenderHealth, 2003.)

Fig. 9. Dissecting forceps used for no-scalpel vasectomy. (From EngenderHealth. No-Scalpel Vasectomy: An Illustrated Guide for Surgeons, Third ed. New York, EngenderHealth, 2003.)

Fig. 10. Creating the vasal nerve block. (From EngenderHealth. No-Scalpel Vasectomy: An Illustrated Guide for Surgeons, Third ed. New York, EngenderHealth, 2003.)

The ringed clamp encircles and firmly secures the vas without penetrating the skin (Fig. 11). A sharp, curved hemostat (the dissecting forceps) punctures and spreads the scrotal skin and vas sheath. The vas is delivered, cleaned, and occluded using the surgeon's preferred technique (Fig. 12). The contralateral vas is then delivered through the same opening and occluded. The puncture wound contracts to about 2 mm, is not visible to the client, and requires no sutures for closure.

Fig. 11. The tissues are spread to make a skin opening twice the diameter of the vas. (From EngenderHealth. No-Scalpel Vasectomy: An Illustrated Guide for Surgeons, Third ed. New York, EngenderHealth, 2003.)

Fig. 12. The ringed clamp is released before elevating the vas with the dissecting forceps. The ringed clamp is open but still in place. (From EngenderHealth. No-Scalpel Vasectomy: An Illustrated Guide for Surgeons, Third ed. New York, EngenderHealth, 2003.)

No-scalpel vasectomy offers several advantages over conventional vasectomy.19 No-scalpel vasectomy results in fewer hematomas and infections compared with conventional vasectomy (Table 3).

Table 3. Incidence of infection and hematoma or bleeding after vasectomy


Reference

No. of subjects

Infections (%)

Hematoma or bleeding (%)

Incisional

   

Philp et al 198420

534

1.3

4.5

Kendrick et al 198721

65, 155

3.5

2.0

Nirapathpongporn et al 199022

523

1.3

1.7

Alderman 199123

1224

4.0

0.3

Sokal et al 199924

627

1.3

10.7

No-Scalpel

   

Nirapathpongporn et al 199022

680

0.2

0.3

Li et al 199114

179, 741

0.9

0.1

Li et al 199114

238

0

0

Sokal et al 199924

606

0.2

1.7

Arellano et al 199725

1000

0

2.1

 

In a 1991 survey conducted in the United States, 78 out of 111 surgeons (70%) said they believed patients undergoing no-scalpel vasectomy with vasal block anesthesia experienced less operative pain than did patients undergoing conventional vasectomy.15 Indeed, men undergoing no-scalpel vasectomy reported less pain during the procedure and early follow-up period, and also reported earlier resumption of sexual activity after surgery.24, 26 Because there is no scrotal incision, no-scalpel vasectomy is believed to decrease men's fears regarding vasectomy.15

Neither conventional nor no-scalpel vasectomy is time consuming; however, there are reports of decreased operating time when skilled providers use the no-scalpel approach. For example, a study in Thailand showed that surgeons who used the no-scalpel technique were able to perform an average of 57 procedures per day, whereas those using the conventional technique performed an average of 33 procedures per day.22 Similarly, in the United States, a 40% reduction in operating time has been reported with no-scalpel vasectomy.14

Several modifications of the NSV approach, successful in the investigator's hands, have been reported in the literature.27, 28, 29, 30

Occlusion of the Vas Deferens

A variety of methods are currently used for occlusion of the vas, including ligation with sutures, division, cautery, clips, excision of a segment of the vas, and combinations thereof. The same techniques are used to occlude the vas whether using conventional or NSV. Simple ligation without division and simple division alone are not recommended, because the potential for failure due to recanalization is high. There is little consensus regarding what occlusion technique is best. In the United States, for example, results of a recent survey indicated that occlusion technique varied: 41% of vasectomies were performed using ligation and cautery, 18% using cautery and clips, 17% using ligation only, 13% using cautery only, 9% using clips only, 2% using cautery, ligation and clips, and 2% using ligation and clips.2

This lack of consensus is partially due to the fact that good research data were, until recently, unavailable to support the use of any one technique over another.31, 32 Most reports in the literature are retrospective reviews of individual physicians' experiences of either a single occlusion method or sequential use of two methods. It is difficult to interpret some studies because details on definitions of failure, follow-up protocols, loss to follow-up rates, or statistical methods are often lacking. Although these factors also contribute to the difficulty in comparing results among studies, the fact that most studies use a different occlusion technique—ligation, clips, cautery, excision versus no excision, closed versus open, fascial interposition versus no fascial interposition, or different combinations of the various techniques—makes most comparisons across studies questionable. Often, however, individual surgeons have their own preferences regarding occlusion method.

Results from a number of recent studies, however, suggest that there are some differences in effectiveness among different occlusion techniques. Several studies found higher than expected failure rates for vasectomy by ligation (with suture or clips) and excision of a segment of the vas.33, 34, 35, 36 Results of a randomized controlled trial demonstrated that use of fascial interposition (suturing the spermatic fascia over one end of the vas to place a tissue barrier between the two cut ends) with ligation and excision significantly improved the effectiveness of vasectomy; ligation and excision without fascial interposition should no longer be recommended.37 Cautery has been shown to be highly effective31, 38 and was found to significantly reduce failures compared to ligation and excision with fascial interposition.39 Data on use of fascial interposition with cautery, differences in the effectiveness of thermal and electrocautery, and the importance of removing a segment of the vas when using cautery are lacking.

There is little information on the relation of the length of vas removed and the success of the procedure. The risk of recanalization was not significantly associated with shorter segments excised in one study where 0.52.0 cm of vas segment were removed.40 Although most surgeons remove a segment of the vas, some investigators report success using division and occlusion of the vas without removal of any vas tissue itself.11, 41, 42, 43

Routine referral of the vas for pathologic study is neither essential nor recommended.44, 45, 46 The presence of two vas specimens does not substitute for determining the endpoint of azoospermia. Because the same vas may have been sectioned twice or a double vas may be present, the patient may still be fertile despite the fact that two separate specimens have been sent to the laboratory.45 Conversely, even if the laboratory cannot confirm the presence of vasa on microscopic examination, the patient may still have a successful procedure, because tissue can be distorted in removal or lost in transit to the laboratory.

Open-ended vasectomy (i.e. not sealing the testicular end of the cut vas) can be used with ligation, cautery or clips, and has been proposed as a way of increasing the likelihood of success if subsequent reversal is requested. The sperm granuloma that form on the end of the vas with open-ended vasectomy are thought to prevent pressure build-up and damage to the epididymis facilitating success of reversal.47 While there is some evidence to suggest that open-ended vasectomy may increase the success of vasectomy reversal,48 rigorous studies are lacking. Although published studies vary, it appears that open-ended vasectomy is not associated with increased failure when the prostatic end is adequate occluded.31  No firm conclusions can be made about the potential benefit of open-ended vasectomy in decreasing the risk of painful granuloma or epididymitis after vasectomy.31

POSTOPERATIVE CARE AND INSTRUCTIONS

Men who have undergone vasectomy may leave the health facility after resting for 30 minutes. If the patient has been sedated, his vital signs should be monitored every 15 minutes until stable; he then can be released. Information should be provided in simple language to the patient regarding how to care for the wound, what side effects to expect, what to do if complications occur, where to go or who to call for emergency care, and where and when to return for a follow-up visit. The patient should be informed that minor pain and bruising are common and do not require medical attention. However, if he develops a fever, if blood or pus oozes from the vasectomy site, or if excessive pain, swelling, or bruising occurs, he should seek medical care. Written postvasectomy instructions should be provided (Fig. 13).

Fig. 13. Sample postoperative instructions for the client









 

INTRAOPERATIVE AND IMMEDIATE COMPLICATIONS

Vasectomy is considered a minor and safe surgical procedure; complications are rare. Intraoperative complications may include vasovagal reaction and lidocaine toxicity. Table 4 provides information on management of intraoperative complications.

Table 4. Potential intraoperative complications of vasectomy

 

  Symptoms Treatment Etiology Prevention
Vasovagal reaction (neurocardiogenic syncope) Fainting
Nausea
Weakness
Lightheadedness
Blurred vision
Sweating
Decreased blood pressure
Heart rate increases initially, then decreases
Pallor
Cold, clammy hands
Restlessness
Reassure the client
Raise the client's feet
Lower the client's head
Administer atropine if the client's pulse is lower than 40 bpm
Administer oxygen
Painful procedure
Anxious client
Use gentle surgical technique
Perform effective anesthetic block
Explain procedure to client in advance
Reassure client during procedure
Lidocaine toxicity Numbness of tongue and mouth
Lightheadedness
Tinnitus (ringing in the ears)
Visual disturbances
Slurred speech
Respiratory depression
Respiratory arrest
Myocardial depression
Arrhythmia
Hypotension
Cardiac arrest
Convulsions
Coma (very high overdose)
Discontinue use of drug
Take general suportive measures
Maintain airway and respiration
Provide oxygen
Administer Diazepam or thiopental (for convulsions)
Administer vasopressors (e.g. norepinephrine or dopamine) for hypotension
Overdose of lidocaine
Intravascular injection
Do not administer a dose > 30cc of 1% solution or > 15 cc of 2% solution
Injury to testicular artery Bleeding observed in fascia around the vas Perform cautery or ligation to control bleeding Injury to blood vessel during stripping of fascia from vas Strip fascia and blood vessels carefully

 

Immediate postoperative complications of vasectomy include bleeding, hematoma, and infection. Hematomas occur in approximately 2% of men; however, a wide range of rates have been reported, from less than 1% to nearly 30%.21 Studies consistently suggest that the incidence of hematoma is directly proportional to surgical skill and experience with the vasectomy procedure. In a large US-based survey among providers of conventional vasectomy (including urologists, family physicians, and general surgeons), the mean hematoma rate was significantly higher among physicians performing 110 vasectomies per year (4.6%) than among those performing 1150 vasectomies per year (2.4%) or more than 50 vasectomies per year (1.6%).21 The corresponding incidences of hospitalization were 0.8%, 0.3%, and 0.2%, respectively.

Most infections are minor, and an average incidence of 3.5% was reported in one series of more than 65,000 vasectomies.21 Higher rates of infection have also been reported.49, 50, 51 The incidence of infection has not been shown to vary by surgeon's experience.21

Rates of immediate complications also vary depending on the approach to the vas, with no-scalpel vasectomy consistently resulting in lower hematoma and infection rates than conventional vasectomy (see Table 3).

No association has been documented between use of general anesthesia or the setting where vasectomies were performed and any complication.21

Another early complication is sperm granuloma formation. Sperm that leak from the end of the cut vas may induce an inflammatory reaction leading to the formation of sperm granuloma. Sperm granulomas are seen in 1540% of men presenting for vasectomy reversal.52, 53 Only approximately 23% of these are painful or in some way symptomatic; such symptoms peak at the second or third postoperative week.21, 52, 54 Discomfort can be treated symptomatically with anti-inflammatory drugs. Open-ended vasectomy has been reported to decrease the occurrence of sperm granulomas.43, 55, 56

Providers can prevent most complications by paying attention to hemostasis, practicing good aseptic technique, and minimizing tissue trauma during vasectomy procedures. Table 5 provides information on prevention and treatment of complications of vasectomy.

Table 5. Potential postoperative complications of vasectomy


 

Symptoms

Treatment

Prevention

Etiology

Bleeding

Bleeding observed at incision site

Most small vessel bleeding can be controlled by compression

Careful surgical technique separates vessels from the vas before transection

Vasectomist's failure to strip spermatic cord

 

Swelling of scrotum

Cautery and ligature may be used for large vessel bleeding

 Vasectomist's failure to control bleeding before wound closure

Hematoma

Swelling of scrotum

Control bleeding by pressure

Careful surgical technique

Rough handling of tissue

  

Cautery and ligature may be used for large vessel bleeding

Understanding and carrying out of postvasectomy instructions regarding heavy lifting by client after vasectomy

Vasectomist's failure to control bleeding before wound closure

  

Rarely, may require incision and drainage

 

Excessive strain or Client's failure to wear snug undergarments after vasectomy

  

If hematoma is stable, allow to resolve on its own

 Client's failure to rest
  

Provide prophylactic antibiotics for 24 hours after vasectomy

  

Infection

Pus, swelling, or pain at the incision site or in the scrotum

Superficial infections: clean and apply local antiseptic and clean dressing

Observance of proper infection prevention procedures

Failure by vasectomist to follow infection prevention procedures

 

Fever

Underlying tissue infection: antibiotics and wound care

Recognition of bleeding

Improper postoperative care of the wound

  

Abscess: antibiotics, drainage and wound care

Client keeps wound dry after vasectomy

 
  

Cellulitis or fascitis: debridement, antibiotics, and wound care

  

Sperm granuloma

Pain at the testicular end of the vas or the tail of the epididymis

Asymptomatic: no intervention

Unknown

Occlusion of vas leads to accumulation of sperm

 

Nodule felt during palpation

Pain: use nonsteroidal analgesics

  
  

Persistent pain: evacuate the cyst; cut and seal the vas ¼ inch toward the testis

  
  

Do not excise the granuloma

  
  

Rarely, chronic pain warrants an epididymectomy

  

Major complications or mortality are extremely rare, although lethal complications can occur.57, 58, 59 The most comprehensive study of vasectomy-related mortality, based on over 400,000 vasectomies worldwide, found a mortality rate of 0.5 per 100,000 vasectomized men.59 Only 13 major complications were reported in a US survey of more than 65,000 vasectomies for a rate of 0.02%.21

SEMEN ANALYSIS AND CLEARANCE

Vasectomy success is routinely confirmed by demonstrating the absence of sperm (i.e. azoospermia) in semen samples obtained at one or more clinic visits following the procedure. The time interval to the first follow-up visit is often between 6 and 12 weeks but may be as great as 4 months postvasectomy. Some clinics schedule follow-up based on the number of ejaculations following vasectomy, which may range from 15 to as many as 30 ejaculations prior to obtaining the first follow-up semen analysis.54, 60, 61, 62

There is little consistency in follow-up protocols in terms of when men are told to come for the first semen analysis or the number of azoospermic samples required before clearance is given.2, 44, 45 In a US-wide study of vasectomy providers, 74% suggested men return for semen analysis based on time since vasectomy, 18% based on number of ejaculations following vasectomy and the remaining 8% based on time and/or number of ejaculations following vasectomy.2 The recommended time or number of ejaculations since vasectomy for the semen analysis, as well as the number of azoospermic samples required before clearance, varied widely among those surveyed.2

This large degree of variability in clinical protocols for postvasectomy follow-up reflects the fact that good data regarding time and number of ejaculations to azoospermia following vasectomy are limited. Although there are more than one dozen published studies reporting on semen characteristics postvasectomy, well-designed clinical trials with serial follow-up visits are few.

A number of studies have reported the results of time or number of ejaculations to azoospermia following vasectomy.35, 37, 38, 63, 64, 65, 66, 67, 68, 69, 70, 71 Follow-up protocols and procedures, definitions of azoospermia or success, and the way in which results are reported vary widely in these studies, and some reported results are conflicting. In addition, in some cases, important study details are lacking in the reports. All of these factors make interpretation or generalization of results and comparisons between studies difficult. For example, reported rates of azoospermia at 6 months range from 48% to 100%.35, 37, 38, 63, 64, 66, 69, 70, 72, 73, 74

Many of the current follow-up protocols require that men return for their first semen analysis at long intervals after vasectomy, and during this time an alternative method of contraception must be used. In addition, if azoospermia is not found at the initial visit, additional visits are necessary and in many cases even if azoospermia is found a confirmation visit is recommended. Compliance with postvasectomy follow-up has been shown to be poor, with 2146% of men not returning for any follow-up, suggesting that the current follow-up protocols do not work very well.74, 75, 76, 77, 78, 79, 80, 81 A recent study found that scheduling an appointment for follow-up at the time of the vasectomy significantly improved compliance with both the initial visit and the recommendation for two consecutive azoospermic samples.82 In addition, there is growing support for granting clearance after one azoospermic semen analysis.44, 83, 84

It is possible that azoospermia may not be the best endpoint for vasectomy, and indeed, achievement of azoospermia may not be necessary. As early as 1979 it was suggested that as long as no motile sperm were present, men could rely on their vasectomy for contraception without risk of pregnancy.85 There are now a number of reports indicating that nonmotile sperm remaining after vasectomy are not associated with pregnancy.20, 67, 68, 85, 86, 87, 88 Suggesting that absence of motile sperm be the endpoint for vasectomy is not unreasonable given the fact that sperm motility is required for penetration of cervical mucus89 and for penetration of the oocyte.90 However, at least in the United States, concerns regarding malpractice in cases in which success has been declared without azoospermia and subsequent pregnancy occurs (even if due to recanalization) are likely to affect follow-up recommendations. None the less, various alternatives to azoospermia, at least in some cases, have been suggested including two consecutive counts of less than 10,000 sperm/ml with no motile sperm at least 7 months since vasectomy20, 86 and no motile sperm after 4 weeks,681218 weeks,70, 87 or greater than 18 weeks70 postvasectomy. The guidelines of the UK Royal College of Obstetricians and Gynecologists includes a 'special clearance' category when there are less than 10,000 non-motile sperm/ml in a fresh semen specimen at least 28 weeks after vasectomy.91 

In resource-poor settings semen analysis may not be available or practical. In these settings it had been recommended that men wait 1012 weeks or 1520 ejaculations before beginning to rely on their vasectomy for contraception. Recent research suggests that telling men to use another form of contraception until 12 weeks after vasectomy is more reliable than 20 ejaculations35, 37, 38 and is now recommended to reduce the risk of pregnancy.92

EFFICACY

Overall, vasectomy is highly effective and one of the most reliable contraceptive methods available. Failure rates are commonly quoted to be between 0.10.4%, but failure rates reported in the literature show broader ranges, and rates as high as 1% to nearly 10% have been reported.1, 33, 34, 93, 94 In general, vasectomy failure rates are believed to be similar to those for female sterilization and lower than those for reversible methods.95 It is important to recognize the limitations of quoting exact failure rates for vasectomy. There are difficulties in interpreting the published studies on vasectomy efficacy because follow-up has been relatively short-term; most reports in the literature are retrospective reviews of individual physicians' experiences; definitions of failure, length of follow-up, and occlusion methods used vary among studies; and details on follow-up protocols, loss to follow-up rates, or statistical methods are often lacking.31 Large, well-designed, long-term studies that describe vasectomy failure rates have not been conducted.

Vasectomy failure may be due to user failure or to failure of the technique itself. User failure occurs when alternate contraception is not used during the period after vasectomy but before all sperm are cleared from the reproductive tract. One-quarter to one-half of pregnancies after vasectomy may occur during this time.34, 93, 96 The most common cause of failure of the vasectomy technique itself is spontaneous recanalization of the vas.62 This occurs when a sperm granuloma forms at the site of the vasectomy and links the two cut ends of the vas, creating passageways for sperm.97, 98 Recanalization can occur at any time after vasectomy and is frequently termed early or late. Early recanalization is characterized by a very low sperm concentration within a few weeks after vasectomy followed by return to large numbers of sperm. Many early recanalizations appear transient, eventually closing off and leading to successful vasectomy.99 Late recanalization occurs after azoospermia has been demonstrated, when motile sperm reappear in the ejaculate.20, 62 Late recanalizations can occur several years after successful vasectomy and are usually only identified when a pregnancy occurs; the actual rate in a large population has never been accurately determined. Other possible but rare causes of failure include occlusion of the wrong structure during the vasectomy procedure or the presence of an extra vas.62

REGRET

The vast majority of men who have a vasectomy do not regret their decision. Regret among men after vasectomy, most often reported as less than 5%, is lower than the reported regret among women after female sterilization.8, 10 Regret among women whose husbands had a vasectomy has been reported to be slightly higher than men's regret at 68%.100, 101 Studies have shown that regret among men is associated with marital instability at the time of vasectomy, young age (younger than 31 years), making the decision to have a vasectomy during a time of financial crisis or related to pregnancy, and having very young or no children at the time of vasectomy.8, 102, 103, 104 Regret is also often the result of client dissatisfaction with adverse health effects caused by or perceived to be caused by the procedure. Risk factors for regret should not be used by providers to restrict access to vasectomy for those in risk groups, but rather should be used to identify individuals who may need more extensive counseling. Satisfaction with presterilization counseling has been found to correlate positively with poststerilization satisfaction.5, 105

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