Vasectomy

Vasectomy
Diagram showing the usual location of a vasectomy. A.) Penis; B.) Urethra; C.) Scrotum; D.) Testicle; E.) Epididymis; F.) Vasectomy; G.) Prostate; H.) Seminal vesicle; I.) Bladder; J.) Pubic bone; K.) Vas deferens
Background
Birth control type	Sterilization
First use	1899 (experiments from 1785)[1]
Failure rates (first year)
Perfect use	<0.1%
Typical use	0.15%, "Vas-Clip" nearly 1%
Usage
Duration effect	Permanent
Reversibility	Possible, but expensive.
User reminders	Two consecutive negative semen specimens required to verify azoospermia.
Clinic review	All
Advantages and disadvantages
STD protection	No
Benefits	No need for general anesthesia. Lower cost/less invasive than tubal ligation for women.
Risks	Temporary local inflammation or swelling of the testes. Long-term genital pain (PVPS).

Vasectomy is a surgical procedure for male sterilization and/or permanent birth control. During the procedure, the vasa deferentia of a man are severed, and then tied/sealed in a manner such to prevent sperm from entering into the seminal stream (ejaculate). Vasectomies are usually performed in a physician's office or medical clinic.

There are several methods by which a surgeon might complete a vasectomy procedure, all of which occlude (seal) at least one side of each vas deferens. To help reduce anxiety and increase patient comfort, men who have an aversion to needles might opt for the "no-needle" application of anesthesia while the "no-scalpel" or "open-ended" techniques help to speed-up recovery times and increase the chance of healthy recovery.

Due to the simplicity of the surgery, a vasectomy usually takes less than 30 minutes to complete. After a short recovery at the doctor's office (usually less than an hour), the patient is sent home to rest. Because the procedure is minimally invasive, many vasectomy patients find that they can resume their typical sexual behavior within a week, and do so with minimal discomfort.

Because the procedure is considered a permanent method of birth control (not easily reversed), men are usually counseled/advised to consider how the long-term outcome of a vasectomy might affect them both emotionally and physically.

Vasectomy should not be confused with castration, which is the surgical removal of the testicle(s).

Procedure

The traditional incision approach of vasectomy involves numbing of the scrotum with local anesthetic (although some men's physiology may make access to the vas deferens more difficult in which case general anesthesia is recommended) after which a scalpel is used to make two small incisions on each side of the scrotum at a location that allows the surgeon to bring each vas deferens to the surface for excision. The vasa deferentia are cut (sometimes a piece removed), separated and then at least one side is sealed by ligating (suturing), cauterizing (electrocauterization), or clamping.^[2] There are several variations to this method that improve healing, effectiveness and help mitigate long-term pain such as post-vasectomy pain syndrome (PVPS)

• Fascial interposition: Recanalization^[3] of the vas deferens is a known cause of vasectomy failure(s). Fascial interposition ("FI") helps to prevent this type of failure, increasing the overall success rate of vasectomy. FI is the positioning of the prostatic "receiving" end of the vas deferens to the outside of the fascial sheath^[4] while leaving the testicular end within the confines of the fascia. The fascia is a fibrous protective sheath that surrounds the vas deferens. This method, when combined with intraluminal cautery (one or both sides of the vas deferens), has been shown to increase the success rate of vasectomy procedures.
• No-needle anesthesia: Fear of needles for injection of local anesthesia is well known.^[5] In 2005, a method of local anesthesia was introduced for vasectomy which allows the surgeon to apply it painlessly with a special jet-injection tool, as opposed to traditional needle application. The numbing agent is forced/pushed onto and deep enough into the scrotal tissue to allow for a virtually pain-free surgery. Initial surveys^[5] show a very high satisfaction rate amongst vasectomy patients. Once the effects of no-needle anesthesia take effect, all other aspects of the vasectomy surgery remain the same.
• No-scalpel vasectomy: Also known as a "key-hole" vasectomy,^[6] in which a sharp hemostat (as opposed to a scalpel) is used to puncture the scrotum (scrotal sac). This method has come into widespread use as the resulting smaller "incision" or puncture wound typically limits bleeding and hematomas. Also the smaller wound has less chance of infection, resulting in faster healing times compared to the larger/longer incisions made with a scalpel. The surgical wound created by the No-Scalpel method usually does not require stitch(es).
• Open-ended vasectomy: The testicular end of the vas deferens is not sealed, which allows continued streaming of sperm into the scrotum. This method may avoid testicular pain as a result of increased back-pressure in the epididymis.^[7] Studies suggest that this method may reduce long-term complications such as Post-vasectomy pain syndrome.^[8][9]
• Vas irrigation: Injections of sterile water or euflavine (which kills sperm) into the distal portion of the vas at the time of surgery brings about a near-immediate sterile (azoospermatic) condition. The use of euflavine did however, decrease time (or, number of ejaculations) to azoospermia vs. the water irrigation by itself. This additional step in the vasectomy procedure, (and similarly, fascial interposition), has shown positive results but is not as prominent in use, given the fact that few surgeons offer it as part of their vasectomy procedure.^[10]

Less prominent techniques

The following methods to vasectomy purportedly have a better chance of reversal, but have seen less use by virtue of higher failure rates and poor long term statistical information as to overall success.

• Clip: A vasectomy using a mechanical clip does not require cutting the vas deferens, but rather uses a clip to squeeze shut the flow of sperm.

An earlier clip device, the VasClip, is no longer on the market, due to unacceptably high failure rates.^[11][12][13] A recently introduced clip device, the Pro-Vas, is no longer available. The manufacturers website contains outdated listings of urologists who no longer offer this procedure, the phone number has been disconnected and they are no longer responding to email.^[14]

The VasClip method had a higher cost and resulted in lower success rates. Also, because vas deferens is not cut and/or tied with this method, it may not technically be considered vasectomy. Vasectomy reversal (and the success thereof) was conjectured to be higher as it only required removing the Vas-Clip. This method appeared to only be in limited use, and therefore little reversal data is available.^[13]

Vas occlusion techniques

• Injected plugs: Similar to the Intra-Vas device technique, there are 2 types of injected plugs. Medical-grade polyurethane (MPU) or medical-grade silicone rubber (MSR) starts as a liquid polymer that is injected into the vas deferens after which the liquid is clamped in place until is solidifies (usually in a few minutes).^[15]
• Intra-Vas device: The vasa deferentia can also be occluded by an Intra-Vas device or "IVD". A small cut is made after which a soft silicone or urethane plug is inserted into each vas tube thereby blocking (occluding) sperm. This method allows for the vas to remain intact. IVD technique is done in an out-patient setting with local anesthetic, just like a traditional vasectomy. IVD reversal can be performed under the same conditions making it much less costly than vasovasostomy which usually requires general anesthesia and longer surgery time.^[16]

Both vas occlusion techniques require the same basic patient setup hence local anesthetic, puncturing of the scrotal sac for access of the vas and then plug and/or injected plug occlusion. The success of the aforementioned vas occlusion techniques remains to be seen as there limited statistical reports as to reliability, reversal and/or use to date. Studies have shown however, that the time to achieve sterility is longer than the more prominent techniques mentioned in this text. The satisfaction rate of patients undergoing IVD techniques does however have a high rate of satisfaction as relates to the surgery experience itself.^[10]

Outlook

A post-vasectomy scrotum, showing typical post-operative bruising, incision stitches and a shaved scrotum.

Sexual intercourse can usually be resumed in about a week (depending on recovery); however, pregnancy is still possible as long as the sperm count is above zero. Another method of birth control must be used until a sperm count is performed either two months after the vasectomy or after 10 to 20 ejaculations have occurred.^[17]

After vasectomy contraceptive precautions must be continued until azoospermia is confirmed. Usually two semen analyses at 3 and 4 months are necessary to confirm azoospermia. The British Andrological Society has recommended that a single semen analysis confirming azoospermia after 16 weeks is sufficient.

Biological implications

Vasectomy essentially ensures that in most cases the patient will be sterile after confirmation of success following surgery. The procedure is regarded by the medical profession as permanent because vasectomy reversal is costly and often does not restore the sperm count and/or motility to pre-vasectomy levels.

Men with vasectomies have a very small (nearly zero) chance of making a woman pregnant, but they will still have exactly the same risk of contracting and spreading sexually transmitted infections.

After vasectomy, the testes remain in the scrotum where Leydig cells continue to produce testosterone and other male hormones that continue to be secreted into the blood stream. One study found that sexual desire after vasectomy was diminished in 6% of vasectomized men,^[18] whereas other studies find higher rates of diminished sexual desire, for example nearly 20%.^[19]

When the vasectomy is complete, sperm cannot exit the body through the penis. Sperm are still produced by the testicles, but they are broken down and absorbed by the body. Much fluid content is absorbed by membranes in the epididymis, and much solid content is broken down by the responding macrophages and re-absorbed via the blood stream. Sperm is matured in the epididymis for about a month before leaving the testicles. After vasectomy, the membranes must increase in size to absorb and store more fluid; this triggering of the immune system causes more macrophages to be recruited to break down and re-absorb more solid content. Within one year after vasectomy, sixty to seventy percent of vasectomized men develop antisperm antibodies.^[20] In some cases, vasitis nodosa, a benign proliferation of the ductular epithelium, can also result.^[21][22] The buildup of sperm increases pressure in the vas deferens and epididymis. The entry of the sperm into the scrotum causes sperm granulomas to be formed by the body to contain and absorb the sperm which the body treats as a foreign substance.^[7]

Effectiveness as birth control

The Royal College of Obstetricians and Gynaecologists states there is a generally agreed upon rate of failure of about 1 in 2000 vasectomies which is considerably better than tubal ligations for which there is one failure in every 200 to 300 cases.^[23] Early failure rates, i.e. pregnancy within a few months after vasectomy typically result from having unprotected intercourse too soon after the procedure. Late failure, i.e. pregnancy after recanalization of the vasa deferentia, has been documented.^[24] A 2005 systematic review of 28 studies described a total of 183 failures or recanalizations from approximately 43,642 vasectomy patients (0.4%), and 20 studies in the same review described 60 pregnancies after 92,184 vasectomies (0.07%).^[25]

Most physicians and surgeons who perform vasectomies recommend one (sometimes two) post-procedural semen specimens to verify a successful vasectomy; however many men fail to return for verification tests citing inconvenience, embarrassment, forgetfulness, or certainty of sterility.^[26] In January 2008 the FDA cleared a home test called SpermCheck Vasectomy^[27] that allows patients to perform postvasectomy confirmation tests themselves; however compliance for postvasectomy semen analysis in general remains low.

Complications

Short-term complications include infection, bruising and bleeding into the scrotum, resulting in a collection of blood known as a hematoma.A study in 2012 demonstrated an infection rate of 2.5% post vasectomy.^[28] The stitches on the small incisions required are prone to irritation, but this can be minimized by covering them with gauze or small adhesive bandages. The primary long-term complications are chronic pain conditions or syndromes that can affect any of the scrotal, pelvic and/or lower-abdominal regions, known as post-vasectomy pain syndrome. Though vasectomy results in increases in circulating immune complexes, these increases are transient. Data based on animal and human studies indicate these changes do not result in increased incidence of atherosclerosis. The risk of prostate and testicular cancer is not increased by vasectomy.^[29]

Following a vasectomy the vas deferens is blocked off, closing the natural passageway for sperm. Sperm continues to be produced in the testicles at a rate of about 50,000 cells per minute. These sperm cells cause a build up of pressure in the delicate epididymis portion of the testicles, eventually leading to ruptures. This most often occurs when there is stress in the area, such as when a man is ejaculating, but can also occur spontaneously. These ruptures can lead to an aching sensation to the testicles, which can be either constant or may wax and wane in a cyclical pattern. Sometimes men will experience what has been described as an ice pick-to-the-testicle like sensation. Long-term post-vasectomy pain is experienced at a frequency which ranges between 2% and 33% of vasectomy patients.^{[citation needed]}

Post-vasectomy pain syndrome

Post-vasectomy pain syndrome (PVPS) is a chronic and sometimes debilitating condition that may develop immediately or several years after vasectomy.^[30] One survey cites studies that estimate incidence at one case every ten to thirty vasectomies.^[31] The pain can be constant orchialgia or epididymal pain, or it can be pain that occurs only at particular times such as with intercourse, ejaculation, or physical exertion.^[7]

Dementia (primary progressive aphasia)

Researchers reported an association between vasectomy and primary progressive aphasia (PPA, a rare variety of frontotemporal dementia) in a 2006 manuscript in Cognitive Behavioral Neurology detailing a case–control study that compared 47 men with the disease to 57 controls.^[32] The rate of vasectomy in PPA patients was 40% (19/47) vs. 16% (9/57) in normal controls. This difference met statistical significance (P=0.02). The study also found that there was a younger age of PPA onset for patients who had undergone vasectomy (58.8 vs. 62.9 years; P=0.03).

However, doubt was cast on this link by a review study in 2012.^[33]

Vasectomy reversal

Although men considering vasectomies should not think of them as reversible, and most men and their partners are satisfied with the operation,^{[34] [35]} life circumstances and outlooks can change, and there is a surgical procedure to reverse vasectomies using vasovasostomy (a form of microsurgery first performed by Earl Owen in 1971^[36][37]). Vasovasostomy is effective at achieving pregnancy in a variable percentage of cases, and total out-of-pocket costs in the United States are often upwards of $10,000.^[38] The typical success rate of pregnancy following a vasectomy reversal is around 55% if performed within 10 years, and drops to around 25% if performed after 10 years.^[39] After reversal, sperm counts and motility are usually much lower than pre-vasectomy levels. There is evidence that men who have had a vasectomy may produce more abnormal sperm, which would explain why even a mechanically successful reversal does not always restore fertility.^[40][41] The higher rates of aneuploidy and diploidy in the sperm cells of men who have undergone vasectomy reversal may lead to a higher rate of birth defects.^[40]

Some reasons that men seek vasectomy reversals include wanting a family with a new partner following a relationship breakdown / divorce, their original wife/partner dying and subsequently going on to re-partner and to want children, the unexpected death of a child, or a long-standing couple changing their mind some time later often by situations such as improved finances or existing children approaching the age of school or leaving home.^[42] Patients often comment that they never anticipated the possibility of a relationship breakdown or death (of their partner or child), or how that may affect their situation at the time of having their vasectomy. A small number of vasectomy reversals are also performed in attempts to relieve post-vasectomy pain syndrome.

Conceiving after vasectomy

In order to allow the possibility of reproduction via artificial insemination after vasectomy, some men opt for cryostorage of sperm before sterilization.

It is advised that all men having a vasectomy consider freezing some sperm before the procedure. Dr Allan Pacey (senior lecturer in andrology at Sheffield University and secretary of the British Fertility Society) notes that men who he sees for a vasectomy reversal which has not worked, express wishing they knew they could have stored sperm. Pacey notes, "The problem is you're asking a man to foresee a future where he might not necessarily be with his current partner - and that may be quite hard to do when she's sitting next to you."^[42]

The cost of Cryo-preservation (Sperm Banking) itself may also be substantially less (approximately $500 every 5 years) than alternative Vaso-vasectomy procedure(s), (est surgery cost of $10,000); however the costs of In-vitro fertilization which are rarely below $10,000 US, and usually run between $12,000–15,000 US, must be considered.^{[citation needed]}

Intracytoplasmic sperm injection: Sperm can be aspirated from the testicles or the epididymis, and while there is not enough for successful artificial insemination, there is enough to fertilize an ovum by ICSI. This avoids the problem of anti-sperm antibodies and may result in a faster pregnancy. IVF (In-vitro fertilization) may be less costly (see aforementioned text) per cycle than reversal in some healthcare systems, but a single IVF cycle is often insufficient for conception. Disadvantages include the need for procedures on the woman, and the standard potential side-effects of IVF for both the mother and the child.^[43]

Psychological impact

In the mid-1970s, surveys were used to examine the effects of vasectomy in relation to post-operative sexual behaviour, satisfaction and happiness, with generally positive answers in their "ticked boxes". However a different picture emerges from psychologically-based clinical interviews and tests, employing more rigorous methodology and measurement techniques. Although men in general verbally expressed satisfaction with their vasectomy, the authors of one review reflected "many men were probably describing feelings which have been distorted as part of an attempt to cope with their private concerns about the consequences of the operation".^[44] In addition, many men experienced difficulty in adjusting to the psychological consequences of vasectomy.^[44]

These differing results between simple surveys, and more elaborate interviews and psychological reviews, are revealing of some of the difficulties in trying to measure the psychological impact of vasectomy on men.

Most surveys following vasectomy show sexual desire and satisfaction levels remaining at the same level or greater (without the risk of pregnancy), and overall most men being content with their decision to have a vasectomy.^[45] Approximately 90% are generally reported in reviews as being satisfied with having had a vasectomy,^[46] while between 7-10% of men regret their decision.^[47] Most surveys frame questions as to "satisfied" or "not satisfied", and do not provide for ambiguous, ambivalent or complex emotions, which may exist alongside "overall satisfaction" with vasectomy.

One of the strongest contraindications to vasectomy, in psychological terms, is disagreement with one's wife or feeling "bullied into" a vasectomy, with men reporting this situation as experienced the highest level of negativity and regret subsequent to having a vasectomy.^[48]

The psychological effects of vasectomy may also continue or re-surface throughout a man's life history, beyond the period of a survey's scope. While a man may initially be satisfied with his decision to have a vasectomy, this view may change "later on his life history" such as subsequent to the breakdown of his primary relationship and re-coupling with a new partner who desires children. This type of situation of re-partnering later on in a man's life history has led to what has been characterised as a boom in vasectomy reversals and regrets, in which although the man was happy with his decision at the time of getting the vasectomy, he subsequently regretted the original decision to have a vasectomy later on in his life.^[42] Altered life situations including death of a partner, relationship breakdown, children starting school or leaving home, death of a child, re-partnering and re-marriage, increased wealth (which previously factored against having more children), mean that the psychological associations and effects of vasectomy are not only those which immediately follow the vasectomy, but may be ongoing throughout a person's life history.^[42][49] It is acknowledged that around 5% of men go on to have a vasectomy reversal, and a much higher percentage enquire about or seek a vasectomy reversal but are put off by the high costs of surgery and its interplay with the only moderate to moderately low success rates.^[49] (See Vasectomy reversal). Men who are of a younger age at the time of having a vasectomy are significantly more likely to regret and seek a reversal of their vasectomy, with one study showing men for example in their twenties being 12.5 times more likely to undergo a vasectomy reversal later in life (and including some who chose sterilization at a young age),^[50] promoting a greater level of pre-vasectomy counseling as being required.

An area not yet subject to adequate study is the psychological impact of conflict and disharmony with his wife or partner over his reticence towards vasectomy or decision not to undergo a vasectomy. Or vice-versa, in situations where it is the man who wants the vasectomy and his partner who is against it, has similarly not been subject to part of survey results in terms of psychological impact.

In relation to masculine identity, some early research suggested that men who have undergone vasectomy adopt more steroptypically masculine behaviors as compensatory for a diminished sense of masculinity, which is opposed by the research of Amor et al. who found that vasectomy often enhanced their sense of masculinity (among their study of 19 men).^[51]

Ideological issues

Egalitarian approaches seek to decrease levels of inequality in the "contraceptive burden" which exist between males and females, with implications for the topic of vasectomy. The corresponding female surgical sterilization procedure known as Tubal ligation is considered a major surgery usually done with general anesthesia (or with an epidural at child-birth), typically done at an in-patient, hospital setting.

The emphasis on "shared responsibility" has been taken up in recent research and articles by Terry and Braun, who regard much of the earlier psychological research on vasectomy as seemingly negative, or 'suspicious' in tone.^[52] In research based on 16 New Zealand men (chosen for their enthusiasm on the topic of vasectomy), researchers extracted primary themes from their interviews of "taking responsibility" and "vasectomy as an act of minor heroism’.^[53]

The need to "target men’s involvement in reproductive and contraceptive practices" was historically raised on a global scale at the 1994 International Conference on Population and Development (ICPD) in Cairo,^[54] in relation to both population control and decreasing the levels of inequality in the ‘contraceptive burden’, which has traditionally placed responsibility for contraception unfairly upon women. Vigoya has referred to a global "cultura anticonceptiva femenina" - a female contraceptive culture, where, despite the possibility of men taking more responsibility for birth control, there is virtually nowhere in the world where true contraceptive equality exists.^[55]

Feminist researchers emphasize the positive identities that men can take up post-vasectomy, as a "man who takes on responsibility for the contraceptive task"^[53] and a man who is willing to "sacrifice" his fertility for his partner and family's sake.^[52] Often these sorts of accounts are constructed within the 'contraceptive economy' of a relationship, where women have maintained responsibility of the contraceptive task up until the point of the operation. Terry notes that a man undergoing a vasectomy may also mean he receives a high degree of gratitude and positive reinforcement for making the choice to be sterilised, perhaps more so than a woman who has been on the oral contraceptive or similar for years prior.^[53]

An alternative viewpoint of contextualizing vasectomy debate is the evolutionary "battle of the sexes" conflict of interest. From an evolutionary Darwinian standpoint, males may increase their genetic fitness by mating with multiple mates over the course of their lifetime (see Sexual Conflict). As a woman's reproductive capacity reduces significantly with age towards menopause, eventually ceasing while a male partner is still able to produce offspring (see Age and Female Fertility), she benefits in evolutionary terms from her partner undergoing vasectomy - eliminating or greatly restricting his ability to mate with other women in the future, thus helping to ensure or protect her partner's investment and resources for herself and any offspring. Vasectomy may in this way be advantageous to female reproductive strategy (after a threshold number of offspring are born), and detrimental to the male reproductive strategy, if viewed in generalized evolutionary fitness terms alone.

Prevalence

Vasectomy is the most effective permanent form of birth control available to men. In nearly every way that vasectomy can be compared to tubal ligation,^[56] it has a more positive outlook. Vasectomy is more cost effective, less invasive, has techniques that are emerging that may facilitate easier reversal, and has a much lower risk of post operative complications. Given the aforementioned, in the United States,^[57] vasectomy is utilized at less than half the rate the alternative female "tubal ligation". According to the research, vasectomy is least utilized among black and Latino populations, groups of which have highest rates of female sterilization.^[57]

New Zealand, in contrast to the US, has higher levels of vasectomy than tubal ligation uptake. 18% of all men, and 25% of all married men have had a vasectomy. The age cohort with the highest level of vasectomy was 40-49 where 57% of men had taken it up.^[58] Canada, the UK, Bhutan and the Netherlands all have similar levels of uptake.^[59]

Tourism

Medical tourism, where a patient travels to a less-developed location where a procedure is cheaper to save money and combine convalescence with a vacation, is infrequently used for vasectomy due to its low cost, but is more likely to be used for vasectomy reversal. Many overseas hospitals list vasectomy as one of their qualified surgical procedures. Medical tourism has come under the scrutiny of some governments for quality of care and post-operative care issues.^[60]

History

The first recorded vasectomy was performed on a dog in 1823.^[61] A short time after that, R. Harrison of London performed the first human vasectomy; however the surgery was not done for sterilization purposes, but to bring about atrophy of the prostate. Vasectomy began to be regarded as a method of birth control during the Second World War. The first vasectomy program on a national scale was launched in 1954 in India.

Availability and legality

Vasectomy costs are (or may be) covered in different countries, as a method of both birth control or population control, with some offering it as a part of a national health insurance. Vasectomy was generally considered illegal in France until 2001, due to provisions in the Napoleonic Code forbidding "self-mutilation". No French law specifically mentioned vasectomy until a 2001 law on contraception and abortion permitted the procedure.^[62]

Sharia (Islamic law) traditionally does not permit permanent sterilization.^{[citation needed]} However, on July 2, 2012, the Indonesian Ulema Council agreed to permit vasectomies in Indonesia subject to certain requirements, including:^[63]

• The vasectomy is not intended to be permanent;
• The man is at least 50 years old;
• The man's wife granted permission;
• The procedure is not being carried out for "immoral purposes."

See also

• Male contraceptive
• Sperm granuloma
• Testicular sperm extraction
• Orchiectomy

References

External links

• Vasectomy : Procedure
• MedlinePlus Encyclopedia
• Vasectomy:Technique