Vasectomy

Vasectomy is a surgical procedure for male sterilization or permanent contraception. During the procedure, the male vas deferens are cut and tied or sealed so as to prevent sperm from entering into the urethra and thereby prevent fertilization of a female through sexual intercourse. Vasectomies are usually performed in a physician's office, medical clinic, or, when performed on an animal, in a veterinary clinic—hospitalization is not normally required as the procedure is not complicated, the incisions are small, and the necessary equipment routine.

Vasectomy
Background
TypeSterilization
First use1899 (experiments from 1785)[1]
Failure rates (first year)
Perfect use0.10%[2]
Typical use0.15%[2]
"Vas-Clip" nearly 1%
Usage
Duration effectPermanent
ReversibilityPossible, but expensive.
User remindersTwo consecutive negative semen specimens required to verify no sperm.
Advantages and disadvantages
STI protectionNo
BenefitsNo need for general anesthesia. Lower cost and less invasive than tubal ligation for women.
RisksTemporary local inflammation of the testes, long-term genital pain.

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

Due to the simplicity of the surgery, a vasectomy usually takes less than thirty 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 little or no discomfort.

Because the procedure is considered a permanent method of contraception and is not easily reversed, men are usually counseled and advised to consider how the long-term outcome of a vasectomy might affect them both emotionally and physically. The procedure is not often encouraged for young single childless men as their chances for biological parenthood are thereby more or less permanently reduced to almost zero. It is seldom performed on dogs (castration, a different procedure, remains the preferred reproductive control option for canines) but is regularly performed on bulls.[3]

Medical uses

A vasectomy is done to prevent fertility in males. It ensures that in most cases the person will be sterile after confirmation of success following surgery. The procedure is regarded as permanent because vasectomy reversal is costly and often does not restore the male's sperm count or sperm motility to prevasectomy levels. Men with vasectomies have a very small (nearly zero) chance of successfully impregnating a woman, but a vasectomy has no effect on rates of 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 bloodstream. Some studies have found that sexual desire after vasectomy may be somewhat diminished.[4][5]

When the vasectomy is complete, sperm cannot exit the body through the penis. Sperm is still produced by the testicles but is 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 reabsorbed via the bloodstream. 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 reabsorb more solid content. Within one year after vasectomy, sixty to seventy percent of vasectomized men develop antisperm antibodies.[6] In some cases, vasitis nodosa, a benign proliferation of the ductular epithelium, can also result.[7][8] The accumulation of sperm increases pressure in the vas deferens and epididymis. The entry of the sperm into the scrotum can cause sperm granulomas to be formed by the body to contain and absorb the sperm which the body will treat as a foreign biological substance (much like a virus or bacterium).[9]

Efficacy
FrequencyRiskSource
1 in 1400Unwanted pregnancy (failure of vasectomy)[10]
1 in 11For comparison: unwanted pregnancy w/ typical use of pill[2]
1 in 6For comparison: unwanted pregnancy w/ typical use of condom[2]
1 in 40Infection after surgery[11]
1 in 7Pain at 7 months after vasectomy[12]
1 in 110Pain at 7 months affecting quality of life[12]

Vasectomy is the most effective permanent form of contraception available to men. In nearly every way that vasectomy can be compared to tubal ligation 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 postoperative complications. Early failure rates, i.e. pregnancy within a few months after vasectomy, typically result from unprotected sexual intercourse too soon after the procedure while some sperm continue to pass through the vasa deferentia. Most physicians and surgeons who perform vasectomies recommend one (sometimes two) postprocedural semen specimens to verify a successful vasectomy; however, many men fail to return for verification tests citing inconvenience, embarrassment, forgetfulness, or certainty of sterility.[13] In January 2008, the FDA cleared a home test called SpermCheck Vasectomy that allows patients to perform postvasectomy confirmation tests themselves;[14] however, compliance for postvasectomy semen analysis in general remains low.

Late failure, i.e. pregnancy following spontaneous recanalization of the vasa deferentia, has also been documented.[15] The Royal College of Obstetricians and Gynaecologists states there is a generally agreed-upon rate of late failure of about one in 2000 vasectomies— better than tubal ligations for which the failure rate is one in every 200 to 300 cases.[16] A 2005 review including both early and late failures described a total of 183 recanalizations from 43,642 vasectomies (0.4%), and sixty pregnancies after 92,184 vasectomies (0.07%).[10]

Complications

Short-term possible 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% postvasectomy.[11] The stitches on the small incisions required are prone to irritation, though 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 or lower-abdominal regions, collectively 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 affected by vasectomy.[17][18][19] According to one study long-term postvasectomy discomfort is experienced at a frequency which ranges between 15% and 33% of vasectomy patients.[20]

Postvasectomy pain
Main article: Post-vasectomy pain syndrome

Post-vasectomy pain syndrome (P.V.P.S.) is a chronic and sometimes debilitating condition that may develop immediately or several years after vasectomy.[21] The most robust study of post-vasectomy pain, according to the American Urology Association's Vasectomy Guidelines 2012 (amended 2015)[22] found a rate of 14.7% reported new-onset scrotal pain at 7 months after vasectomy with 0.9% describing the pain as "quite severe and noticeably affecting their quality of life".[12] The pain can be constant orchialgia or epididymal pain (epididymitis), or it can be pain that occurs only at particular times such as with sexual intercourse, ejaculation, or physical exertion.[9]

Psychological effects

Approximately 90% are generally reported in reviews as being satisfied with having had a vasectomy,[23] while 7–10% of men regret their decision.[24] For men in relationships, regret was less common when both people in the relationship agreed on the procedure.[25]

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);[26] prevasectomy counseling is therefore of particular importance in younger patients.

Dementia

An association between vasectomy and primary progressive aphasia, a rare variety of frontotemporal dementia, was reported.[25] However, it is doubtful that there is a causal relationship.[27] The putative mechanism is a cross-reactivity between brain and sperm, including the shared presence of neural surface antigens.[28] In addition, the cytoskeletal tau protein has been found only to exist outside of the CNS in the manchette of sperm.[28]

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 may be recommended) after which a scalpel is used to make two small incisions, one 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 section may be removed altogether), separated, and then at least one side is sealed by ligating (suturing), cauterizing (electrocauterization), or clamping.[29] There are several variations to this method that may improve healing, effectiveness, and which help mitigate long-term pain such as post-vasectomy pain syndrome (PVPS) or epididymitis, however the data supporting one over another are limited.[30]

  • Fascial interposition: Recanalization of the vas deferens is a known cause of vasectomy failure(s).[31] Fascial interposition ("FI"), in which a tissue barrier is placed between the cut ends of the vas by suturing, may help to prevent this type of failure, increasing the overall success rate of vasectomy while leaving the testicular end within the confines of the fascia.[32] The fascia is a fibrous protective sheath that surrounds the vas deferens as well as all other body muscle tissue. This method, when combined with intraluminal cautery (where one or both sides of the vas deferens are electrically "burned" closed to prevent recanalization), 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.[33] 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 show a very high satisfaction rate amongst vasectomy patients.[33] Once the effects of no-needle anesthesia set in, the vasectomy procedure is performed in the routine manner. However, unlike in conventional local anesthesia where needles and syringes are used on one patient only, the applicator is not single use and cannot be properly cleaned leading to concerns regarding infection control.
  • No-scalpel vasectomy (NSV): Also known as a "key-hole" vasectomy,[29] is a vasectomy in which a sharp hemostat (as opposed to a scalpel) is used to puncture the scrotum. 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 stitches. NSV is the most commonly performed type of minimally invasive vasectomy, and both describe the method of vasectomy that leads to access of the vas deferens.[34]
Open-ended Vasectomy
  • Open-ended vasectomy: In this procedure 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 resulting from increased back-pressure in the epididymis.[9] Studies suggest that this method may reduce long-term complications such as post-vasectomy pain syndrome.[35][36]
  • Vas irrigation: Injections of sterile water or euflavine (which kills sperm) are put into the distal portion of the vas at the time of surgery which then brings about a near-immediate sterile ("azoospermatic") condition. The use of euflavine does however, tend to 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 prominently in use, and few surgeons offer it as part of their vasectomy procedure.[30]

Other techniques

The following vasectomy methods have purportedly had a better chance of later reversal but have seen less use by virtue of known higher failure rates (i.e., recanalization). An earlier clip device, the VasClip, is no longer on the market, due to unacceptably high failure rates.[37][38][39]

The VasClip method, though considered reversible, has had a higher cost and resulted in lower success rates. Also, because the vasa deferentia are not cut or tied with this method, it could technically be classified as other than a vasectomy. Vasectomy reversal (and the success thereof) was conjectured to be higher as it only required removing the Vas-Clip device. This method achieved limited use, and scant reversal data are available.[39]

Vas occlusion techniques
  • Injected plugs: There are two types of injected plugs which can be used to block the vasa deferentia. Medical-grade polyurethane (M.P.U.) 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).[40]
  • Intra-vas device: The vasa deferentia can also be occluded by an intra-vas device (IVD). A small cut is made in the lower abdomen 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, similar to a traditional vasectomy. IVD reversal can be performed under the same conditions making it much less costly than vasovasostomy which can require general anesthesia and longer surgery time.[41]

Both vas occlusion techniques require the same basic patient setup: local anesthesia, puncturing of the scrotal sac for access of the vas, and then plug or injected plug occlusion. The success of the aforementioned vas occlusion techniques is not clear and data are still limited. Studies have shown, however, that the time to achieve sterility is longer than the more prominent techniques mentioned in the beginning of this article. The satisfaction rate of patients undergoing IVD techniques has a high rate of satisfaction with regard to the surgery experience itself.[42]

Recovery
Incision stitches and a shaved scrotum
14 days after vasectomy surgery

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 contraception must be relied upon until a sperm count is performed either two months after the vasectomy or after ten to twenty ejaculations have occurred.[43]

After a vasectomy, contraceptive precautions must be continued until azoospermia is confirmed. Usually two semen analyses at three and four months are necessary to confirm azoospermia. The British Andrological Society has recommended that a single semen analysis confirming azoospermia after sixteen weeks is sufficient.[44]

Conceiving after vasectomy

In order to allow the possibility of reproduction via artificial insemination after vasectomy, some men opt for cryopreservation 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 had known 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."[45]

The cost of cryo-preservation (sperm banking) may also be substantially less than alternative vaso-vasectomy procedures, compared to the costs of in-vitro fertilization (IVF) which usually run to $15,000.

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 intracytoplasmic sperm injection. This avoids the problem of antisperm antibodies and may result in a faster pregnancy. IVF may be less costly per cycle than reversal in some health-care 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.[46]

Vasectomy reversal
Main article: Vasectomy reversal

Although men considering vasectomies should not think of them as reversible, and most men and their partners are satisfied with the operation,[47][48] 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[49][50]). 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.[51] 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.[52] 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.[53][54] 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.[53]

Some reasons that men seek vasectomy reversals include wanting a family with a new partner following a relationship breakdown or divorce, their original partner dying and subsequently going on to repartner and to want children, the unexpected death of a child, or a long-standing couple changing their minds some time later, often prompted by situations such as improved finances or existing children approaching the age of school or leaving home.[45] Patients often comment that they never anticipated the possibility of a relationship breakdown or death, 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 postvasectomy pain syndrome.[55]

Prevalence

Internationally, vasectomy rates are vastly different.[56] While female sterilisation is the most widely used method worldwide, with 223 million women relying on it, only 28 million women rely on their partner's vasectomy.[57] In the world's 69 least developed countries less than 0.1% of men use vasectomies on average. Of 54 African countries, only ten report measurable vasectomy use and only Swaziland, Botswana, and South Africa exceed 0.1% prevalence.[56]

country vasectomy usage notes
Canada 22% "of all women rely on vasectomy"
UK 17% - 21% only range given
New Zealand 17% to 21% only range given
South Korea 17% to 21% only range given
Australia ~10%
Belgium ~10%
Denmark ~10%
Spain ~10%
Switzerland ~10%
Swaziland 0.3%
Botswana 0.4%
South Africa 0.7%

In North America and Europe vasectomy usage is on the order of 10% with some countries reaching 20%.[56] Despite its high efficacy, in the United States, vasectomy is utilized less than half the rate of the alternative female tubal ligation.[58] According to the research, vasectomy in the US is least utilized among black and Latino populations, the groups that have the highest rates of female sterilization.[58]

New Zealand, in contrast, has higher levels of vasectomy than tubal ligation. 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.[59] Canada, the UK, Bhutan and the Netherlands all have similar levels of uptake.[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 done not for sterilization purposes, but to bring about atrophy of the prostate.[62] Soon, however, it was believed to have benefits for eugenics. The first case report of vasectomy in the United States was in 1897, by A.J. Ochsner, a surgeon in Chicago, in a paper titled, "Surgical treatment of habitual criminals." He believed vasectomy to be a simple, effective means for stemming the tide of racial degeneration widely believed to be occurring.[63] In 1902, Harry C. Sharp, the surgeon at the Indiana Reformatory, reported that he had sterilized forty-two inmates in an effort to both reduce criminal behavior in those individuals and prevent the birth of future criminals.[64]

Not all vasectomies were performed with the goal of sterilization. Eugen Steinach (1861–1944), an Austrian physician, believed that a unilateral vasectomy (severing only one of the two vas deferentia) in older men could restore general vigor and sexual potency, shrink enlarged prostates, and cure various ailments by somehow boosting the hormonal output of the vasectomized testicle.[65] This surgery, which became very popular in the 1920s, was undertaken by many wealthy men, including Sigmund Freud and W. B. Yeats.[66] Since these operations lacked rigorous controlled trials, any rejuvenating effect was likely due to the placebo effect, and with the later development of synthetic injectable hormones, this operation fell out of vogue.[65][67]

Vasectomy began to be regarded as a method of consensual birth control during the Second World War.[68] The first vasectomy program on a national scale was launched in 1954 in India.[69]

Society and culture

Availability and legality

Vasectomy costs are (or may be) covered in different countries, as a method of both contraception or population control, with some offering it as a part of a national health insurance. The Affordable Care Act of the U.S. does not cover vasectomy. 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 infanticide permitted the procedure.[70] In 2014, the Iranian parliament voted for a bill that would ban vasectomies.[71]

Ideological issues

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.[72] 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".[73]

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,[74] 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 contraception, there is virtually nowhere in the world where true contraceptive equality exists.[75]

Critical health researchers emphasize the positive identities that men can take up post vasectomy, as a "man who takes on responsibility for the contraceptive task"[73] and a man who is willing to "sacrifice" his fertility for his partner and family's sake.[72] Often these sorts of accounts are constructed within the 'contraceptive economy' of a relationship, in which 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 an oral contraceptive or similar for years prior.[73]

Tourism
Main article: Medical 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 hospitals list vasectomy as being available. Medical tourism has been scrutinised by some governments for quality of care and postoperative care issues.[76]

Shooting of Dr. Andrew Rynne

In 1990, chairperson of the Irish Family Planning Association, and the Republic of Ireland's first vasectomy specialist,[77] Andrew Rynne, was shot by a former client. The incident is the subject of a short film The Vasectomy Doctor by Paul Webster.[78]

See also

References
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