Vasectomy

Vasectomy is a procedure in which the two tubes that carry sperm from the two testicles to the urinary tract are surgically altered so sperm cannot pass through and be released to fertilize a woman's egg during sexual intercourse. For couples who have made the decision not to have any more children, vasectomy is the safest and easiest form of surgical sterilization. While reversible in many cases, vasectomy should be considered a permanent form of birth control.

Vasectomy has grown in popularity throughout the world since its inception in the 19th century. Many men each year choose to undergo a vasectomy in the United States alone. Many vasectomies are performed by urologists (specialists in men's health), and 15% are performed by family practitioners. The cost ranges from $800 to $1,500 and is frequently covered by insurance plans. Some doctors that do the procedure also offer to store frozen sperm in case the person's situation changes and desires children sometime after the vasectomy and either does not want to undergo a vasectomy reversal operation or the reversal operation is unsuccessful.

Anatomy and technique

• A vasectomy involves the surgical interruption of both vas deferens, which are the tubes that carry the sperm from the testicles to the urinary tract. The surgeon reaches the vas deferens through a very small opening made in the front surface of the scrotum, after a local anesthetic makes the area numb. The vas deferens is then brought to skin level, where it is cut or cauterized (burned), then clipped off or tied before being dropped back into the scrotum. A section of the vas deferens may or may not be removed. The man must continue to use contraception (such as a condom) until an examination of his semen reveals that no sperm are present. The disappearance of sperm from the semen is not detectable by the patient. Only a specific laboratory and microscopic analysis of the semen can verify the total lack of sperm, which is the goal of the vasectomy surgery.
• The no-scalpel vasectomy -- a slightly less invasive procedure - was developed in China in the 1970s and was brought to the United States in the late 1980s. This modification uses special instruments, allowing vasectomies to be done faster and through an even smaller opening. Some studies have shown less pain and bleeding with this newer technique.

Terms to know

• Bladder: A muscular, elastic pouch that serves to store and expel urine
• Epididymis: Tightly coiled, very small tubes covering the back and sides of the testis, where sperm are stored and mature after leaving the testis before they are transported to the vas deferens
• Prostate gland: Located below the bladder, gland that contributes significantly to seminal secretions and is where the ejaculatory ducts, the vas deferens, and the urethra join
• Scrotum: The sac that contains the testicles, epididymis, and vas deferens
• Semen: The combination of sperm and glandular fluid released by the urethra when a man ejaculates; normally a mixture of less than 1% sperm and 99% seminal fluid
• Seminal vesicle: A sac at the end of the vas deferens that produces a component of seminal secretions, the fluid that is ejaculated by a man at sexual climax and that transports and nourishes the sperm
• Testes/testicles: Located in the scrotum, the male reproductive glands that produce sperm and male hormone (testosterone)
• Urethra: The passageway running from the bladder to the tip of the penis, which carries urine and semen outside the body
• Vas deferens: The two muscular tubes that carry sperm from the testicle and epididymis to the urinary tract and out the urethra; each referred to as a vas and together as vasa

• Risks with vasectomy are few. No death has ever been attributed to this procedure. On the other hand, tubal ligation, a frequently performed surgical sterilization procedure in women, is associated with no fewer than 20 deaths per year. These deaths occur because of the risks of the procedure itself, anesthesia complications, and increased ectopic pregnancy rates.
• Complications with vasectomy are usually related to bleeding or infection. Prolonged pain sometimes occurs as a result of inflammation along the vas due to sperm leakage (sperm granuloma) or congestion of sperm at the epididymis (epididymitis). These conditions usually go away with rest and anti-inflammatory medication.
• Some earlier studies suggested that vasectomy may be associated with an increased risk of heart disease and prostate cancer. According to the National Institutes of Health, research that examined this issue found no evidence that men with vasectomies were more likely than others to develop heart disease or any other immune illness. Other studies, including a recent study of 2,000 men, have shown that the risk of prostate cancer is not increased among vasectomized men.
• Fears about the procedure: Fear can prevent a man from choosing a vasectomy. The following issues are addressed to help a man understand that a vasectomy procedure is simple and safe:
  • Fear of pain - Men don't like to think of any procedure near their genitals. Fact: What men need to understand is that an anesthetic is used to numb the area. There is usually no pain or just some pulling after the anesthetic is given. The procedure is usually so well tolerated that upon completion of the procedure, men are frequently surprised that it is over.
  • Fear of loss of masculinity - Fact: A vasectomy does not affect manliness. A vasectomy does not affect the blood and hormone supply to the penis. The amount and appearance of semen ejaculated will not change noticeably. Of course, during the recovery process, men may be sore, thus making sex less desirable. Later, some men report that sex is actually more enjoyable without the threat of pregnancy. Women may appreciate that their partners have chosen to take the responsibility for sterility (permanent birth control).
  • Fear of failure of the procedure - Fact: Except for complete abstinence, no method is more effective than vasectomy in preventing pregnancy.
• Alternatives: Before choosing a vasectomy, a couple should seriously consider the many alternative methods of contraception (birth control). Table 1 shows that the effectiveness of each of the methods can vary greatly. For a more complete description, visit vasectomy.md.

In countries with a high rate of vasectomies, such as Canada and New Zealand, two-thirds of couples choose vasectomy over the alternative surgical contraception of female tubal ligation. In the United States, one-third of couples choose vasectomy, while two-thirds choose tubal ligation. Efforts are presently under way in the United States to inform couples that vasectomy is much safer and easier than tubal ligation.

• The person needs to wash thoroughly and put on clean, snug underwear or an athletic supporter (jock strap) before their appointment.
• The doctor may ask the person to shave the front portion of the scrotum the night before surgery.
• Do not take aspirin or other anti-inflammatory medication (such as Nuprin, Advil, Motrin) for 10 days before the procedure. Such medication can increase the risk of bleeding with vasectomy.
• Prepare any questions for the doctor. The person will be asked to sign a consent form that states they understand the risks involved with vasectomy and that sterility cannot be absolutely guaranteed.

The entire procedure usually takes about 10-20 minutes.

• The patient will be asked to change into a gown and lie on the examination table. The incision site will be washed, shaved, and sterilized, usually with an iodine solution. Sterile drapes will be placed over the patient to guard against infection.
• A local anesthetic is administered via a small needle. Some physicians avoid using a needle by utilizing a jet spray device to achieve the full local anesthesia (no-needle anesthesia).
• One or two small opening(s) are made in the scrotum. Either the right or left vas deferens is lifted through this opening. The vas is cut, and a section may be removed. A slight pulling sensation may be noticed during this process.
• The two ends of the vas are cauterized (heat sealed), tied, or clipped before being returned to the scrotum.
• The opposite vas deferens is then lifted through the opening for the same procedure.
• The remaining opening can heal with closure by stitches or naturally without stitches.

If sedation was not used, then the patient may drive himself home. Any discomfort is usually mild, and pain relievers should be used if needed. The local anesthetic begins to wear off after an hour or so. Recovery time after a no-scalpel vasectomy is usually a little less than that after a traditional vasectomy. The following are general guidelines that help ensure a speedy recovery (talk with the doctor who did the procedure for specific instructions):

• Apply an ice pack or package of frozen peas (or other such package) to the scrotum for the first 24 hours after the procedure. Wrap the ice pack in a towel. Do not place ice directly on the skin.
• Avoid walking or standing as much as possible for a couple of days.
• Wear snug cotton briefs or an athletic supporter to help apply pressure against the procedure area and for support of the scrotum for the first week or two after the procedure.
• Avoid heavy lifting or exercise for at least 2 to 3 days. Doctors commonly allow a return to work within 1 to 2 days unless the job involves physical exertion. In general, avoid activities that cause discomfort.
• Wait at least a week before resuming sexual activity; use birth-control methods until the doctor indicates the patient is sterile (see below).
• Semen will be collected (usually at home) approximately six to 12 weeks after surgery (and possibly even later) and examined under a microscope at the doctor's office or with a new home test kit called SpermCheck Vasectomy Home Test (Alere) to make certain that no sperm remain. It is important to use some form of birth control until the doctor specifically tells the patient that they are sterile (no sperm are present).

Contact the doctor if any of the following symptoms develops:

• Fever and chills
• A large black and blue area
• Increasing pain
• Drainage (sign of infection)
• A growing mass (sign of internal bleeding or infection)
• Excessive swelling of the scrotum (expect some swelling)
• Other concerns

While the best thing about a vasectomy is that it is permanent in almost every individual that gets the procedure, couples sometimes choose to reverse a vasectomy. This reversal procedure is not guaranteed to restore fertility and is usually not covered by insurance.

• Reasons for vasectomy reversal include the following:
  • A joint decision by the couple to have another child
  • Death of a child
  • Remarriage

The success of a reversal is measured in two separate ways: the ability to open the vas channel and the ability to deliver effective sperm. Delivering sperm, while the most important, is affected by the period of blockage upon the testicles. As an alternative to seeking a reversal later, some men freeze and store sperm at a sperm bank before their vasectomy in case they later choose to have a child.

A vasectomy is a choice only a man can make, preferably with the support of his partner. While it is safe and simple, the permanent nature of the procedure requires careful consideration. By choosing this nearly 100%-effective procedure, a man can control the size of the family without placing his partner at increased risk. For more information about vasectomies, contact your doctor.