Vasectomy is an elective surgical sterilisation procedure that involves division and occlusion of both vas deferens to prevent the passage of sperm from the testes to the penis in order to achieve what is usually permanent contraception. While permanence should always be the intent, vasectomy can be reversed in most men who wish to restore their fertility due to a change of mind or marital circumstance.
In Australia vasectomies are performed in a range of settings including general practices, family planning centres, hospital outpatient clinics, day surgeries and general hospitals. Vasovasostomy (vas deferens to vas deferens) and vasoepididymostomy (vas deferens to epididymis) for vasectomy reversal require advanced microsurgical methods and as such are usually performed as in-patient procedures on a day surgical basis.
Vasectomy is the sole acceptable highly effective method of male contraception. Australia is one of less than 10 nations in which vasectomy is more common than fallopian tube occlusion for female sterilisation. It is currently six times more popular than female tubal occlusion as a method of contraception. This ratio has changed remarkably over the last 30 years, as tubal occlusion was a more frequent than vasectomy in 1980. Compared to tubal occlusion methods (ligation, clips, rings, resection) vasectomy is as effective in preventing pregnancy however, vasectomy is simpler, faster, safer and less expensive.
Between 15,000 and 16,000 vasectomies are performed annually in Australia. Less than 1% of these are for men aged less than 25 years of age and 90% were for men aged 30–49. There has been a consistent increasing trend of the age of men undergoing the procedure. The Australian Institute of Health and Welfare report that one-quarter of men aged 40 and over have undergone a vasectomy. Over the last decade the incidence of vasectomy has decreased by approximately one third (about 24,000 vasectomies were undertaken in 2004-05). The steady increase in the use of progestin laden intrauterine devices and subcutaneous implants for female contraception, which can have the combined benefit of a reduction of menstrual symptoms as well as contraceptive efficacy that compares to both vasectomy and fallopian tube occlusion is most likely responsible for the reduction in the frequency of vasectomy.
Men who undergo vasectomy are typically well educated, married with higher incomes and more likely to have a tertiary education. Approximately 70% of such men are defined as being of middle to high socioeconomic status. They tend to have greater contact with the medical system and are more likely to undergo regular medical check-ups by comparison to those who do not have vasectomy.
Vasectomy is one of the most effective methods of birth control. It is about 33 times more effective than oral contraception and about 90 times more effective than condoms. Pregnancy occurs in approximately 15 out of 10,000 couples after vasectomy. By comparison, pregnancy occurs in 1,400 of every 10,000 couples each year using condoms, and 500 of every 10,000 each year using oral contraceptive pills. Almost all pregnancies that do occur following vasectomy do so within the first year after the procedure.
Reasons for vasectomy
Vasectomy is perceived as the most secure any of avoiding pregnancy and couples that elect it for permanent contraception view it as safer and simpler than tubal occlusion. It has the obvious advantages of being user non-dependent and is a way for men to take their turn to take responsibility for and share the contraceptive burden. Sociological reasons given include a desire to better care for their current family, maintain financial responsibility and social support.
As with any surgical procedure, vasectomy requires a doctor-patient discussion about the risks, benefits and alternatives. A general medical history with questioning on bleeding diathesis and other possible contraindications to surgery should be obtained. Despite the fact that the majority of vasectomies can be technically reversed emphasis should be placed on consideration of vasectomy as being a ‘permanent’ method of contraception. In order to minimise the prospect of regret a thoughtful exploration of the patients motive and understanding is wise.
A physical exam of the genitalia should be performed prior to vasectomy; this may be undertaken immediately before the operative procedure. Abnormality of the testis or epididymis should be noted. Unilateral congenital absence of the vas occurs in approximately 1 in 400; as this condition is associated with the presence of cystic fibrosis gene mutations arrangements should be made to undertake a full family history and mutation testing not only of the patient but his relatives. Apart from this exception and for those with a positive history for significant medical conditions no specific preoperative investigations are necessary.
Surgical methods of vasectomy
Vasectomy can be performed in almost all patients with local anaesthesia alone using a fine bore needle for infiltration (25–32 gauge). Rarely pre-operative examination may indicate that isolation of the vas is particularly difficult or painful and in some circumstances due to patient or surgeon preference then vasectomy may be performed with oral or intravenous sedation or general anaesthesia.
The two key surgical steps in performing vasectomy are:
- isolation of the vas
- occlusion of the vas
The risks of intraoperative and early postoperative pain, bleeding and infection are related mainly to the method of vas isolation. Prophylactic antibiotics are not indicated unless multiple comorbidities indicate a high risk of infection. The failure rates of vasectomy are related to the method of vas occlusion.
There are two main surgical techniques for isolating the vas deferens. The available evidence indicates that minimally invasive vas isolation procedure results in less discomfort during the procedure and in fewer postoperative complications.
One mid-line or bilateral scrotal incisions are made with a scalpel. Incisions are usually 1.5-3.0 cm long. No special instruments are used. The vas usually is grasped with a towel clip or an Allis forceps. The area of dissection around the vas usually is larger than occurs with no-scalpel or minimally techniques.
Several different methods of vassal occlusion can be used including cautery with or without fascial interposition; ligatures and clips. As there is no significant difference in failure rates between them the method of occlusion should be one of personal preference. Opened ended vasectomy – where the testicular end of the vas is not occluded is associated with less post-operative pain but higher failure rates. Excision of a segment of vas deferens for histological examination is superfluous and not recommended.
Minimally invasive Vasectomy
This method that uses specific instruments such as the vas ring clamp and vas dissector to isolate the vas and then pull it through a small scrotal hole. The incision is usually less than 1cm. The ends are either cauterised or tied off and then put back in place. The area of dissection around the vas is kept to a minimum.
A common variant of this technique is known as the ‘no-scalpel vasectomy’. With this method a vas ring clamp is applied around the vas, peri-vasal tissue and overlying skin before making the skin opening. Then the skin is pierced to create an opening of ≤10 mm. The tissue overlying the vas is then spread with the vas dissector to expose the bare anterior wall of the vas, which is then pierced with one tip of the vas dissector. A supination manoeuvre is then used to elevate the vas above the skin opening. a partial thickness of the vas is then re-grasped and the posterior dissection is completed with the vas dissector to isolate the vas from surrounding peri-vasal tissue and vessels. The vas divided with or without excision of a vas segment, and then occlusion of the vas is performed in a manner and with a preference similar to conventional vasectomy. Usually the skin opening can be left un-sutured.
Post-vasectomy semen analysis
Vasectomy is not immediately effective. Another method of contraception should be used until the remaining sperm are cleared out of the semen. This takes 15 to 20 ejaculations. Even then, some men will still have sperm in the semen and will need to have further semen analyses. A semen analysis to assess the success of vasectomy should be undertaken 3 months post vasectomy. Patients may cease using other methods of contraception when azoospermia has been achieved. Vasectomy failure occurs in less than 1% of vasectomies and is determined by the presence of any motile sperm six months after vasectomy. The recanalization rate following initial documentation of azoospermia is 0.51% for vasal ligation and 0.28% where diathermy is used to ablate the vasal lumen. Where azoospermia is not achieved or if recanalization occurs, repeat vasectomy should be offered.
Risks and complications
Vasectomy is generally uncomplicated. The discomfort that occurs after surgery usually settles promptly and there are no sequelae. While the common complications are potentially serious, conservative management mostly leads to spontaneous resolution. Haematoma, infection, sperm granulomas, vasectomy failure, chronic pain and "regret" are all documented. Haematoma and infection occur following 1-2% of procedures. Sperm granuloma is rarely symptomatic. Chronic scrotal pain sufficient to disrupt quality of life also occurs in 1-2% of men that may require vasovasostomy or epididymectomy, and in rare instance orchidectomy. There is one report of death after vasectomy due to Fournier’s gangrene, a necrotising mixed aerobic and anaerobic bacterial infection of the perineum.
After a vasectomy, most men go home the same day and in the absence of complications resume all normal activities within a week. Sexual activity can resume after one week or beyond that when comfortable to do so.
Between 50% and 70% of men develop circulating anti-sperm antibodies following vasectomy. The precise cause of the development of sperm antibodies is uncertain. The so-called ‘testis-blood barrier’ usually minimises exposure of sperm. Leakage of sperm at the time of vasectomy is likely to contribute to the development of sperm antibodies. Some investigators have suggested that such antibodies may decrease the chance for successful pregnancy after vasectomy reversal. Studies into pregnancy rates following vasectomy reversal demonstrate mean postoperative conception rate of between 60% and 85% for patients of less than 15 years from their vasectomy undergoing microsurgical vasovasostomy. As the presence of circulating anti-sperm antibodies correlates poorly with postoperative fecundability the value of preoperative anti-sperm antibody testing prior to vasectomy is unproven and unnecessary.
Testicular changes after vasectomy
Pathologic changes in testicular histology commonly occur following vasectomy. Electron microscopy revealed that interstitial fibrosis was present in the testis of 23% of men following vasectomy and that some evidence of adverse impact on spermatogenic cells within the seminiferous tubules is almost universal. These testicular changes are not associated with antisperm antibody status. The fertility in men who undergo successful vasectomy reversal (as defined by both sperm in the ejaculate and conception) is strongly inversely correlated with pathological changes in the testes post-vasectomy.
Vasectomy has been the subject of a considerable amount of litigation. Limitations in patient understanding of the possibility of pregnancy due to vasectomy failure or vasal recanalization and post chronic post vasectomy pain of sufficient severity to affect quality of life are the most common contributors to medico-legal cases. Injury to or loss of a testis, while a rare occurrence, is highly likely to lead to legal action. While there various techniques of vasectomy may result in minor variations in the frequency of complications, when both vas are divided, technical negligence is seldom a cause for litigation.
Preoperative patient counselling, careful documentation in the informed consent and follow-up support when requested are crucial to show that the patient was carefully informed about the nature and intent of the procedure and well aware of the possible risks and complications of vasectomy.
Other relevant issues
Rates of dissatisfaction with vasectomy and/or regret at having undergone the procedure are in the range of 1-2% across a large number of studies, settings, and techniques. Men who have vasectomy before age 30 are the group proportionately most likely to want to suffer regret and request vasectomy reversal in the future.
Sexual function after vasectomy
While many men are concerned that vasectomy may affect sexual function there is little evidence that this occurs. Just as many men (5%) report an increase in sexual satisfaction after vasectomy as report a decrease. Patients may be assured that there is currently no good evidence of any negative effect on sexual function. Vasectomy does not change the risk for sexually transmitted diseases.
Prostate cancer following vasectomy
While initial epidemiologic studies suggested an association between vasectomy and prostate cancer more recent studies demonstrate that vasectomy and prostate cancer are reassuring. The primary reason for this discrepancy is a strong population bias. Men of similar socioeconomic backgrounds are coincidentally more likely to undergo vasectomy and also develop prostate cancer. As prostatic cancer is usually asymptomatic and slowly progressing, it is not generally detected in men that do not undergo regular screening. Men who have undergone vasectomy are more likely to have consulted with a urologist or a general practitioner with an interest in male health both at the time of vasectomy and into the future thus increasing the likelihood of undergoing screening for prostate cancer as they age. Vasectomized men are however, more likely to be diagnosed with earlier stage, lower grade prostate tumours, consistent with more regular screening for the disease.
Vasectomy is intended to be a permanent form of contraception. As vasectomy does not produce immediate sterility another form of contraception is necessary until the absence of sperm is confirmed by post-vasectomy semen analysis.
The risk of pregnancy after vasectomy is approximately 1 in 2,000 for men who have post-vasectomy azoospermia (absence of sperm). Patients should refrain from ejaculation for approximately one week after vasectomy. Complications are uncommon with events such as symptomatic haematoma and infection occur follow 1-2% of vasectomies.
Repeat vasectomy is necessary in ≤1% of men. Post vasectomy pain syndrome occurs after vasectomy in about 1- 2% of men and may require additional surgery.