Vasectomy

Vasectomy is a surgical procedure wherein the vasa deferentia of a man are severed, and then tied/sealed in a manner that prevents sperm from entering the seminal stream (ejaculate). Vasectomy is different from castration, which is actual removal of the testicles.

Procedure

Diagram showing the site of the vasectomy.

Usually done in an outpatient setting, a vasectomy involves application of local anesthetic to the scrotum after which one or two small incisions are made exposing the vasa deferentia. The vasa deferentia are cut and sealed by ligating, stitching, cauterizing, or clamping to prevent sperm from entering the seminal stream.

Variations

There are variations of the procedure currently in practice, most of which have been employed to reduce healing times, lower chance of infection, and decrease the chance of post-vasectomy pain. The goal (outcome) is always the same, hence sealing off or obstruction of sperm.

The methods used to make the scrotal incision (or puncture) are interchangeable with the methods used for sealing off the flow of sperm in the vas deferens.

With conventional vasectomy, the surgeon uses a scalpel to make a small incision on each side of the scrotum, allowing access to each vas deferens. The vas deferens is severed, and usually a small piece removed. It is then is tied-off and/or cauterized to make the seal. The surgeon (and/or patient) may elect to forgo some of the "traditional" methods in favor of newer variations as described below.

1. A no-scalpel vasectomy (termed key-hole),^[2] in which a sharp hemostat, rather than a scalpel, is used to puncture the scrotum. It may reduce healing times as well as lower the chance of infection from incision. Usually, there are no stitches needed.
2. An "open-ended" vasectomy obstructs or seals only one end only of the vas deferens, which allows continued streaming of sperm (by virtue of the un-sealed vas-deferens) into the scrotum. This method may avoid build-up of pressure in the epididymis. Testicular pain (from "backup pressure") may also be reduced using this method.^[3]
3. A "Vas-Clip" vasectomy does not require cutting the vas deferens, but rather uses a clip to squeeze shut the flow of sperm. This method may facilitate a better chance or outlook for reversal, as well as reduced pain (post-procedure). That said, statistics suggest a much lower overall success rate compared to traditional methods.

In recent years, fascial interposition has been added to the procedure to decrease failure rates. There is a fibrous layer surrounding the vas deferens that is pulled away from and sewed around it which helps prevent failure due to "recanalization".

Side effects

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. Some studies find that sexual desire is unaffected in over 90% of vasectomized men,^[4] whereas other studies find higher rates of diminished sexual desire, for example nearly 20%.^[5] The sperm-filled fluid from the testes contributes about 10% to the volume of an ejaculation (in men who are not vasectomized) and does not significantly affect the appearance, taste, texture, or smell of the ejaculate.^[6]

When the vasectomy is complete, sperm cannot exit the body through the penis. Sperm is 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 once it leaves the testicles. Approximately 50% of the sperm produced never make it to the orgasmic stage in a non-vasectomized man. After vasectomy, the membranes 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 of the solid content. Within one year after a vasectomy, sixty to seventy percent of vasectomized men develop antisperm antibodies. In some cases, vasitis nodosa, a benign proliferation of the ductular epithelium, can also result.^[7][8] The buildup of sperm increases pressure in the vas deferens and epididymis. To prevent damage to the testes, these structures eventually rupture in more than half the cases. 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.^[9]

Effectiveness

The Royal College of Obstetricians and Gynaecologists state 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. 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 but is very rare.^[10]

Most physicians and surgeons who perform vasectomies recommend one (sometimes two) post-procedural semen specimens to verify a successful vasectomy. Sexual intercourse can be resumed as soon as it is comfortable, usually in about a week. However, pregnancy is still possible as long as the sperm count is above zero. Another method of birth control must be used until a follow-up sperm count test two months after the vasectomy (or after 10 to 20 ejaculations over a shorter period of time). Once the sperm count is zero, no other birth control method is necessary.

Advantages

Vasectomy essentially ensures that the patient will be sterile after surgery. Men who consider vasectomy should consider the fact that the procedure is regarded by the medical profession as permanent. Men with vasectomies will no longer cause a woman to become pregnant, but they will still have exactly the same risk of contracting and spreading sexually transmitted diseases. While the contraceptive effect may be seen as desirable for the man and his partner, current and future, care and forethought should influence the decision to have a vasectomy. If the man is married, his wife may be required to sign a legal agreement before he can have the surgery performed.

Complications

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

Short-term complications include temporary bruising and bleeding, known as hematoma. The stitches on 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 complication is a permanent pain condition—post-vasectomy pain syndrome.

Animal and human data indicate that vasectomy does not increase atherosclerosis and that increases in circulating immune complexes after vasectomy are transient. Furthermore, the weight of the evidence regarding prostate and testicular cancer suggests that men with vasectomy are not at increased risk of these cancers.^[11]

Post-vasectomy pain syndrome

Post-vasectomy pain syndrome (PVPS) is a long-term complication of vasectomy, a chronic scrotal pain of varying intensity lasting more than three months, possibly indefinitely. One survey cites studies that place incidence at one case per 10-30 vasectomies.^[12] The pain can be orchialgia, pain with intercourse, ejaculation, or physical exertion, or tender epididymides.^[9] In one study, vasectomy reversal was found to be effective for 9 out of 13 patients in reducing the symptoms of chronic post-vasectomy pain.^[13] Another study found that nerve stripping provided complete relief in 13 of 17 cases, and that the other four patients improved enough that they were satisfied with the results.^[14]

Reversal

Although men considering vasectomies should not think of them as reversible, and most men and their spouses are satisfied with the operation,^[15][16][17] there is a procedure to reverse vasectomies using vasovasostomy (a form of microsurgery first performed by Earl Owen in 1971^[18][19]). Vasovasostomy is effective at achieving pregnancy in only 50%-70% of cases, and it is costly, with total out-of-pocket costs in the United States of approximately $7,000.^[20] The rate of pregnancy depends on such factors as the method used for the vasectomy and the length of time that has passed since the vasectomy was performed. The reversal procedures are frequently impermanent, with occlusion of the vas recurring two or more years after the operation.

Since the body often produces antibodies against sperm, sperm counts are rarely at 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.^[21][22] 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.^[23]

In order to allow a possibility of reproduction (via artificial insemination) after vasectomy, some men opt for cryostorage of sperm before sterilization.^[24]

History

The first recorded vasectomy was performed on a dog in 1823^[25]. A short time after that, R. Harrison of London performed the 1st human vasectomy, however the procedure was not done for sterilization purposes, but to bring about atrophy of the prostate. Vasectomy was finally regarded as a method of birth control at some time during the Second World War. The 1st vasectomy program on a national scale was launched in 1954 in India.

Availability

In the UK vasectomy is often available free of charge through the National Health Service upon referral by one's GP. However, some PCTs do not fund the procedure. There are private clinics (such as Marie Stopes International) who perform the operation with short waiting times.

Vasectomy is also covered in Australia, Canada and Mexico.

In Costa Rica, vasectomy is covered by the Caja Costarricense del Seguro Social (Costa Rica's national insurance).

In 2006 Argentina approved vasectomy in public health service.^[26]

See also

• Male contraceptive
• Vasectomy Reversal : How it Works

References