Patient information: Vasectomy

INTRODUCTION

Vasectomy is a safe, effective, and permanent method of birth control for men. It is also the most cost-effective form of birth control, costing half as much as a tubal ligation (having a woman's "tubes tied"). In the United States, one out of five men over the age of 35 has had a vasectomy.

This topic reviews recommendations for men who are considering vasectomy, including the success and failure rates, as well as how the procedure is done. Topics discussing other methods of birth control are available separately. (See "Patient information: Permanent sterilization procedures for women" and "Patient information: Hormonal methods of birth control" and "Patient information: Long-term methods of birth control" and "Patient information: Barrier methods of birth control".)

VASECTOMY DEFINITION

Sperm are produced in the testicles and then move into the epididymis, which sits on the upper surface of each testicle. Sperm are stored in the epididymis, where they mature and become capable of fertilization (figure 1).

At the time of ejaculation, the seminal fluid and sperm move from the epididymis through the vas deferens and are then expelled from the penis. The vas deferens are long, thin tubes that start in the scrotum and run behind the bladder and then return forward to empty into the urethra inside of the prostate gland; the urethra is the tube inside the penis that carries urine and semen.

When a vasectomy is performed, the vas deferens are cut and sutured closed, preventing sperm from leaving the epididymis. This way, no sperm are expelled from the penis at the time of ejaculation. (See "Overview of vasectomy".)

WHO SHOULD CONSIDER A VASECTOMY?

Vasectomy is for men who want ALL of the following from their birth control method:

• Permanent, not meant to be reversed
• No preparation before or during sex
• A high success rate and low risk of complications
• No other children

Men who are not sure that vasectomy is right for them can consider a number of other contraceptive options. (See "Patient information: Birth control; which method is right for me?" and "Patient information: Permanent sterilization procedures for women".)

VASECTOMY SUCCESS RATES

Vasectomy is successful in more than 99 percent of men. A second method of birth control is necessary until testing is done to confirm that there are no sperm in the semen. A man needs to ejaculate at least 20 times after vasectomy to clear the ducts of sperm before the eight-week check.

The sperm count must be checked twice, usually at six and eight weeks after the procedure, to ensure that no sperm remain in the ejaculate. A sperm count requires that the man give a semen sample, usually obtained by masturbation. A man who continues to have sperm may require a second procedure.

If the eight week check shows no sperm, there is a 0.1 percent chance that a partner may become pregnant because of a partial failure of the procedure. This failure rate is as good as or better than most other currently available methods of birth control.

VASECTOMY PROCEDURE

Consultative visit — Men who are considering a vasectomy usually have a consult visit before the procedure. At this visit, the doctor will explain the procedure and answer any questions.

Men frequently have a great deal of anxiety about vasectomy. Much of the anxiety is related to a fear of pain or damage to the penis or scrotum. The consult visit is an excellent opportunity to discuss the procedure, risks, and potential complications. It is preferable for the man to bring his partner to this visit.

Although most men have thought about having a vasectomy for a long period of time before their first appointment, some states and insurance companies require a waiting period between the consult visit and the procedure.

The procedure — Most vasectomies are performed in a physician's office and take about 30 minutes. (See "Vasectomy and other vasal occlusion techniques for male contraception".)

• A local anesthetic is injected under the skin (not into the testicle) using a very small needle. Only the area around the vas deferens (vas or sperm duct) becomes numb. The injection of the local anesthetic will sting briefly.
• Once the area is numb, some men will still feel a pulling and/or cramping sensation during the procedure. The physician finds the vas deferens by feeling through the skin of the scrotum. A clamp is placed around the vas through the skin.
• To expose the vas, a small (less than one-half inch) incision is made with a scalpel. A no-scalpel technique is also available.
• A loop of vas is brought to the surface and a small segment is removed (about 3 or 4 millimeters). The two cut surfaces of the vas are then either cauterized (treated with heat), tied off, or clipped. When one side is complete, the other side is treated.

An alternative to cutting the vas is the placement of a small clip that prevents sperm from exiting the epididymis.

• The skin edges are then closed with stitches or surgical staples. There will be a small scar from the incision, but this will be barely visible once healed.
• An athletic supporter (jock strap) is used to hold a bandage in place and apply pressure to the scrotum.

After the procedure — The man may go home a few minutes after the vasectomy is completed but should have someone available to accompany him and assist with tasks (driving, heavy lifting, etc).

• The most important factor in a smooth recovery is rest. It is best to take it easy for two to three days after the procedure.
• Patients may be asked to limit their activities for about five days. Strenuous exercise or lifting should be avoided for a total of seven days.
• Patients should not bathe or swim for 24 to 48 hours after the procedure.
• Sexual intercourse can be resumed after three days, but a back-up method of birth control is necessary until testing is done to confirm that sperm are no longer present in the ejaculate (usually at six and eight weeks after the procedure).
• Men need to ejaculate approximately 20 times to clear the ducts of sperm before the six and eight-week sperm check.

PAIN CONTROL FOLLOWING VASECTOMY

After the vasectomy, there will be some cramping and discomfort at the incision site. This can be relieved with a pain medication such as acetaminophen (Tylenol®). Ibuprofen and aspirin should be avoided for at least one week because these medications may increase the risk of bleeding around the incision. For more severe pain, a stronger pain medication may be prescribed. Most men find that they do not need the stronger medication.

VASECTOMY COMPLICATIONS

Vasectomy is a relatively simple procedure to perform. Complications are unusual, although possible.

• Bleeding — Excessive bleeding occurs in less than 5 percent of men who undergo vasectomy. Most bleeding problems occur within the first 48 hours after the procedure. Bleeding within the scrotum can lead to a hematoma, an expanding mass of blood within the tissues around the vas. This can grow to a large size if not treated promptly.

Men can help to prevent bleeding by avoiding aspirin, ibuprofen, and other non-steroidal antiinflammatory medications for at least one week prior to surgery and by following the instructions regarding rest and limited activity after surgery.

• Infection — Infection occurs in up to 6 percent of men who undergo vasectomy. This typically involves an incision of the scrotal skin around the incision. Occasionally, the epididymis will become swollen after a vasectomy. This is usually treated with a short course of oral antibiotics.
• Sperm granuloma — A sperm granuloma occurs in 15 to 40 percent of men who undergo vasectomy. A sperm granuloma is a mass that develops as a result of the body's immune reaction to sperm leaking from the cut end of the vas. It is typically treated with an anti-inflammatory medication, such as ibuprofen. The mass is not dangerous. There are instances, however, in which a sperm granuloma causes significant scrotal discomfort. This may be treated by surgically removing the granuloma.
• Sperm congestion — Sperm congestion (a sensation of fullness) occurs in up to 6 percent of men after a vasectomy. This is due to stretching of the surface of the testicle (epididymis) from stored sperm cells. The full sensation will resolve after a few weeks and requires no treatment.
• Antibodies — Sperm antibodies develop in 40 percent of men after a vasectomy. These are formed when leaked sperm cells interact with the body's immune system. These antibodies cause no harm but can make sperm cells less effective if the vasectomy is reversed in the future.
• Chronic pain — Long-term testicular pain occurs in 0 to 6 percent of men after a vasectomy.

HEALTH EFFECTS OF VASECTOMY

Sex drive — Having a vasectomy will not affect testosterone (male hormone) levels, sex drive, or the ability to have an erection.

Risk of cancer — Although there have been some concerns regarding a link between vasectomy and prostate and testicular cancer, many large studies suggest that there is no increased risk of any cancer following vasectomy [1-4].

Heart disease — Similar to the situation with cancer, there have been some concerns about a link between vasectomy and heart disease; however, studies have found no such link.

CHILDREN AFTER VASECTOMY

A man should not have a vasectomy unless he is sure that he does not want children in the future. However, about 5 percent of men who have a vasectomy eventually decide that they would like to have it reversed.

Vasectomy reversal — Vasectomy reversal is called a vasovasostomy. This is a microsurgical technique that reconnects the vas deferens. The success rate of this procedure depends upon the condition of the vas. The more time that has elapsed since the vasectomy, the less likely a vasovasostomy is to be successful. If sperm antibodies have developed, these also may reduce fertility after vasovasostomy.

In the United States, vasectomy reversal is not covered by most insurance plans.

Three years or less after vasectomy, vasovasostomy is successful about 76 percent of the time, while after fifteen years or more it is successful about 30 percent of the time [5,6].

Sperm banking — Another option to achieve pregnancy is sperm banking prior to vasectomy or collection of sperm from the ducts at the time of vasectomy reversal surgery. Sperm banking involves storing a collected sample of sperm at a very low temperature with a preservative. The initial cost of storing sperm is about $500, with annual storage costs between $300 and $1000 per year.

BIRTH CONTROL AFTER VASECTOMY

If the eight-week check shows no evidence of residual sperm in the ejaculate, a second form of birth control (eg, condoms) is no longer needed to prevent pregnancy. However, vasectomy does not protect against sexually transmitted diseases (STDs) such as HIV. Men who have more than one sexual partner and men whose partner has other partners should consider using condoms to reduce the risk of STDs.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Permanent sterilization procedures for women
Patient information: Hormonal methods of birth control
Patient information: Long-term methods of birth control
Patient information: Barrier methods of birth control
Patient information: Birth control; which method is right for me?

Professional Level Information:
Overview of contraception
Overview of vasectomy
Vasectomy and other vasal occlusion techniques for male contraception

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• Planned Parenthood Federation of America

      (www.plannedparenthood.org)

• Managing Contraception

       (www.managingcontraception.com)

• Vasectomy Information

       (www.vasectomy-information.com)

[1-5]