Who gets a vasectomy?
The following abstract
of an article entitled “The American man who chooses vasectomy: a profile”
appeared in AVSC News. 1988;26(1):3 (no authors were listed):
“Who is the typical
American man choosing vasectomy?
The evidence from
studies is clear.
He is most likely to be
He lives in the West.
He is better educated
and has a higher income than the average.
He is in his mid- to
late thirties and has at least 1 son.
He has been actively involved in birth control
and strongly dislikes other contraceptive methods.
Vasectomy, to him, is a
matter of convenience.
He is more strongly
motivated than his wife to end childbearing and is protective of his wife’s
He is secure, with lower
than average need for social approval.
How does he arrive at a
American men take a long
time to make a decision about vasectomy. The process may last anywhere from 2
to 10 years. Stephen Mumford has outlined a 7-step decision making process.
- A man: becomes aware of
- talks to a vasectomized
- decides to have no more
- seriously considers
- decides temporary
methods are no longer acceptable,
- decides vasectomy is the
best method, has a pregnancy “scare”
- He then calls Dr. Kelly for the procedure...
Association (AUA) Guideline
Ira D. Sharlip,
Arnold M. Belker, Stanton Honig, Michel Labrecque, Joel L. Marmar,
Lawrence S. Ross,
Jay I. Sandlow, David C. Sokal
by the AUA
Board of Directors May 2012
disclosure of potential conflicts of interest and author/staff
contributions appear at the end of the article.
2012 by the American Urological Association
The Panel would like to
acknowledge Susan L. Norris M.D., M.P.H., M.S. and her team for their
methodological contributions and to also thank Martha Faraday, Ph.D. for her additional
methodological input and
her invaluable contributions to the drafting of the final report.
Purpose: The purpose of this Guideline is to
provide guidance to clinicians who offer vasectomy services. This guidance
covers pre-operative evaluation and consultation of prospective vasectomy
patients; techniques for local anesthesia, isolation of the vas deferens and
occlusion of the vas deferens during vasectomy; post-operative follow-up;
post-vasectomy semen analysis (PVSA) and potential complications and
consequences of vasectomy.
A systematic review of the literature using the MEDLINE and POPLINE
databases (search dates January 1949 to August 2011) was conducted to identify
peer -reviewed publications relevant to vasectomy. The search identified almost 2,000 titles and
abstracts. Almost 900 articles were retrieved for full-text review. These yielded an evidence base of 275 articles after application of inclusion and
exclusion criteria. These publications
were used to create the evidence-based portion of the Guideline. When sufficient evidence existed, the body of
evidence for a particular treatment was assigned a strength rating of A (high),
B (moderate) or C (low). Additional
information is provided as Clinical Principles and Expert Opinion when
insufficient evidence existed.
A preoperative interactive consultation should be
conducted, preferably in person. If an in-person consultation is not possible,
then preoperative consultation by telephone or electronic communication is an
acceptable alternative. Expert Opinion
The minimum and necessary concepts that should be
discussed in a preoperative vasectomy consultation include the following: Expert
is intended to be a permanent form of contraception.
does not produce immediate sterility.
vasectomy, another form of contraception is required until vas occlusion is
confirmed by post- vasectomy semen analysis (PVSA).
after vas occlusion is confirmed, vasectomy is not 100% reliable in preventing
risk of pregnancy after vasectomy is approximately 1 in 2,000 for men who have
post-vasectomy azoospermia or PVSA showing rare non-motile sperm (RNMS).
vasectomy is necessary in ≤1% of vasectomies, provided that a technique for vas
occlusion known to have a low occlusive failure rate has been used.
should refrain from ejaculation for approximately one week after
for fertility after vasectomy include vasectomy reversal and sperm retrieval
with in vitro fertilization. These options are not always successful, and
they may be expensive.
rates of surgical complications such as symptomatic hematoma and infection are
1-2%. These rates vary with the
surgeon’s experience and the criteria used to diagnose these conditions.
scrotal pain associated with negative impact on quality of life occurs after
vasectomy in about 1-2% of men. Few of these men require additional
permanent and non-permanent alternatives to vasectomy are available.
Clinicians do not need to routinely discuss
prostate cancer, coronary heart disease, stroke, hypertension, dementia or
testicular cancer in pre-vasectomy counseling of patients because vasectomy is
not a risk factor for these conditions. Standard (Evidence Strength Grade B)
Prophylactic antimicrobials are not indicated for
routine vasectomy unless the patient presents a high risk of infection. Recommendation (Evidence Strength Grade C)
Vasectomy should be performed with local anesthesia
with or without oral sedation. If the patient declines local anesthesia or if
the surgeon believes that local anesthesia with or without oral sedation will
not be adequate for a particular patient, then vasectomy may be performed with
intravenous sedation or general anesthesia.
Isolation of the vas should be performed using a
minimally-invasive vasectomy (MIV) technique such as the noscalpel vasectomy
(NSV) technique or other MIV technique.
Standard (Evidence Strength Grade B)
The ends of the vas should be occluded by one of
three divisional methods:
cautery (MC) with fascial interposition (FI) and without ligatures or clips
without FI and without ligatures or clips applied on the vas;
ended vasectomy leaving the testicular end of the vas unoccluded, using MC on
the abdominal end and FI;
OR by the
non-divisional method of extended electrocautery. Recommendation
(Evidence Strength Grade C)
The divided vas may be occluded by ligatures or
clips applied to the ends of the vas, with or without FI and with or without
excision of a short segment of the vas, by surgeons whose personal training
and/or experience enable them to consistently obtain satisfactory results with
such methods. Option (Evidence Strength Grade
Routine histologic examination of the excised vas
segments is not required. Expert Opinion
Men or their partners should use other
contraceptive methods until vasectomy success is confirmed by PVSA. Clinical
To evaluate sperm motility, a fresh, uncentrifuged
semen sample should be examined within two hours after ejaculation. Expert Opinion
Patients may stop using other methods of
contraception when examination of one well-mixed, uncentrifuged, fresh post-vasectomy
semen specimen shows azoospermia or only rare non-motile sperm (RNMS or ≤
100,000 non-motile sperm/mL). Recommendation
(Evidence Strength Grade C)
Eight to sixteen weeks after vasectomy is the
appropriate time range for the first PVSA. The choice of time to do the first
PVSA should be left to the judgment of the surgeon. Option (Evidence Strength Grade C)
Vasectomy should be considered a failure if any
motile sperm are seen on PVSA at six months after vasectomy, in which case
repeat vasectomy should be considered. Expert
If > 100,000 non-motile sperm/mL persist beyond
six months after vasectomy, then trends of serial PVSAs and clinical judgment
should be used to decide whether the vasectomy is a failure and whether repeat
vasectomy should be considered. Expert
European vasectomy guidelines
While vasectomy is a highly effective procedure, challenges may arise concerning preoperative information provided to patients, the procedure itself, and in postoperative follow-up. Requests for reversal, a procedure that may be associated with reduced semen quality, may be more common among younger men and those who are childless at the time of the procedure. The European Association of Urology issued guidelines for vasectomy in January 2012. This update will provide highlights of these guidelines. However,clinicians should review the full guidelines available through this link before implementing recommendations in patient care(http://www.europeanurology.com/article/S0302-2838(11)01101-8/fulltext). The level of evidence for each of the recommendations varies.
The authors of the guidelines used a search of Medline and EMBASE covering the years 1980 to 2010. Their search focused on indications for the procedure, information provided preoperatively, vasectomy techniques and associated complications and failure rates, as well as postoperative follow-up. The Cochrane database was also searched. The authors attempted to focus on high-quality clinic trials and identified 113 candidate publications for review. Non-English language publications, abstracts, and reports from meetings were excluded.
Indications for vasectomy:
The decision by the patient to proceed with the procedure must be made in a considered fashion and not under stressful conditions
There are no absolute contraindications to vasectomy
Relative contraindications include:
Lack of current relationship
Preoperative information for patients:
Patients should be informed of the following prior to vasectomy:
It should be considered irreversible
It carries a low complication rate and a low, but not zero, failure rate (e.g. chance of early/late recanalization)
Contraceptive measures must continue until sterility is confirmed through postoperative semen analysis
Based on data, the procedure is safe
Alternatives to surgery, as well as complications of the procedure
Note: Many patients are not aware of the risk of failure. Patients should be counseled concerning failure risk. All counseling should be strictly documented.
Regardless of technique, vasectomy:
Can usually be performed on an outpatient basis with local anesthesia
Both deferential ducts are exposed
The no-scalpel technique of isolation carries fewer early complications
Discontinuity of the deferential ducts can be achieved through:
Excision of a piece of the vas deferens, with suture or clip ligation
Prevention of recanalization through interposition of tissue
Cautery performed on the luminal side
The authors note that no technique has been shown to be definitely superiority in achieving sterility.
Operative technique should be clearly documented.
The vas does not require routine pathologic examination.
Patients usually are asked to refrain from exertion for a given period, the length of which is at the discretion of the physician. Eighty percent of patients are usually back to normal activity within 1 week.
Postoperative semen analysis is usually performed 3 months following vasectomy and after 20 ejaculations. Eighty percent of men will have no spermatozoa by this time point.
Men without spermatozoa can be cleared for sexual activity without additional contraception
Men with low numbers of nonmotile spermatozoa can be given clearance if nonmotile spermatozoa occur at <100,000/mL.
In men with motile spermatozoa or >100,000 spermatozoa/mL of semen, reexamination should be performed at 6-week intervals until no spermatozoa are found or count is <100,000 nonmotile spermatozoa/mL.
Men with persistent motile spermatozoa at 6 months of follow-up should have a repeat procedure.