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Managing the
vasectomy patient: From preoperative counseling through postoperative
follow-up
TABLE OF CONTENTS
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PREVALENCE
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MANAGEMENT
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VASECTOMY FAILURES
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POSTVASECTOMY SEMEN ANALYSIS
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CONCLUSION
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UROlogic
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REFERENCES
Vasectomy, a form of male sterilization utilizing bilateral disruption
of the vas deferens to halt the transmission of spermatozoa during ejaculation,
is an outpatient procedure that can be performed in the office setting
under local anesthesia, with most patients reporting only minimal postoperative
pain. Unlike many of the other methods of contraception, which require
continuous usage or repeat administrations, vasectomy needs to be performed
only once for a man to be rendered durably sterile.
Despite advances in other methods of family planning during the last
several decades, vasectomy has remained among the most popular forms of
contraception. The safety, simplicity, and durability of the procedure
make it an attractive option for patients and physicians alike. However,
many controversies remain regarding the appropriate management of patients
after the procedure. This article discusses the importance of preoperative
counseling and reviews vasectomy techniques and outcomes after sterilization.
1. PREVALENCE
Worldwide, it has been estimated that 5% of all married couples of reproductive
age—or approximately 42 to 60 million people—depend on vasectomy
as their sole contraceptive method.1,2 This number varies widely
between countries, with the highest rate of vasectomy (23% of men) reported
in New Zealand.3
Vasectomies are much more common in white men than in black men (14%
vs. 2%).4 In the United States, 11% of women of reproductive
age rely on vasectomy for family planning. Those most likely to elect
vasectomy as their contraceptive method of choice include women between
30 and 45 years of age, married women, and women with at least a high
school education.5
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2. MANAGEMENT
Vasectomy can be performed under local anesthesia with relative ease,
and the patient may return to his normal level of activity within several
days of the procedure.
Preoperative counseling.
Given the finality of vasectomy, thorough
preoperative counseling regarding the risks and benefits of the procedure
and alternatives to it is imperative. In addition, reasonable expectations
regarding postoperative recovery should be fostered. Patients should be
forewarned about the need for continued postoperative surveillance. After
counseling, the patient should be able to demonstrate a clear understanding
of the time delay between surgery and achievement of azoospermia and of
the need for postoperative semen analyses to confirm the absence of spermatozoa.
In addition, every patient should be able to demonstrate a clear understanding
of the potential complications that may result from the procedure. Specifically,
the risk of chronic inflammation and postvasectomy pain syndrome (PVPS)
should be discussed. Patients with PVPS present with intermittent or constant
pain in 1 or both testicles after vasectomy, lasting for 3 or more months.
PVPS is considered relatively uncommon following vasectomy, although
the incidence has been suggested to be as high as 19%.6 The exact mechanism
of the syndrome remains unknown, but theories involving epididymal congestion,
painful sperm granulomas, vascular stasis, and nerve impingement have
been put forth.
Most patients with PVPS can be managed conservatively with reassurance,
nonsteroidal anti-inflammatory drugs, scrotal support, or nerve blocks.
However, patients who do not respond to these measures may need secondary
surgical procedures such as vasectomy reversal, epididymectomy, or spermatic
cord denervation.6-9
In the past, some urologists counseled men under age 35 about a potentially
increased risk of prostate cancer later in life. Although several studies
published in the early 1990s reported an increased risk of prostate cancer
in men having undergone vasectomy,10-12 various large-scale
epidemiologic studies carried out under the auspices of the American Urological
Association (AUA) have since shown no proof of a relationship between
vasectomy and prostate cancer risk.13-15 Similarly, although
it was suggested in the early 1980s that vasectomy may be associated with
the development of atherosclerosis and cardiovascular disease, this notion
has long since been dispelled.16,17
Finally, while several realistic options for the re-establishment of vasal
continuity do exist, vasectomy is still considered a permanent form of male
sterilization. As such, every candidate must consider his individual circumstances,
both current and future, before deciding to proceed. Prior to undergoing
vasectomy, every patient should be made aware of the option of "fertility
insurance" by means of semen cryopreservation.
The goal of preoperative counseling should not be to dissuade or scare
the patient from undergoing vasectomy. Rather, the goal should be to provide
him with the knowledge necessary to make a fully informed decision. When
done appropriately, preoperative counseling can result in patients who
are more satisfied, more compliant, and less litigious than those who
receive inadequate or no counseling.
Surgical technique.
The vasectomy procedure is begun by palpation
of the vas deferens through the scrotal skin. The vas is then secured
with the surgeon's fingers and the scrotal skin is opened. Access to the
vas deferens may be obtained using either the conventional incisional
method or the no-scalpel method popularized by Li and colleagues in the
late 1980s.18 With the conventional method, a scalpel is used
to make an approximately 1-cm incision either in the midline (if a single
incision is used) or in each hemiscrotum (if 2 separate incisions are
used). With the no-scalpel technique, a specialized sharp forceps is used
to puncture the scrotal skin, thereby creating a hole through which the
vasectomy can be performed.
After the vas deferens is identified, it is brought out through the scrotal
incision and divided. A variable length of vas is resected, and the remaining
free ends are occluded. To accomplish vasal occlusion, the cut ends may
be secured with nonabsorbable suture, cautery, and/or metal clips. Many
urologists also interpose fascia between the cut ends to minimize the
risk of vasal recanalization. The crucial step for vasectomy success is
vasal occlusion; the exact method of occlusion is a matter of preference.
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3. VASECTOMY FAILURES
Vasectomy is the most reliable practical method of permanent contraception.
However, vasectomy failures have been reported. Most sources estimate
the occurrence of undesired pregnancy following vasectomy to be approximately
1 in 2,000 cases.19-21 This failure rate of less than 0.1%
compares favorably with the 1.85% failure rate associated with tubal ligation.22
Vasectomy failures are divided into 2 categories: early and late. Early
failures occur within the first few months following vasectomy and are
usually attributed to unprotected intercourse prior to obtaining a negative
semen analysis. A vas inadvertently missed during the procedure can also
cause early failure. This may occur if the surgeon excises 2 portions
from 1 vas (when using a single midline incision) or if the surgeon ligates
a structure other than the vas.
Late failures may occur years to decades after vasectomy and are most
often attributed to recanalization of the vas deferens. The majority of
vasectomy failures are early failures and occur in men who are ineffectively
counseled regarding the delay between vasectomy and achievement of azoospermia.
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4. POSTVASECTOMY SEMEN ANALYSIS
While most urologists agree on the need for a semen analysis to verify
the achievement of azoospermia after vasectomy, there is no consensus
on the exact timing for it. Most physicians use an arbitrarily determined
time period or an arbitrary number of ejaculations before obtaining a
semen analysis. In a survey of 1,800 physicians performing vasectomy in
the United States in 1995, Haws and associates found that postvasectomy
semen analysis was obtained at 6 weeks or less by 59% of the physicians,
at 7 to 9 weeks by 29%, and at 9 weeks or more by 12%.23
 Rate
of achievement of azoospermia. While most physicians obtain the postvasectomy
semen analysis within 6 weeks, a review of the available literature suggests
that this may be too soon to determine whether the procedure was a success.
Figure 1, incorporating data from 12 peer-reviewed studies,24-35
shows the rate of development of postvasectomy azoospermia plotted as a
function of time. Three months after vasectomy, only 72% of men have achieved
azoospermia. Six months after vasectomy, this number increases to 85%; and
by 1 year after vasectomy, 99% of men are azoospermic. This slow, constant
rate suggests that the number of ejaculations after vasectomy may have only
minor impact on the achievement of azoospermia.
Similarly, it has been shown that there is no association between the
method of vasal occlusion or length of vas excised and the length of time
required for a man to achieve azoospermia following a vasectomy.23,36-39
Given the relatively slow rate of achievement of postvasectomy azoospermia,
our current practice is to obtain a semen analysis no sooner than 3 months
after vasectomy.
The significance of azoospermia. Postvasectomy semen analysis may show
any 1 of 3 findings:
- complete absence of spermatozoa (azoospermia),
- presence of motile spermatozoa, or
- presence of nonmotile spermatozoa.
The presence of motile spermatozoa 3 to 6 months after vasectomy indicates
vasectomy failure due to technical error or to early recanalization.40
The significance of nonmotile spermatozoa detected on semen analysis depends
on how long after the procedure they are found. In the early postvasectomy
period, this finding is thought to be caused by the release of nonviable
residual spermatozoa in the distal reproductive tract.28 If found a significant
amount of time after vasectomy, nonmotile spermatozoa generally indicate
recanalization of the vas deferens.41 However, it is important
to understand that the isolated finding of nonmotile spermatozoa does
not necessarily signal vasectomy failure.
As shown in Table 1,25,28,39,41,42 multiple investigators
have reported on the reappearance of rare nonmotile spermatozoa years
to decades after vasectomy in men previously documented to be azoospermic.
It is widely believed that the presence of a small number of nonmotile
spermatozoa in vasectomized men is a normal and usual sequela of vasectomy.
Additionally, it has been shown that the risk of pregnancy from nonmotile
spermatozoa is only 0.05%—which is identical to the risk of pregnancy
after 2 azoospermic semen analyses.19,43
Although the AUA has not to date issued guidelines for the management
of postvasectomy patients, current guidelines from the British Andrology
Society recommend routine centrifugation of all postvasectomy semen specimens
to increase the likelihood of detecting rare nonmotile spermatozoa.32
While semen centrifugation is a useful sperm-harvesting technique for
intracytoplasmic sperm injection in men with obstructive or nonobstructive
azoospermia,44 it is not currently the US clinical standard
of care for postvasectomy patients. Centrifugation is an effective means
of detecting rare nonmotile spermatozoa, but, as discussed earlier, the
presence of rare nonmotile spermatozoa after vasectomy is of only trivial
significance and should not alter patient management.
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5. CONCLUSION
Vasectomy remains among the safest, easiest, and surest methods of male
sterilization. As such, it is one of the most popular methods of permanent
contraception worldwide. However, despite the popularity of the technique,
there has been a notable lack of consensus on the appropriate management
of patients after vasectomy. We recommend waiting at least 3 months after
vasectomy to assess azoospermia by semen analysis. A semen analysis indicating
the complete absence of spermatozoa or the presence of only rare nonmotile
spermatozoa is considered a marker of vasectomy success. Routine centrifugation
of azoospermic semen to detect rare nonmotile spermatozoa is not currently
considered the clinical standard of care in the United States.
It is clear that multiple issues must be addressed after vasectomy. In
a patient's mind, the judicious handling of these issues can make the
difference between a successful sterilization and an unpleasant experience.
When vasectomy is no longer represented to patients as a procedure but
rather as a process, they may be more appropriately counseled on the facts—that
continued follow-up after vasectomy is essential, sterility after vasectomy
cannot be guaranteed, and the possibilities of spontaneous recanalization
or PVPS, although small, do exist.
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6. UROlogic
- Due to its simplicity, safety, and effectiveness, vasectomy has remained
among the most popular forms of contraception. The failure rate is typically
less than 0.1%, comparing favorably with the 1.85% failure rate for
tubal ligation.
- Thorough preoperative counseling regarding the risks, benefits, alternatives,
and permanency of vasectomy is imperative.
- Reasonable expectations should be fostered in patients regarding postoperative
recovery, and patients should be informed of the time delay between
treatment and achievement of azoospermia and the need for postoperative
semen analyses to confirm azoospermia.
- Obtaining the postvasectomy semen analysis within 6 weeks may be too
soon to confirm success of treatment. At 3 months follow-up, only 72%
of men have achieved azoospermia.
- The majority of vasectomy failures are early failures in men who are
ineffectively counseled regarding the delay between vasectomy and azoospermia.
- Late vasectomy failures or the presence of motile spermatozoa may
indicate recanalization of the vas deferens.
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7. REFERENCES
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10. Mettlin C, Natarajan M, Huben R. Vasectomy and prostate cancer risk.
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to the risk of cancer. Am J Epidemiol. 1994;140(5):431-438.
12. Giovannucci E, Tosteson TD, Speizer FE, et al. A long-term study
of mortality in men who have undergone vasectomy. N Engl J Med. 1992;326(21):
1392-1398.
13. Stone N, Blum DS, DeAntoni EP, et al. Prostate cancer risk factor
analysis among > 50,000 men in a national study of prostate-specific
antigen (PSA). J Urol. 1994;151(5 suppl):278A. Abstract 201.
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between vasectomy and prostate cancer: a systematic review of the literature.
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15. Lesko SM, Louik C, Vezina R, et al. Vasectomy and prostate cancer.
J Urol. 1999;161(6):1848-1852; discussion 1852-1853.
16. Clarkson TB, Alexander NJ. Does vasectomy increase the risk of atherosclerosis?
J Cardiovasc Med. 1980;5(11):999-1002.
17. Coady SA, Sharrett AR, Zheng ZJ, et al. Vasectomy, inflammation,
atherosclerosis and long-term followup for cardiovascular diseases: no
associations in the atherosclerosis risk in communities study. J Urol.
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18. Li SQ, Goldstein M, Zhu J, et al. The no-scalpel vasectomy. J Urol.
1991;145(2):341-344.
19. Haldar N, Cranston D, Turner E, et al. How reliable is vasectomy?
Long-term follow-up of vasectomised men. Lancet. 2000;356(9223):43-44.
20. Smith JC, Cranston D, O'Brien T, et al. Fatherhood without apparent
spermatozoa after vasectomy. Lancet. 1994;344(8914):30.
21. Weiske WH. Vasectomy. Andrologia. 2002; 33:125-134.
22. Peterson HB, Xia Z, Hughes JM, et al. The risk of pregnancy after
tubal sterilization: findings from the US Collaborative Review of Sterilization.
Am J Obstet Gynecol. 1996;174(4):1161-1168; discussion 1168-1170.
23. Haws JM, Morgan GT, Pollack AE, et al. Clinical aspects of vasectomies
performed in the United States in 1995. Urology. 1998;52(4):685-691.
24. Alderman PM. The lurking sperm. A review of failures in 8879 vasectomies
performed by one physician. JAMA. 1988;259(21):3142-3144.
25. O'Brien TS, Cranston D, Ashwin P, et al. Temporary reappearance of
sperm 12 months after vasectomy clearance. Br J Urol. 1995;76(3):371-372.
26. Alcaraz A, Arango O. Cancer and other risks of vasectomy. Eur J Contracept
Reprod Health Care. 1996; 1(4):311-318.
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time to azoospermia after vasectomy in Mexico City. Contraception. 1997;56(4):215-222.
28. DeKnijff DW, Vrijhof HJ, Arends J, et al. Persistence or reappearance
of nonmotile sperm after vasectomy: does it have clinical consequences?
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seminal analysis important? Br J Urol. 1998;81(3):458-460.
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33. Mason RG, Dodds L, Swami SK. Sterile water irrigation of the distal
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35. Barone MA, Nazerali H, Cortes M, et al. A prospective study of time
and number of ejaculations to azoospermia after vasectomy by ligation
and excision. J Urol. 2003;170(3):892-896.
36. Clenney TL, Higgins JC. Vasectomy techniques. Amer Fam Phys. 1999;60(1):137-152.
37. Esho JO, Ireland GW, Cass AS. Vasectomy. Comparison of ligation and
fulguration methods. Urology. 1974;3(3):337-338.
38. Esho JO, Cass AS. Recanalization rate following methods of vasectomy
using interposition of fascial sheath of vas deferens. J Urol. 1978;120(2):178-179.
39. Labrecque M, Hoang D, Turcot L. Association between length of the
vas deferens excised during vasectomy and the risk of postvasectomy recanalization.
Fertil Steril. 2003;79(4):1003-1007.
40. Edwards IS. Earlier testing after vasectomy, based on the absence
of motile sperm. Fertil Steril. 1993; 59(2):431-436.
41. Lemack GE, Goldstein M. Presence of sperm in the pre-vasectomy reversal
semen analysis: incidence and implications. J Urol. 1996;155(1):167-169.
42. Freund MJ, Weidmann JE, Goldstein M, et al. Microrecanalization after
vasectomy in man. J Androl. 1989;10(2):120-132.
43. Benger JR, Swami SK, Gingell JC. Persistent spermatozoa after vasectomy:
a survey of British urologists. Br J Urol. 1995;76(3):376-379.
44. Jaffe TM, Kim ED, Hoekstra TH, et al. Sperm pellet analysis: a technique
to detect the presence of sperm in men considered to have azoospermia
by routine semen analysis. J Urol. 1998;159(5):1548-1550.
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