Criteria for Determining a Vasectomy has Succeeded

Portrait of a doctor or nurse. (iStockphoto/Thinkstock)
Portrait of a doctor or nurse. (iStockphoto/Thinkstock)

No-scalpel vasectomy procedure became popular in North America after U.S. surgeons went to China and learned the technique. The procedure is simple with a low complication rate. Infection and scrotal bleeding occur in four to 22 per cent of patients, chronic scrotal pain in two to five per cent, and failure to achieve sterilization in 0.03 to 12 per cent.

Vasectomy is one of the oldest and most commonly performed surgical procedures worldwide. However, there is no general agreement on the best approach to ensure contraceptive success. Surgeons differ significantly in their use of cautery, clips, ties and fascial interposition (position of outer tissue between the two ends of the divided vas). One international multicenter trial in 2004, of vasectomy with and without fascial interposition, demonstrated a twofold reduction of failure with the use of fascial interposition.

The American Urological Association, Inc. (AUA) recommends physicians not consider pathology confirmation of the vas deferens as a measurement of success. The finding of no sperm after vasectomy is the standard of success (2003). The AUA says the persistence of sperm in the semen after vasectomy is a surgical failure, regardless of a pathology report stating both vas deferens were removed.

Semen analysis after vasectomy is required to establish sterilization. Patient should deliver the specimen to the laboratory within one hour of collection. The general consensus in medical literature is one semen specimen three months after surgery should be analysed to confirm success. This protocol varies widely. Several studies document decreased patient compliance with each additional test.

An article in the Journal of the Royal Society of Medicine (2001) states post-vasectomy sterilization is confirmed by semen analysis, but the disappearance of sperm from the semen can be slow. Age and frequency of ejaculation influence the time to achieve complete disappearance of sperm from the semen. The authors state some patients will have small numbers of non-motile sperm in their semen for months or years after vasectomy. The authors go on to report that no pregnancies have been reported in the partners of these men. Many surgeons advise their patients that alternative contraception can be safely discontinued at this stage.

A Dutch study published in 2005, based on guidelines issued by Dutch Urological Association, says patients can stop using contraception at three months if their first semen analysis has no sperm or if less than 100,000 non-motile sperms are present. Researchers found 51 per cent of the samples contained no sperm and 45 per cent contained less than 100,000 non-moving sperms. Follow-up at least one year later showed none of these men, 96 per cent, reported getting a woman pregnant.

If there are motile sperms present six months after a vasectomy, repeat surgery is considered. When counseling a patient regarding the potential risks and benefits of a vasectomy, it is important to emphasize that a vasectomy can fail early or late. Late failure happens less often.

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Dr. B Talks About No Scalpel Vasectomy

This is my second video blog.

No scalpel vasectomy is a procedure which I do in my office. For more information please view these links: What you should know about vasectomy? and Information/Instructions for No-Scalpel Vasectomy.

I hope you enjoyed this video! Comments may be left by clicking on the video above and leaving them on the Youtube website!

Thanks for watching!

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What you should know about vasectomy?

Dear Dr. B: My husband and I have two beautiful children. We have decided that my husband should get a vasectomy. What should we know about vasectomy?

Answer: Vasectomy is a type of contraception – a surgical method of male sterilization. Contraception allows us to choose the number of children we want. There are many ways to do this. Most methods are designed for women. For men there are only two methods of contraception: condom or vasectomy.

More than 220 million couples worldwide use sterilization as their contraceptive method of choice. In western countries, about 20 – 25 percent of couples of reproductive age choose vasectomy as their method of contraception. Approximately 500,000 vasectomies are performed in the United States annually.

In my own practice the number of vasectomies done each year has gone up. For example, in the year 2003, I did 194 no-scalpel vasectomies compared to year 2000 when I did 117. In the last seven years, I have done 896 vasectomies.

Vasectomy is a permanent and irreversible procedure. Reversal procedures are being done but the success rate varies a lot. Therefore, it is important that you exercise this option carefully. You should undertake pre-operative counseling and consultation with your family physician and the surgeon doing the procedure.

Vasectomy is an office procedure. It is done under local anesthetic. Except for some discomfort for few seconds associated with infiltration of local anesthetic, the procedure itself is painless. But most patients are anxious. In my practice, I prescribe pre-operative sedation which helps calm the nerves.

The procedure is usually bloodless. It is done through a very tiny opening in the middle of the scrotum with a special instrument (not a scalpel) and no stitches are required.

Are there any post-operative complications?

Studies have shown that no-scalpel method has fewer complications than the conventional method.

Swelling and pain due to bleeding or infection is a possibility. The incidence can be anywhere from one to 10 percent. Mostly it is minor. About five percent of patients may have some chronic discomfort in the scrotal area. The nature of this can vary a lot.

Can vasectomy fail? Failure rate for tubal ligation is 18 per 1000 procedures. For vasectomy, the failure rate is one per 500 to 1000 procedures. In the last 13 years, I have had two documented vasectomy failures. One was in 1991 and second one in 1993.

Vasectomy does not immediately render the patient sterile. The sacs that hold semen contain sperms after vasectomy has been done. Other methods of contraception should be used until semen analyses (after two and three months) show that no sperms are left. Unfortunately, 30 percent of patients do not go for sperm analyses. That is not good.

Sperm granuloma, the cause of some pain after vasectomy, is caused by leakage of sperm from the vas. It develops in about 15-40 percent of men after surgery and may cause pain in three percent.

Vasectomy does not adversely affect a man’s sexual function. Current evidence does not show that vasectomy causes prostate or testicular cancer or would adversely affect a man’s health in any way.

Post-operatively, patients are advised to use ice-packs and to take it easy for couple of days. Exertion should be avoided for a week. If there are no complications then no pain killers are required.

So, vasectomy is a safe and effective method of long-term contraception. Remember, it is permanent and irreversible. Reversal procedures are being done but the success rate can be low. On the other hand, it is also important to remember that vasectomy can fail and there is no guarantee of permanent sterility.

Update (May 3, 2007): I have recorded a short video about this procedure on my video blog which can be viewed here.

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Information/Instructions for No-Scalpel Vasectomy

Instructions for Vasectomy

1. You have been booked for bilateral vasectomy to be done in my office under local anesthetic. Phone us 2 to 3 days before your appointment to confirm that you will be coming for the procedure. We reserve the right to bill patients who do not show up for their appointments.

2. Have somebody bring you to my office and pick you up after the procedure. You should not drive for 24 hours. You will be here for about 1 hour. The procedure itself takes about 10 – 15 minutes.

3. You should shave the scrotum in the front at the junction of the penis and scrotum completely and trim the pubic hair the day before the procedure.

4. Bring an athletic supporter with you. Have a shower on the day of the procedure and wear clean underwear, socks and clothing.

5. Please take 2 tablets of Tylenol #3 with water and Ativan 2 mg sublingually (under your tongue) one hour before you come to my office for the procedure.


Information About Bilateral No-Scalpel Vasectomy

Vasectomy is an increasingly popular, simple method of sterilization. Complications are minimal. Studies comparing various methods of birth control show that couples relying on vasectomy, on the average, have sexual intercourse more frequently and find greater fulfillment and satisfaction in their sexual relations than couples using other methods of contraception.

Informed consent is essential. You should know that this is a permanent, irreversible procedure. Reversal procedures are being done, but they are expensive and the results are unpredictable. Therefore, vasectomy should not be used as a temporary contraception. You should remember that you are not considered sterile until a sperm count establishes that fact. At least two sperm counts, 2 months and 3 months after vasectomy should be obtained. Other methods of contraception should be used until a sperm count demonstrates sterility. Recanalization and failure of vasectomy occurs in about 1% of patients, usually within two months of the operation. There are reports of late failures as well. You will get an appointment to see me 2 months after vasectomy when instructions will be given to you regarding the sperm counts. Current evidence does not show that vasectomy would adversely affect your health in anyway.

Are there any complications after vasectomy?

Complications after vasectomy are rare – but there is no guarantee that nothing will go wrong. About 95 – 99% of the patients do very well with no complaints. A small percentage of patients do get complications like: bleeding, infection, swelling and pain. Pain usually starts after 3 to 5 days. If this occurs, then get in a hot bath 2 to 3 times a day and take Tylenol #3. If the pain does not get better within 24 -48 hours then see your doctor or come back and see me. Usual healing process takes about a week. So use common sense and be careful. If there are no complications then you should feel no pain.

Post-vasectomy pain syndrome: Sometimes patients have complained of pain in the testicular area long after the vasectomy. In some cases, the pain corresponds with ejaculation. This symptom is rare. The exact mechanism underlying this pain is not known, but it could be related to the active transport of sperms from the testicles to the surgically divided vas. Occasionally, you may get a swelling where the vasectomy is done and this is called sperm granuloma. Sometimes, this area gives pain and discomfort and this can be excised if it is a source of discomfort and concern.

Post-Vasectomy Instructions

1. Do not drive for 24 hours. You are legally impaired after taking Tylenol #3 and Ativan.

2. Rest at home until the day after surgery. Put ice-pack on the scrotal area as often as possible on the day of surgery. You may resume your normal activities after one or two days. But avoid work and strenuous exercise for at least 48 hours. This will help the wound heal.

3. You may shower day after surgery. You can get the incision wet, but do not rub anything in that area for 48 hours. Dab it dry. Apply polysporin and gauze for three days. The scrotal incision has no stitiches and takes about 3 days to heal. Sometimes pain starts after 3 days, then sit in hot bath 3 – 4 times a day and take Tylenol #3. If it is no better than see me or your family doctor.

4. Do not pull or scratch the wound while it is healing.

5. Wear a snug undergarment or scrotal support for at least one week after surgery. This will help you to be comfortable.

6. You may have sex with your partner as soon as it is comfortable for you. This is usually two or three days after the operation. Remember, vasectomy does not work immediately, and you can still get your partner pregnant. Sperms should be gone after 20 ejaculations. Use condoms, or ask
your partner to use another family planning method until you have two negative sperm counts – one after two months and second after three months. If there are no sperms then we will let you know that you are sterile.

7. You may have a little pain, bruising, or swelling where the wound is. Watch it to be sure that it does not get worse. A small amount of pain, bruising, or swelling that does not get worse is normal. Take the medication recommended. Be sure to follow the instructions given to you. An ice pack may help relieve the pain, bruising, or swelling. Hot bath also helps.

8. Call me:
-If you have fever within one week of surgery
-If there is any bleeding or pus in the wound
-If there is pain or swelling around the wound that gets worse or does not go away
-If your partner ever misses a period or thinks she is pregnant. This is very important. It may mean the operation has failed, and your partner may be pregnant.

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