What is a vasectomy?
The term vasectomy , literally meaning "cutting the tubes," describes a minor surgical procedure performed on a man who desires a permanent form of birth control. Vasectomy results in sterilization because it obstructs the passageway through which sperm travel to reach the female ovum. A man’s testicles produce both male hormones (that stimulate male characteristics and sex drive) and sperm. A collection of small tubes called the epididymis along each testicle mature and deliver sperm to a single tube called the vas (or vas deferens), which is about the width of a spaghetti noodle. Each vas runs through the scrotum, up the groin on each side, and through the wall of the abdomen, ending in a storage area called the seminal vesicle, which is next to the prostate gland near the base of the penis. From there, the sperm mix with semen from the prostate gland and are expelled from the penis during ejaculation.
Vasectomy occludes (closes off) the vas to block the passage of sperm without affecting the important hormonal functions of the testicle. The surgery is done in the first, straight part of the vas, above the testicle and through the skin of the scrotum, making the procedure relatively easy and safe to perform.
Physicians performing vasectomy come from the specialties of urology, family medicine, general practice, or general surgery. Since the procedure is relatively simple, in comparison with other surgeries, physicians’ expertise usually depends more on specific training and interest in performing vasectomies and following up on the procedure than on their particular specialty training.
Vasectomies are usually done on an outpatient basis, either in a physician’s office or in a hospital-based or freestanding ambulatory surgery facility. Local anesthesia of the skin and the vasae is produced by an injection into the scrotum, which can be briefly uncomfortable until the medication has taken its full effect (usually after several seconds). Because of anxiety on the part of many men about having any discomfort in this area, many patients and physicians also choose to use sedation in the form of either tranquilizer pills or an injection for both mental and physical relaxation during vasectomy.
A number of techniques can be used safely and effectively by a physician performing a vasectomy, but the procedure can be thought of in terms of accomplishing three basic goals: The first is anesthesia, or the placement of numbing or freezing medication into the scrotum; the second is to gain access to the vas; and the third is its occlusion to prevent the passage of sperm.
Vasectomy can be made almost completely painless when local anesthesia in the form of medication such as lidocaine is used; this drug is similar to the anesthesia commonly used for dental procedures. By blocking the local nerves that send pain messages to the brain, normally painful procedures can be performed with little or no discomfort. A man having a vasectomy will feel the needle used to inject the medication into the skin and then a brief stinging sensation until it takes effect. The rest of the injection into the tubes themselves may or may not cause further discomfort, what some men describe as a pulling sensation.
The standard access procedure that the physician uses can vary with training and experience. It involves making either one incision into the scrotum in the middle of the front side or two incisions, one on either side. The incisions are made after the physician positions the vas directly under the skin, and then the other layers of tissue are separated to expose the vas itself. After each vas is occluded, the incision, which is between 1 and 1.5 centimeters long, must be closed with stitches, usually the type that dissolve and do not have to be removed.
A refinement of the access procedure, called the “no-scalpel” vasectomy, was introduced into the United States in the late 1980s. It originated in China in 1974, and a study comparing it with a standard technique found a more than 80 percent reduction in postoperative complications. It is being adopted only gradually by United States physicians, however, because performing it requires two simple but specially designed surgical instruments and because some physician retraining is required. Many physicians with experience in the new procedure believe that it should become the new standard for the vasectomy access procedure.
The occlusion of the vas is important because it determines the success of the vasectomy in preventing pregnancy. The physician can choose to occlude the vas ends by simple tying, folding back and tying, applying small metal clips, or cauterizing (burning with heat or special electrical current). In addition, one of the vas ends can be covered with a layer of the tissue that surrounds it to form a further barrier to sperm. Although all occlusion methods have been effective, cautery of the opening of the vasae may be the most reliable because it depends less on the technical precision of the physician doing the vasectomy than do the other methods, which can fail if applied too loosely or too tightly.
Finally, some physicians perform an open-ended technique, in which the end of the vas coming from the testicle is left open while only the outgoing end is occluded. This is thought to reduce the amount of backed-up sperm that can cause later complications and to make it easier to perform a vasectomy reversal. Some physicians believe, however, that the rate of vasectomy failure is higher with this technique.
Men from all over the world choose to have vasectomy performed, including about one-half million Americans every year. Vasectomy has been commonly available in the United States since the 1960s and is the fourth most commonly used birth control method overall, with one in eight women stating that they rely on this contraceptive method.
Some men who have undergone vasectomies choose, for various reasons, to reverse them. In such a reversal procedure, the patient, under general anesthesia, has a one- to two-inch incision made in the scrotum over the site of the previous vasectomy. The ends of the vas deferens are located and cut free of the surrounding scar tissue. A drop of fluid from the testicular end of the vas is placed on a glass slide and examined under an electronic microscope to determine precisely what kind of microsurgery is most appropriate.
Most physicians make recommendations to the patient about what should be done, or not done, following a vasectomy, including activity restriction, pain control strategies, and follow-up. A period of rest for about forty-eight hours after a vasectomy helps to prevent pain and complications such as postoperative bleeding into the scrotum, which causes swelling. All sexual activity should be avoided for up to a week. Many men find more relief from an ice pack applied to the scrotum for the first few days following the surgery than from any medication, although acetaminophen (such as Tylenol) or mild prescription narcotics are often helpful as well. Aspirin and ibuprofen, although effective for pain, are generally best avoided in the first few days following a vasectomy because they have a blood-thinning effect that may increase the tendency to bleed. Because aspirin has a longer-lasting blood-thinning effect on platelets (the small blood cells that initiate normal blood clotting and stop minor bleeding), it should also not be taken for about ten days prior to the vasectomy.
Follow-up with a physician should be available in case complications occur in the period immediately following the vasectomy. The physician must also check the semen to ensure that no sperm are present. If sperm remain, it may indicate that one or both vasae remain open or have grown back together, meaning that the procedure has failed and the man remains fertile. If there are no sperm in the semen three to six months after the vasectomy, then it is extremely unlikely that a failure can still occur. Most doctors do not recommend any further follow-up unless a problem arises.
Informed consent means that the patient who will undergo a treatment has been given the opportunity to understand the risks and benefits of that treatment. In the case of vasectomy, the risks are pain, complications, the chance that it will fail, and the possibility that there will be a change of heart and that the man will want to father more children. The benefit is having very reliable, safe, and permanent birth control without ongoing costs or effort required.
The complications of vasectomy are best thought of in terms of those occurring early and late. Early complications include infection and hematoma. Infection is fairly uncommon but can include symptoms of pain, swelling, fever, redness, and abnormal drainage from the vasectomy wound. Treatment consists primarily of antibiotic medication. A hematoma is a collection of blood in a localized area such as the scrotum. Blood vessels in the scrotum that are cut or torn during vasectomy and not tied, clipped, or cauterized can ooze a small or large amount of blood. In the worst case, surgery to remove the blood may be considered to relieve pain and pressure. Fortunately, small hematomas resolve without surgery in a few weeks’ time, and the more serious ones are rare, probably occurring in far less than 1 percent of vasectomies.
Later complications include problems with the area between the vasectomy incision and the testicles. Because the sperm are blocked from leaving the vas, and therefore the testicle, they can accumulate and cause three possible problems. First, sperm may back up at the site of the vasectomy and form a knot of sperm and inflamed scar tissue known as a sperm granuloma. It can be a painless lump, tender to pressure, or in rare cases it may be painful enough to require surgery to remove it. If swelling occurs because of accumulated sperm along the collecting area between the straight vas and the testicle (called the epididymis), the area can become tender or painful; this is known as congestive epididymitis. If this process extends backward to the testicle, it is known as orchitis. Fortunately, it is also rare for surgical removal of the entire epididymis to be required for relief of pain; sperm production slows in response to the pressure, and the body reabsorbs old sperm, eventually eliminating the pressure. Therefore, it is usually recommended that congestive epididymitis be treated with anti-inflammatory pain relievers such as ibuprofen, as well as with soaking in a warm bath.
Since there are many misconceptions about the risks and complications of vasectomy, it is useful to point out some problems that are not associated with the procedure. The complications of vasectomy are relatively minor and very rarely require hospitalization. Deaths and major surgical complications are largely unheard of. Impotence, loss of sexual drive, and changes in male characteristics such as beard growth, body hair, and voice do not occur. An apparent link between vasectomy and the hardening of the arteries that causes heart attacks has been disproven since the only such study was publicized in the late 1970s. Although a slight statistical association between vasectomy and cancer of the prostate gland was noted in two studies published in 1993, experts do not believe that vasectomy causes or contributes to prostate cancer because there is no reasonable mechanism for it to do so. Many men with milder forms of prostate cancer never die from it, and the statistics can be misleading because men who have seen a doctor for a vasectomy are also more likely to see a doctor for a prostate examination. Therefore, vasectomy may lead not to a greater risk of prostate cancer but to better detection of this disease.
Vasectomy has been performed to cause sterility since 1925, but its common use for that purpose started in the 1960s. The concepts of birth control and the desirability of limiting family size became increasingly valued in industrialized countries. Some states in the United States removed legal barriers to sterilization around this time, and the oral contraceptive or birth control pill became available to large numbers of women. These developments and the increased openness to discussion of sexual topics helped to form the basis for what was labeled the sexual revolution. In this environment, vasectomy became quite popular. It exceeded female sterilization by the early 1970s, driven in part by reports of the side effects of birth control pills. Sterilization for women (also called tubal ligation, literally “tying the tubes”) is more invasive than vasectomy because the surgeon must enter the woman’s abdomen to occlude the tubes that enable eggs to pass into her uterus. Therefore, vasectomy is somewhat safer when seen in the perspective of family planning. The women’s movement of the 1960s placed a new emphasis on the control that women have over their bodies, especially in relation to health and medical decisions. Because the man can assume some of the reproductive responsibility and undergo a safer procedure, vasectomy also has a philosophical advantage for many couples.
Technological innovation by the mid-1970s had produced the first laparoscopic instruments, which enabled a gynecologic surgeon to enter a women’s abdomen through two pencil-sized openings and identify and occlude her Fallopian tubes. This procedure, safer than the old one, with visibly smaller scars, and performed by obstetrician-gynecologists (the physicians whom women see most often), quickly became more popular than vasectomy and has remained so ever since. In spite of its high degree of safety, laparoscopic tubal ligation still occasionally results in deaths from general anesthesia and abdominal complications necessitating major surgery. Yet, even though tubal ligation costs three to five times more than vasectomy, it is still done more than twice as often. There are probably several reasons for this discrepancy, one of the most important being that when a woman has to make the sterilization decision alone, only tubal ligation can be chosen. When a woman is single or in a relationship with a lower level of commitment, or when there is a lack of consensus or support for the decision between the two partners, it is often easier for the woman to choose a tubal ligation. When a decision is made by a couple together, however, the risks and benefits give a comparative advantage to the male sterilization procedure.
When a couple makes a well-informed and mutual decision to choose vasectomy, the feelings in the months following the procedure most commonly include an increased sense of relaxation about sex because of lack of fear of unwanted pregnancy and an absence of anxiety and/or side effects related to contraceptive methods. On the other hand, if one of the partners was not ready and feels pressured into acceptance, the vasectomy decision can create irreconcilable conflict in the relationship.
Most doctors and clinics that counsel men about vasectomy emphasize the fact that vasectomy should be regarded as permanent. Every year, thousands of men seek the reversal of their vasectomies. Although the vasae can be surgically “spliced” back together in a safe and minor operation called vasovasostomy, sometimes years after a vasectomy, there are many reasons not to expect a simple reversal of the procedure. Reversal is expensive and often not covered by medical insurance, and the chances of restored fertility (as measured by later pregnancy) are only about 50 percent. The odds of reversal can be improved if the surgeon (usually a urologist) has substantial experience in the procedure, a microsurgical technique is used, and the vasectomy was relatively recent, and perhaps if the open-ended technique was used as well.
Some highly experienced urologists claim a 95 percent success rate in reversals, so patients should be cautioned to seek out a urologist who has extensive experience in performing the procedure. Reversal certainly offers hope to someone who has undergone a divorce or personal tragedy and wants to start a new family, but an ambivalent couple should not be reassured that after vasectomy they can change their minds and easily reverse the procedure.
The decision process by a man or a couple to pursue a vasectomy for family planning reasons often begins years before the procedure is actually done. First, they must feel that they have completed their family and be aware of vasectomy as a birth control option. Dissatisfaction with other birth control methods because of inconvenience and real or feared side effects often presses the decision. Discussion about vasectomy with one or more patients who have had one is a very common prerequisite to the decision for many men. Finally, a scare that an unwanted pregnancy can occur—such as a late period or a broken condom discovered too late—or even an actual unplanned pregnancy itself may be the last straw for many couples. The high rates of satisfaction with vasectomy may be attributable to the strong sense of comfort that follows this long and thorough decision process.
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