Vasectomy: permanent fertility control method for men.

Introduction:

Vasectomy is one of the safest, easiest and most reliable permanent fertility control(sterilization) method.

As there are no reliable oral male contraceptive pill, vasectomy is one of the few contraceptive options available to men.

Vasectomy was first performed by Sir Astley Cooper on his pet dog in 1832. It is now the most common urological procedure in use.

Though vasectomy is easier, safer and less costly than tubectomy, it is three to five times less common than tubectomy.

Vasectomy is a simple, minor surgical procedure. Usually takes 5-15 minutes to perform, after 5-10 minutes for pre-operative preparation and administration of local anesthesia.

To have a safe vasectomy following are required:

The person has to be counseled properly regarding the procedure, the complications that can arise, the precautions to be taken after surgery and have to specify that this is a permanent procedure.

The surgeon has to assess the client by doing systemic and local examination.

Before procedure  informed and written consent to be taken.

Strict aseptic precautions to be taken.

Proper anesthesia to be used.

The patient to instructed what he has to do before and after procedure.

Before the procedure, the man should:

Bathe thoroughly, especially he has to clean the genital area and upper inner thighs.

And has to wear clean and loose fitting clothing to the health facility.

Not take any medicines for 24 hours prior to the procedure, unless heath care provider performing the procedure tells him to do so.

There are two methods in vasectomy:

1. Conventional vasectomy

2. No-scalpel vasectomy

1. Conventional vasectomy:

In conventional vasectomy after taking strict aseptic precautions,  the vas is located, 1 cm incision is made on the skin with the scalpel, then the sheath of vas being cut open and a portion of the vas is removed, then the vas is ligated on both the ends. Either coagulation or hemoclips can also be used to separate the ends.

Then same procedure is repeated on other side and incisions on both sides are closed with catgut sutures.

For better results some providers also use fascial transposition. 
In this procedure the fascial sheath, that is the thin layer that surrounds the vas, is sutured over one end of the cut vas. 
Fascial interposition places a tissue between two cut ends of vas.

2. No-scalpel vasectomy:

It was introduced by Dr Li Shungiang in China in 1974.

In it two special instruments are used, a extracutaneous ringed forceps, used to hold vas and a dissecting forceps, used to puncture the scrotal skin to deliver the vas.

In this technique only one small opening is made on one side of the scrotum and both the vasa are operated through same opening. Ligation and cutting are same as conventional method.

Here no skin sutures are necessary. It takes less time, having faster recovery and because of  vas block it is less painful. But needs good practical training.

The patient may feel faint briefly after the procedure because of handling the vas. If possible, he should rest for 15-30 minutes. The man receives instructions on how to care for the wound. If his wife is not using an effective contraceptive, he receives condoms to use until sperms are cleared from his system. He leaves the clinic within a few hours, often in less than 1 hour.

In both these procedures by  blocking the vas deference we can  prevent sperm from passing. This keeps sperms out of his semen. The man can still have erections and ejaculate semen.  But his semen will not contain spermatozoa, no there is no chance of fertilization.

In case of fascial Interposition, results from randomized controlled trials found that use of fascial interposition with ligation and excision of vas during vasectomy leads to more rapid decrease in sperm count than when ligation and excision were used alone.

After the procedure, the man should:

If possible he can put cold compresses on the scrotum for 4 hours to lessen swelling.

He has to take rest  for 2 days and should not do heavy work or vigorous exercise for a few days.

He has to keep the incision clean and dry for 2-3 days.

 He can use a towel to wipe his body clean but should not soak in water.

He can wear snug underwear or pants for 2-3 days to help support the scrotum. This will decrease swelling, bleeding and pain.

He may take paracetamol or another safe, locally available analgesic as needed. He should not take aspirin or ibuprofen, which will slow the blood clotting.

He has to use condoms or another effective family planning method for at least 3 months after the procedure or till sperms are cleared from semen.

In most cases, using good surgical technique to minimize the trauma and limit bleeding, practicing aseptic technique, and giving clients good post-operative instructions can prevent bleeding, hematoma, and infection.

The patient has to visit the health care provider in case of:

For a follow-up, either  within 7 days or at least within 2 weeks of the procedure and to have stitches removed, if necessary.

If his wife misses her menstrual period or thinks she is pregnant.

He has questions or problems of any kind.

He has to visit clinic immediately in case of:

If he is having high fever, with temperature  greater than 38^oC  in the first 4 weeks and especially in the first week.

 Or if  bleeding or pus comes from the wound.

 Or if he develops signs of inflammation like  pain, heat, swelling, or redness at an incision that becomes worse or does not stop.

All these problems to be properly  taken care of with analgesics and antibiotics. If needed the patient has to hospitalized.

If patient develops fear of impotence, he has to be reassured that vasectomy will not lead to impotency.

Effectiveness of vasectomy:

Vasectomy is a very effective and permanent method.

When commonly used,  0.15 to 1.2% pregnancies are noted  per 100 women partners in the first year after the procedure

When used correctly the failure rate is 0.1 pregnancies in 100 women partners.

Correct use means using condoms or another effective family planning method consistently for at least first 3 months, or till sperms are cleared from the semen.

Immediately after the procedure any form of guarantee cannot be given. Only after histopathological examination of the tubes and when the semen becomes clear of sperms the assurance can be given.

Secondary failure after confirmation of sterility is less common but can occur due to reconnection of the cut ends of the vas.

Advantages of vasectomy:

It is simple and permanent procedure. A small, quick procedure leads to lifelong, safe and very effective family planning.

Once after the procedure nothing to remember except to use condoms or another family planning method for at least 3 months, until the semen becomes clear of sperms.

After the procedure there will be no interference with sex like in case of usage of condoms etc.. and it does not affect the man’s ability to have sex.

There will be increased sexual enjoyment as no need to worry about pregnancy.

Unlike mechanical devices no supplies to get, and no repeated clinic visits required.

As per the records no apparent long-term health risks are there.

When compared with voluntary female sterilization, vasectomy is:

Probably slightly more effective as per the results.

Slightly  safer as simple procedure compared with tubectomy.

 Compared with the technique of tubectomy  it is easier to perform.

When compared in costs in private hospitals it is often less expensive.

The effectiveness of the procedure can be tested at any time by doing simple semen analysis.

If at all pregnancy occurs in the man’s partner, the chances of being ectopic is less likely when compared to pregnancy after tubectomy.

Disadvantages of vasectomy:

Like all other surgeries it can have common minor short-term complications related to surgery can occur like local anesthesia hypersensitivity.

The patient may feel uncomfortable for 2 or 3 days.

He may experience pain in scrotum, swelling and bruising at the operated area.

There may be brief feeling of faintness after the procedure, because of handling the vas.

Some uncommon complications of surgery can occur like, bleeding or infection at the incision site or inside the incision.  Or blood clots may accumulate in the scrotum.

Compared with mechanical methods it requires minor surgery by a trained provider.

And vasectomy is not immediately effective, as after procedure also in the reserve of semen the man will contain spermatozoa.

Sperm granuloma can be formed under the pressure of obstruction and congested and distended epididymis can cause painful post vasectomy syndrome which will settle down normally.

Reversal surgery is difficult, expensive, and not available in most areas of the world. Development of anti-sperm antibodies will make reversal surgery unsuccessful but some studies are showing successful pregnancies in the presence of anti-sperm antibodies also.

In this procedure success cannot be guaranteed until  histopathological examination of the tubes confirms the vas structure and when the semen becomes clear of sperms.

Unlike mechanical barriers this will not offer any  protection against STIs or HIV.

Medical Eligibility for vasectomy:

Most men can have vasectomy.

Most men who want vasectomy can have safe and effective procedures in the routine settings without contraindications:

This includes men of any age who have no children.

Men having sickle cell disease or hereditary anemia.

Men who are  HIV positive or at high risk of HIV or other STIs .

The cases where vasectomy has to be delayed:

In case of active sexually transmitted infection, vasectomy has to be delayed and patient should be referred for treatment.

When patient have inflamed, swollen and tender  tip of penis, ducts or testicles or scrotal skin infection or mass in the scrotum, he has to be treated for that particular condition before surgery.

In case of having acute systemic infection or significant gastroenteritis also surgery to be done after treating the underlying problem.

Patient has to refer to higher center with experienced staff and equipment in case of:

Having filariasis or elephantitis  of scrotum which will create great difficulty in palpating the vas.

In case of having hernia in the groin, in this case vasectomy can be performed at the same time as repairing hernia. If this is not possible, the hernia should be repaired first.

In case of undescended testicles  on  both sides.

The patient having current-AIDS related illness.

And the man having coagulation disorders.

Extra caution to be taken in case of:

Patient having history of previous scrotal surgery or injury.

In man with large varicocele having swollen veins , or hydrocele accumulation of fluid in membranes in the spermatic cord or testes, causing swollen scrotum making surgery difficult. These two conditions can be operated followed by vasectomy.

In case of undescended testicles in one side only, vasectomy  can be performed on the normal side only. Then if any sperm remains in the semen after 3 months, on the other side also surgery must be done.

In patients having diabetes extra caution to be taken.

In patients with depressive disorders also caution to be taken as after surgery they make thought that they lost their libido and may become more depressive.

In case of dealing with young men, it should be kept in mind that he can come for recanalization.