Clinical aspects of vasectomies performed in the United States in 1995

Vasectomy reversal vs. sperm retrieval with in vitro fertilization: a contemporary, comparative analysis

OBJECTIVE

To explore the primary options available to men who desire fertility after a vasectomy.

DESIGN

Literature review.

SETTING

University of Miami Miller School of Medicine.

PATIENT(S)

Men with a previous vasectomy now seeking fertility.

INTERVENTION(S)

The two main options to achieve paternity for men following vasectomy include vasectomy reversal (VR) and surgical sperm retrieval with subsequent in vitro fertilization (IVF).

MAIN OUTCOME MEASURE(S)

We reviewed and compared the important considerations for men deciding between these 2 options, including: obstructive interval, female partner age, antisperm antibodies, male partner age, female infertility factors, and cost.

RESULT(S)

Both VR and IVF represent reasonable options for the couple seeking fertility after vasectomy. Specific circumstances may favor one modality over another, depending on obstructive interval, possible female fertility factors, female partner age, male partner age, and cost. In the absence of insurance coverage, VR is often more cost-effective than IVF. Alternatively, when a female factor may contribute to infertility in addition to vasectomy, IVF is often the better choice. Antisperm antibodies are unlikely to contribute to infertility following a successful VR.

CONCLUSION(S)

VR or surgical sperm retrieval with IVF are reasonable options for couples seeking children after vasectomy. Pregnancy rates for both options are overall similar, so prior to pursuing either option, a thorough discussion with a reproductive urologist who possesses microsurgical skills in VR and a reproductive endocrinologist with expertise in IVF is imperative. Making a final choice through shared decision-making while considering these points is ideal.

Vasectomy and vasectomy reversal: a comprehensive approach to the evolving spectrum of care

Male reproduction and male contraception form an important spectrum within men's health. In this issue's Views and Reviews, four author groups detail important new developments in vasectomy clinical practice guidelines, emerging and investigational techniques in the fields of hormonal and nonhormonal male contraception, useful paradigms for patient care when deciding between sperm extraction with in vitro fertilization and vasectomy reversal, and finally, a state-of-the-art overview of recent developments in vasectomy reversal microsurgery. These articles will provide readers with a contemporary understanding of the rapidly evolving spectrum of male reproductive and contraceptive health care.

A novel laboratory procedure to validate American Urological Association guideline on vasectomy success and to diagnose obstructive azoospermia

The objective was to develop a laboratory procedure to validate American Urological Association (AUA) Guideline on vasectomy success when nonmotile spermatozoa are found in the post-vasectomy ejaculate. The neutral α-glucosidase (NAG) an epididymal protein assay modified to determine the activity at 30 and 90 min of incubation from 24 pre- and 47 post-vasectomy ejaculates. The difference between the two points in the relative activity was calculated and if the difference was nonsignificant will confirm vasectomy success. The mean differences in the relative NAG activity were significantly different in pre- and post-vasectomy ejaculates, respectively. The mean differences in the relative NAG activity were similar in post-vasectomy ejaculates with and without nonmotile spermatozoa. No difference in relative NAG activity in post-vasectomy ejaculates between two time points of incubation may be a reliable method to confirm occlusion of the vas deferens. It also validates the recommendation by AUA Guideline on vasectomy success in the presence of few nonmotile spermatozoa.

Development of Novel Male Contraceptives

Unintended pregnancy is surprisingly common, accounting for 40-50% of pregnancies worldwide. Contraception is the most effective means of preventing unintended pregnancy. Seventy percent of all contraceptives are used by women; however, some women are unable to use contraceptives due to health conditions or side effects. Many men wish to take a more active role family planning, but currently have only two effective male contraceptive options, condoms and vasectomy. Therefore, work to develop novel male contraceptives analogous to popular female methods, such as daily pills or long-acting shots and implants, is underway. This paper will briefly discuss the pros and cons of condoms and vasectomies, and then review the research into novel methods of male contraception.

Vasectomy: tips and tricks

According to data from the National Study of Family Growth, vasectomy is utilized by 6–13% of American couples for their form of contraception. Physician surveys have shown that over 500,000 men undergo vasectomies per year, and more than 75% of vasectomies are performed by urologists. This chapter provides a brief history of vasectomy, as well as recommendations for preoperative counseling, an overview of the modified no-scalpel vasectomy technique, and a brief description of the complications of vasectomy.

Male contraception

Although female contraceptives are very effective at preventing unintended pregnancy, some women can not use them because of health conditions or side-effects, leaving some couples without effective contraceptive options. In addition, many men wish to take active responsibility for family planning. Thus, there is a great need for male contraceptives to prevent unintended pregnancies, of which 80-90 million occur annually. At present, effective male contraceptive options are condoms and vasectomy, which are not ideal for all men. Therefore, efforts are under way to develop novel male contraceptives. This paper briefly reviews the advantages and disadvantages of condoms and vasectomies and then discusses the research directed toward development of novel methods of male contraception.

CUA guideline: Vasectomy

<p>Vasectomy is a safe and effective method of birth control. Although it is a simple elective procedure, vasectomy is associated with potential minor and major complications. The early failure rate of vasectomy (presence of motile sperm in the ejaculate at 3‒6 months post-vasectomy) is in the range of 0.3‒9% and the late failure rate is in the range of 0.04–0.08%. The no-scalpel vasectomy technique is associated with a lower risk of early postoperative complications and the use of cautery or fascial interposition will reduce the risk of contraceptive failure. As such, detailed preoperative counselling and careful assessment of the post-vasectomy ejaculate (for presence of sperm) is imperative. Failure to provide and document adequate information and counselling to patients may lead to litigation.</p><p>The focus of this guideline is the management of men presenting for vasectomy. Specifically, the topics covered include: preoperative counselling, vasectomy efficacy and complications, technical aspects of vasectomy, post-vasectomy semen testing, and interpretation-communication of post-vasectomy semen results. By performing an extensive literature review, we have generated an evidence-based consensus on the management of these men. The objective of this guideline is to help standardize the treatment of men presenting for vasectomy.</p>

Prospective comparison of ligation and bipolar cautery technique in non-scalpel vasectomy

OBJECTIVES

There is no trial comparing bipolar cautery and ligation for occlusion of vas in non-scalpel vasectomy. This study aimed to compare the effectiveness of these vasectomy occlusion techniques.

MATERIALS AND METHODS

Between January 2002-June 2009, patients were allocated in alternate order. We recruited 100 cases in cautery group and 100 cases in ligation group. Non-scalpel approach was performed during vasectomy and fascial interposition was performed in all cases. First semen analysis was done 3 months after vasectomy. Vasectomy success was defined as azoospermia or non-motile sperm lower than 100.000/mL.

RESULTS

Four patients from the cautery group were switched to the ligation group due to technical problem of cautery device. Thus, data of 96 patients as cautery group and 104 patients as ligation group were evaluated. After vasectomy, semen analyses were obtained from 59 of 96 (61.5%) patients in cautery group and to 66 of 104 (63.5%) patients in ligation group. There was no statistical significant difference between the two groups in terms of the success of vasectomy (p=0.863).

CONCLUSION

Although bipolar cautery technique is safe, effective and feasible in non-scalpel vasectomy, it has no superiority to ligation. There was no statistically significant difference in terms of the success and complications between the two groups.

Short-term morbidity following No-Scalpel Vasectomy: an assessment of clients' perceptions by novel postcard system

OBJECTIVE

Data on short-term (within a week) morbidity of No-Scalpel Vasectomy (NSV) is lacking. We studied clients' perceptions of early post-vasectomy morbidity by self innovated postcard pictorial questionnaire.

METHODS

Between March 2011 and April 2012, 821 men underwent NSV and provided pre-printed revalidated pictorial postcards depicting various grades of severity of local pain, swelling, and bleeding. Clients were asked to tick mark their problems and post them on the third day after NSV. Data were compiled and statistically analyzed.

RESULTS

Completed postcards were returned by 702 clients (85.5%). 25 postcards were excluded due to illegitimate filling of card. About 80.8% of clients complained of pain and minimal, moderate and severe pain was experienced by 77.69%, 18.09% and 4.20%, respectively. 16.24% of clients observed local swelling, which was minimal in 90.9%, moderate and severe in 7.27% and 1.81% of cases. 2.95% of clients noted mild bloody discharge. Most of clients managed their problems by following the instructions given in postcards; level 1 and 2 morbidity did not affect their daily activity.

CONCLUSION

Early morbidity after NSV is usually mild in severity and easily manageable. The postcard system is a feasible, effective, and economical way of collecting data and managing short-term post NSV problems.

Estimating the number of vasectomies performed annually in the United States: data from the National Survey of Family Growth

PURPOSE

While hospital discharge and ambulatory surgery registries provide accurate estimates of female sterilization procedures, current estimates of male sterilization rates are lacking since these procedures are done in many settings. Population based data are used to estimate annual sterilization numbers.

MATERIALS AND METHODS

We analyzed data on 4,928 men and 7,643 women from the 2002 National Survey of Family Growth. We determined the year of vasectomy in men and the year of tubal ligation in women who reported a history of surgical sterilization. After accounting for the complex survey design of the National Survey of Family Growth we calculated the estimated number of individuals who underwent surgical sterilization in the United States.

RESULTS

A total of 141 men reported vasectomy, representing an overall 6% prevalence in National Survey of Family Growth survey population, while 1,173 women (16%) reported tubal ligation. Using National Survey of Family Growth data an estimated 175,000 to 354,000 vasectomies were done yearly from 1998 to 2002. In the same period the National Survey of Family Growth estimated that 546,000 to 789,000 tubal ligations were done annually in the United States. This compares closely to the 596,000 to 687,000 tubal ligations calculated using ambulatory surgery and hospital discharge data from a similar period.

CONCLUSIONS

The estimated annual number of tubal ligations from the National Survey of Family Growth is in line with the current literature using hospital discharge and ambulatory surgery registries, suggesting the accuracy of the method of estimating surgical sterilization numbers. This suggests that the National Survey of Family Growth may be used to provide an estimate of vasectomy use in the United States.

Vasectomy by epithelial curettage without suture or cautery: a pilot study in humans

Curettage of the epithelium of the vas deferens might be a safe and effective method of male sterilization. We conducted a pilot study of vasectomy by epithelial curettage with a novel microcurette called the Vas-X in 12 normal men requesting elective sterilization. Seminal fluid analysis was obtained monthly after the procedure for 6 months. Pain was assessed by questionnaire. Three months after the procedure, all men attained sperm concentrations of less than 0.2 million sperm per mL, and seven were azoospermic. Post-procedural pain was minimal. Nine men ultimately achieved and maintained azoospermia; however, 4 to 6 months after the procedure, sperm concentrations increased in three of the 12 subjects, necessitating repeat vasectomy. Microscopic examination of the vas deferens from these failures revealed re-canalization. Vasectomy by epithelial curettage can result in effective sterilization; however, 1/4 of the subjects were not effectively sterilized by the procedure due to re-canalization of the vas deferens. Epithelial curettage will require further refinement to determine if it is a viable form of vasectomy.

Demographics of vasectomy--USA and international

Vasectomy is safer, simpler, less expensive, and equally as effective as female sterilization--yet it remains one of the least known and least used methods of contraception. Worldwide, an estimated 33 million of married women ages 15 to 49 (less than 3%) rely on their partner's vasectomy for contraception.

Paternity after vasectomy with two previous semen analyses without spermatozoa

CONTEXT

The risk of paternity after vasectomy is rare but still exists. Overall failure to achieve sterility after vasectomy occurs in 0.2 to 5.3% of patients due to technical failure or recanalization. The objective of this report was to describe a rare but notable case of proven paternity in which the semen analyses had not given evidence of spermatozoa.

CASE REPORT

A 44-year-old vasectomized man whose semen analyses had shown azoospermia became a father four years after sterilization. Blood sample DNA analysis on the child and husband proved biological paternity. Vasectomy may fail in the long run even without spermatozoa in semen analysis. The patient must be aware of this possibility.

Vasectomy in the United States, 2002

PURPOSE

We estimated the number of vasectomies performed in the United States in 2002 and gathered information on the vasectomy procedures and protocols used. It follows similar studies done in 1991 and 1995.

MATERIALS AND METHODS

A retrospective mail survey with telephone followup was performed in 2,300 urologists, family physicians and general surgeons randomly sampled from the American Medical Association Physician Masterfile.

RESULTS

The response rate was 73.8%. An estimated 526,501 vasectomies were performed in 2002 for a rate of 10.2/1,000 men 25 to 49 years old. Overall 37.8% of physicians reported currently using no scalpel vasectomy and almost half of the vasectomies performed in 2002 were no scalpel vasectomies. Methods of vas occlusion varied in and among specialties with a combination of ligation and cautery being most common (41.0% of cases). Of the physicians 45.6% reported routinely performing fascial interposition, 94.4% reported removing a vas segment, 23.3% reported routinely folding back 1 or 2 ends of the vas and 7.5% reported using open-ended vasectomy. Followup protocols varied widely. Of respondents 53.5% reported charging $401 to $600 for vasectomy in 2002.

CONCLUSIONS

Although the estimated number of vasectomies performed in the United States during 2002 represents an increase from 1991 and 1995, incidence rates remained unchanged at approximately 10/1,000 men 25 to 49 years old. The percent of vasectomies performed using no scalpel vasectomy as well as the number of physicians who reported that they use no scalpel vasectomy increased substantially since 1995. Wide variation in surgical techniques and followup protocols were found.

HOW LITTLE IS ENOUGH? THE EVIDENCE FOR POST-VASECTOMY TESTING

PURPOSE

Post-vasectomy semen analysis (PVSA) is the traditional method of confirming sterility after vasectomy. However, PVSA protocols vary in the end points accepted, and the number and timing of tests. In this systematic review we make evidence based recommendations on the appropriate PVSA protocol.

MATERIALS AND METHODS

Databases (MEDLINE, Current Contents, Cochrane Library and EMBASE) were searched up to and including March 2003. Studies were included if they dealt with post-vasectomy testing and contained data on at least 1 of the time or number of ejaculations to azoospermia, pregnancy, repeat vasectomy and histological analysis of vas specimens.

RESULTS

A total of 56 studies were included in the review. Time to achieve azoospermia was variable, although the median incidence of patients with azoospermia was consistently more than 80% after 3 months and after 20 ejaculations. A small percent of patients (14,845 or 1.4%) demonstrated persistent nonmotile sperm, although some of them eventually achieved azoospermia. The reappearance of nonmotile sperm was reported in 7 studies, occurring up to 22 months after vasectomy.

CONCLUSIONS

The evidence supports a PVSA protocol with 1 test showing azoospermia after 3 months and 20 ejaculations. If the sample is positive, periodic testing can continue until azoospermia is achieved. Patients with persistent nonmotile sperm in low numbers could be given cautious assurance of success. No evidence was located to support histological testing of the excised vas deferens.

Vasectomy surgical techniques in South and South East Asia

Background

Simple ligation of the vas with suture material and excision of a small vas segment is believed to be the most common vasectomy occlusion technique performed in low-resource settings. Ligation and excision (LE) is associated with a risk of occlusion and contraceptive failure which can be reduced by performing fascial interposition (FI) along with LE. Combining FI with intra luminal thermal cautery could be even more effective. The objective of this study was to determine the surgical vasectomy techniques currently used in five Asian countries and to evaluate the facilitating and limiting factors to introduction and assessment of FI and thermal cautery in these countries.

Methods

Between December 2003 and February 2004, 3 to 6 major vasectomy centers from Cambodia, Thailand, India, Nepal, and Bangladesh were visited and interviews with 5 to 11 key informants in each country were conducted. Vasectomy techniques performed in each center were observed. Vasectomy techniques using hand-held, battery-driven cautery devices and FI were demonstrated and performed under supervision by local providers. Information about interest and open-mindedness regarding the use of thermal cautery and/or FI was gathered.

Results

The use of vasectomy was marginal in Thailand and Cambodia. In India, Nepal, and Bangladesh, vasectomy was supported by national reproductive health programs. Most vasectomies were performed using the No-Scalpel Vasectomy (NSV) technique and simple LE. The addition of FI to LE, although largely known, was seldom performed. The main reasons reported were: 1) insufficient surgical skills, 2) time needed to perform the technique, and 3) technique not being mandatory according to country standards. Thermal cautery devices for vasectomy were not available in any selected countries. Pilot hands-on assessment showed that the technique could be safely and effectively performed by Asian providers. However, in addition to provision of supplies, introducing cautery with FI could be associated with the same barriers encountered when introducing FI in combination with LE.

Conclusion

Further studies assessing the effectiveness, safety, and feasibility of implementation are needed before thermal cautery combined with FI is introduced in Asia on a large scale. Until thermal cautery is introduced in a country, vasectomy providers should practice LE with FI to maximize effectiveness of vasectomy procedure.

Delayed vasectomy success in men with a first postvasectomy semen analysis showing motile sperm

OBJECTIVE

To determine the frequency of and factors associated with delayed vasectomy success in men with first postvasectomy semen analysis showing motile sperm.

DESIGN

Descriptive study.

SETTING

One hospital-based family planning clinic and two private clinics from the Quebec City area, Canada.

PATIENT(S)

Three hundred nine men vasectomized between 1990 and 2001 and who had a first semen analysis showing motile sperm.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Vasectomy success, based on the last available semen analysis-either in the medical record or as requested for the study-and on sterility as established by a telephone-based questionnaire in 2003.

RESULT(S)

Among the 309 men, 174 (56.3%, 95% confidence interval 50.7%-61.7%) had delayed vasectomy success. Significant independent factors associated with delayed vasectomy success were lower sperm count in the first postvasectomy semen analysis and shorter interval between vasectomy and first postvasectomy semen analysis.

CONCLUSION(S)

Delayed vasectomy success occurs in more than half of men with a first postvasectomy semen analysis showing motile sperm. The decision to repeat vasectomy should not rely on a single semen analysis showing motile sperm.

Effectiveness of vasectomy using cautery

Background

Little evidence supports the use of any one vas occlusion method. Data from a number of studies now suggest that there are differences in effectiveness among different occlusion methods. The main objectives of this study were to estimate the effectiveness of vasectomy by cautery and to describe the trends in sperm counts after cautery vasectomy. Other objectives were to estimate time and number of ejaculations to success and to determine the predictive value of success at 12 weeks for final status at 24 weeks.

Methods

A prospective, non-comparative observational study was conducted between November 2001 and June 2002 at 4 centers in Brazil, Canada, the UK, and the US. Four hundred men who chose vasectomy were enrolled and followed for 6 months. Sites used their usual cautery vasectomy technique. Earlier and more frequent than normal semen analyses (2, 5, 8, 12, 16, 20, and 24 weeks after vasectomy) were performed. Planned outcomes included effectiveness (early failure based on semen analysis), trends in sperm counts, time and number of ejaculations to success, predictive value of success at 12 weeks for the outcome at 24 weeks, and safety evaluation.

Results

A total of 364 (91%) participants completed follow-up. The overall failure rate based on semen analysis was 0.8% (95% confidence interval 0.2, 2.3). By 12 weeks 96.4% of participants showed azoospermia or severe oligozoospermia (< 100,000 sperm/mL). The predictive value of a single severely oligozoospermia sample at 12 weeks for vasectomy success at the end of the study was 99.7%. One serious unrelated adverse event and no pregnancies were reported.

Conclusion

Cautery is a very effective method for occluding the vas. Failure based on semen analysis is rare. In settings where semen analysis is not practical, using 12 weeks as a guideline for when men can rely on their vasectomy should lessen the risk of failure compared to using a guideline of 20 ejaculations after vasectomy.

Vasectomy surgical techniques: a systematic review

BACKGROUND

A wide variety of surgical techniques are used to perform vasectomy. The purpose of this systematic review was to assess if any surgical techniques to isolate or occlude the vas are associated with better outcomes in terms of occlusive and contraceptive effectiveness, and complications.

METHODS

We searched MEDLINE (1966-June 2003), EMBASE (1980-June 2003), reference lists of retrieved articles, urology textbooks, and our own files looking for studies comparing two or more vasectomy surgical techniques and reporting on effectiveness and complications. From 2,058 titles or abstracts, two independent reviewers identified 224 as potentially relevant. Full reports of 219 articles were retrieved and final selection was made by the same two independent reviewers using the same criteria as for the initial selection. Discrepancies were resolved by involving a third reviewer. Data were extracted and methodological quality of selected studies was assessed by two independent reviewers. Studies were divided in broad categories (isolation, occlusion, and combined isolation and occlusion techniques) and sub-categories of specific surgical techniques performed. Qualitative analyses and syntheses were done.

RESULTS

Of 31 comparative studies (37 articles), only four were randomized clinical trials, most studies were observational and retrospective. Overall methodological quality was low. From nine studies on vas isolation, there is good evidence that the no-scalpel vasectomy approach decreases the risk of surgical complications, namely hematoma/bleeding and infection, compared with incisional techniques. Five comparative studies including one high quality randomized clinical trial provided good evidence that fascial interposition (FI) increases the occlusive effectiveness of ligation and excision. Results of 11 comparative studies suggest that FI with cautery of the vas lumen provides the highest level of occlusive effectiveness, even when leaving the testicular end open. Otherwise, firm evidence to support any occlusion technique in terms of increased effectiveness or decreased risk of complications is lacking.

CONCLUSIONS

Current evidence supports no-scalpel vasectomy as the safest surgical approach to isolate the vas when performing vasectomy. Adding FI increases effectiveness beyond ligation and excision alone. Occlusive effectiveness appears to be further improved by combining FI with cautery. Methodologically sound prospective controlled studies should be conducted to evaluate specific occlusion techniques further.

Pregnancy rates after vasectomy: a survey of US urologists

We surveyed 2000 US urologists using mailed questionnaires. The aim of this survey was to estimate the incidence of pregnancy after vasectomy and to gather information on the surgical methods used. Of 586 responding urologists, 538 reported performing vasectomies, and they reported a total of 177 pregnancies during the preceding 5 years. Ninety pregnancies (51%) were attributed to unprotected intercourse during the immediate post-vasectomy period. The remaining pregnancies were attributed to recanalization or other less common causes of method failure. Based on the number of vasectomies performed by these surgeons, about 1 pregnancy was reported per 1000 vasectomies. This is probably an underestimate of the true rate. The risk of pregnancy was lower following vasectomies by surgeons who performed more than 50 procedures per year.

Vasectomy by ligation and excision, with or without fascial interposition: a randomized controlled trial [ISRCTN77781689]

BACKGROUND

Randomized controlled trials comparing different vasectomy occlusion techniques are lacking. Thus, this multicenter randomized trial was conducted to compare the probability of the success of ligation and excision vasectomy with, versus without, fascial interposition (i.e. placing a layer of the vas sheath between two cut ends of the vas).

METHODS

The trial was conducted between December 1999 and June 2002 with a single planned interim analysis. Men requesting vasectomies at eight outpatient clinics in seven countries in North America, Latin America, and Asia were included in the study. The men were randomized to receive vasectomy with versus without fascial interposition. All surgeons performed the vasectomies using the no-scalpel approach to the vas. Participants had a semen analysis two weeks after vasectomy and then every four weeks up to 34 weeks. The primary outcome measure was time to azoospermia. Additional outcome measures were time to severe oligozoospermia (<100 000 sperm/mL) and vasectomy failure based on semen analyses.

RESULTS

We halted recruitment after the planned interim analysis, when 841 men had been enrolled. Fascial interposition decreased time to azoospermia (hazard ratio [HR], 1.35; P < 0.0001) and time to severe oligozoospermia (HR, 1.32; P < 0.0001) and reduced failures based on semen analysis by about half, from 12.7% (95% confidence interval [CI], 9.7 to 16.3) to 5.9% (95% CI, 3.8 to 8.6) (P < 0.0001). Older men benefited less from fascial interposition than younger men in terms of the speed of achieving azoospermia. However, the number of vasectomy failures was reduced to a similar degree in all age groups. Slightly more adverse events occurred in the fascial interposition group, but the difference was not significant. These failure rates may appear high to practitioners in countries such as the USA, but they are similar to results from other careful studies of ligation and excision techniques.

CONCLUSION

Fascial interposition significantly improves vasectomy success when ligation and excision is the method of vas occlusion. A limitation of this study is that the correlation between postvasectomy sperm concentrations and risk of pregnancy is not well quantified.

Vasectomy: a "seminal" analysis

Vasectomy is one of the most reliable and cost-effective permanent methods of contraception. Despite its popularity, certain issues pertaining to the procedure remain unresolved. Appropriate selection of candidates for vasectomy requires thorough counseling and screening, though a foolproof method of eliminating dissatisfaction and regret remains a mystery. Debate continues over the relative merits of the various techniques of isolating and sealing the vasal ends. Postoperative complication rates remain minimal regardless of the technique used, and no single strategy attempting to maximize patient compliance with postoperative semen analysis has enjoyed unmitigated success. Long-term consequences, other than regret, are rare. Finally, issues regarding residency training in the procedure and its impact on procedure morbidity are scarcely addressed in the literature. This study reviews the evolution of vasectomy as a contraceptive procedure and attempts to summarize current literature addressing these unresolved issues.

A prospective study of time and number of ejaculations to azoospermia after vasectomy by ligation and excision

PURPOSE

We obtained detailed information on the time and number of ejaculations to azoospermia after vasectomy by ligation and excision.

MATERIALS AND METHODS

Men seeking vasectomy at 3 public clinics in Mexico City were invited to participate in this prospective noncomparative study. Vasectomy was performed using the no-scalpel technique. The vas was occluded using 2 silk sutures and the segment of vas between the ligatures was excised. Men were followed biweekly up to 24 weeks after vasectomy or until azoospermia was confirmed. Semen was examined at each visit for sperm concentration and motility. The main outcome measure was azoospermia in uncentrifuged semen samples.

RESULTS

The life table rate for time to azoospermia was 81.5/100 men (95% CI 76.2 to 86.9) by the end of the study. Cumulative Kaplan-Meier event probability attained a maximum of 79.5/100 men (95% CI 73.7 to 85.2) at 70 ejaculations. Only 60/100 and 27.9/100 men were azoospermic by 12 weeks and 20 ejaculations, respectively. These end points are the commonly recommended waiting periods when semen analysis is unavailable. Of the 217 men 36 (16.6%) did not achieve azoospermia by 24 weeks, of whom 25 (11.5% of all participants) were considered to have vasectomy failure.

CONCLUSIONS

Our results suggest that it is not possible to develop guidelines for clearance based only on the time or number of ejaculations when ligation and excision are performed. In addition, of the methods for vas occlusion during vasectomy ligation and excision may not provide the best success rates.

Vasectomy effectiveness in Nepal: a retrospective study

The main purpose of this retrospective, cross-sectional study was to evaluate the effectiveness of vasectomy in an ongoing public sector program in Nepal. We evaluated semen samples from men who had previously had a vasectomy, and asked about the occurrence of pregnancies in the men's partners. In addition, the surgeons who performed the vasectomies completed a questionnaire about their techniques. A two-stage stratified sampling procedure was used to select 1263 men from among over 30,000 men, who had previously undergone a no-scalpel vasectomy, mostly by ligation and excision, in 32 districts between July 1996 and June 1999. Semen samples were preserved and analyzed at a central laboratory. A US andrology laboratory validated the lab results. Twenty-three men (2.3%, 95% confidence interval [CI] 1.1-3.6) had >/=500,000 sperm/mL in their semen. Fifteen of those men reported pregnancies conceived after their vasectomy. In addition, six men with azoospermia reported pregnancies for which conception occurred within 3 months after vasectomy. Eleven men with azoospermia reported pregnancies for which conception occurred more than 3 months after vasectomy. Reported pregnancy was more likely in younger partners. The life table pregnancy rates for all men interviewed were 0.7 (95% CI 0.2-1.1), 1.7 (95% CI 1.4-2.1) and 4.2% (95% CI 3.2-5.2) at 3, 12 and 36 months, respectively. In low-resource, programmatic settings, vasectomy failure rates may be higher than commonly cited rates, especially in younger populations. Additional research is needed to determine if other occlusion techniques could reduce failure rates. Counseling on vasectomy should always convey the possibility of failure and partner pregnancy.

Association between the length of the vas deferens excised during vasectomy and the risk of postvasectomy recanalization

OBJECTIVE

To evaluate the association between the length of the vas deferens excised during vasectomy and the risk of recanalization.

DESIGN

Nested case-control study.

SETTING

Hospital-based Family Planning Clinic in Quebec City (Canada).

PATIENT(S)

Among 870 vasectomized men, all 47 cases of spontaneous recanalization and 188 controls whose first semen analysis showed either azoospermia (controls A) or <1 x 10(6)/mL nonmotile sperm (controls B).

MAIN OUTCOME MEASURE(S)

Spontaneous recanalization defined as a semen analysis showing any motile sperm 6 weeks or more after vasectomy.

RESULT(S)

Individual vas segments excised ranged from 5 to 20 mm in 227 (97%) of the 235 participants. The mean +/- SD of the average of both segments for each man was 12 +/- 4 mm, identical in cases and in controls. In cases and controls A, the risk ratio (95% confidence interval [CI]) of recanalization with an average of segments of <10 mm and 10-14 mm was 0.6 (0.1-2.0) and 0.6 (0.2-1.6) when compared to 15 mm or more, respectively. In cases vs. controls B, the risk ratio of recanalization was 1.6 (0.4-7.7) and 0.6 (0.2-1.7), respectively.

CONCLUSION(S)

In this cohort, there was no association between the length of vas segment excised and the risk of recanalization.

Percutaneous vasectomy: a simple modification eliminates the steep learning curve of no-scalpel vasectomy

PURPOSE

We report a simplified method to avoid the most difficult step of no-scalpel vasectomy, while maintaining its minimally invasive advantages.

MATERIALS AND METHODS

Using the no-scalpel vasectomy instruments in percutaneous fashion we perform vasectomy in the office setting without fixation of the vas to skin using the ring clamp. The sharp no-scalpel hemostat punctures the skin. The vas is then grasped with the ringed instrument instead of piercing the vas and performing the supination maneuver, as described for no-scalpel vasectomy.

RESULTS

Percutaneous vasectomy was performed in 573 men by a single surgeon. In the 35 consecutive cases recently reviewed average operative time was 9.3 minutes with an additional 67 seconds added when a resident performed the procedure on 1 side in 15 cases. As determined by the knuckle of vas pulled through a puncture, average incisional length was 8.4 mm. Patients reported complete recovery in an average of 8.9 days. No major complications occurred. A single case of recanalization (0.17%) was successfully corrected by repeat percutaneous vasectomy.

CONCLUSIONS

Percutaneous vasectomy is a minimally invasive option for permanent male sterilization that avoids the difficult aspects of no-scalpel vasectomy.

Effectiveness and complications associated with 2 vasectomy occlusion techniques

PURPOSE

We compared the effectiveness and complications associated with 2 common vasectomy occlusion techniques, namely clipping and excision of a small vas segment and thermal cautery with fascial interposition and an open testicular end.

MATERIALS AND METHODS

We retrospectively reviewed the computerized records of 3,761 men who underwent initial vasectomy at a single university hospital family planning clinic and at 2 private clinics in the Quebec City, Canada area, including concurrent and historical controls. All procedures were performed by 1 surgeon, who used the scalpel-free technique to expose the vas.

RESULTS

The risk of vas occlusion failure in men with at least 1 semen analysis was much greater in the clipping and excision group than in the cautery, interposition and open testicular end group (126 of 1,453 or 8.7% versus 3 of 1,165 or 0.3%, OR 37, 95% CI 12 to 116). Medical consultations for hematoma or infection were more frequent in the cautery group (28 of 1,721 cases or 1.6% versus 10 of 2,040 or 0.5%, OR 3.4, 95% CI 1.6 to 6.9). Consultations for noninfectious pain were similar for the 2 techniques (71 of 1,721 cases or 4.1% versus 72 of 2,040 or 3.5%, OR 1.2, 95% CI 0.8 to 1.6).

CONCLUSIONS

Cautery and interposition with an open testicular end are much more effective than clipping and excision. The effectiveness and morbidity associated with the components of the cautery, interposition and open testicular end technique need further evaluation.

Use of EMLA cream with vasectomy

OBJECTIVES

To determine whether the application of a eutectic mixture of anesthetic cream (EMLA cream) can decrease the pain of lidocaine injection during vasectomy.

METHODS

A double-blind, prospective study was performed in which each patient acted as his own control. One hour before a double-incision vasectomy, EMLA cream was applied to one side of the scrotum and a white lanolin hand cream to the other side. A double-incision vasectomy was performed, and each patient was asked to rate the pain associated with each side of the procedure.

RESULTS

Eighty-nine patients agreed to the study; 61 patients thought the EMLA cream decreased the pain of the vasectomy, 16 preferred the lanolin hand cream, and 3 said there was no difference. These results were significant at the 0.0001 level using the Student t test.

CONCLUSIONS

EMLA cream significantly decreases the pain associated with lidocaine injections given as local anesthesia for vasectomy.

Vasectomy

Vasectomy is regarded as the safest method now available for male fertility control. Almost 100 million men worldwide have relied on vasectomy for family planning. This review discusses all currently relevant operative techniques, including no-scalpel vasectomy, complications, possible long-term effects on the testis and epididymis, and diseases for which associations with vasectomy have been suggested, such as arteriosclerosis, autoimmune diseases and cancer of the prostate and testis. Other topics of discussion include the timing of post-operative semen analysis, patient noncompliance concerning post-operative controls, persistent cryptozoospermia and transient reappearance of spermatozoa after vasectomy, vasectomy failure and legal aspects.

Population-based outcomes after 28,246 in-hospital vasectomies and 1,902 vasovasostomies in Western Australia

OBJECTIVES

To examine trends in vasectomy and vasovasostomy, and the surgical complications and factors associated with reversal after vasectomy, and paternity after vasovasostomy.

PATIENTS AND METHODS

Procedure rates were estimated from 1980 to 1996 in the population of Western Australia. Linked hospital morbidity records were used in the follow-up of men after vasectomy to estimate the risks of complications and reversals. Records of vasovasostomies were linked to the paternity field on birth registrations. Independent effects of the study factors were examined using Cox regression.

RESULTS

There was little net change in vasectomy rates, whereas vasovasostomy rates increased in men aged 30-49 years. Risks of surgical complications were low and decreased for vasovasostomy. At 12-15 years after vasectomy, the risk of reversal levelled at 2. 4% in the total cohort and at 11.1% in men aged 20-24 years. The risk of vasovasostomy was 69% greater after vasectomy performed in 1994-96 than in 1980-84 (P = 0.011). The factors strongly associated with reversal were age < 30 years and being single, divorced or separated at the time of vasectomy. Paternity was achieved after an estimated 53% of vasovasostomies. Successful reversal was more likely if the man was younger at vasectomy and the time elapsed was comparatively short. Compared with vasovasostomies performed in 1980-84, the success rate of those in 1994-96 was almost four times higher.

CONCLUSION

Population rates of vasectomy are stable but the risk of seeking a reversal has increased. Outcomes after vasovasostomy have improved. Care should be taken during the counselling of men before vasectomy, and especially in those aged <30 years.

New contraceptive methods

As the number of abortion procedures performed each year reaches nearly 1 million, the incentive to decrease the incidence of unwanted pregnancy in the United States is high. Better education regarding women's health issues and enhanced contraceptive development are necessary to impact this long-standing problem. Several new contraceptive products are likely to become available in years to come to increase the number of choices that women and their health care providers have for pregnancy prevention. These products include long-acting implants, the levonorgestrel intrauterine device, patches, and the vaginal ring. This article surveys the near future of male and female contraception.

Vasectomy. A safe, effective, economical means of sterilization

Vasectomy is a common office procedure that is a permanent, safe, and effective form of birth control. It is less expensive and safer than tubal ligation. Physicians who wish to perform the procedure should be aware of the potential complications and explain them to the patient. Physicians also should perform the procedure often enough to have a low complication rate.