Vasectomy in the United States, 1991

Thoughts on the popularity of ICSI

Purpose

Intracytoplasmic sperm injection (ICSI) is the most widely utilized assisted reproductive technique (ART) worldwide. In this feature, we review the early assisted fertilization attempts that eventually led to the development of ICSI, and discuss its current utilization in cases of male and non-male factor infertility.

Methods

We researched the literature related to the development, indications, and current use of ICSI, such as sperm structural abnormalities, male genetic indications, surgically retrieved sperm, high sperm chromatin fragmentation, oocyte dysmorphism, and preimplantation genetic testing (PGT). We also describe the potential future applications of ICSI.

Results

This review summarizes the early micromanipulation techniques that led to the inception of ICSI. We also explore its current indications, including non-male factor infertility, where its use is more controversial. Finally, we consider the benefits of future advancements in reproductive biology that may incorporate ICSI, such as in vitro spermatogenesis, neogametogenesis, and heritable genome editing.

Conclusion

The versatility, consistency, and reliability of ICSI have made it the most prevalently utilized ART procedure worldwide.

The epidemiology and etiology of azoospermia

The misconception that infertility is typically associated with the female is commonly faced in the management of infertile men. It is uncommon for a patient to present for an infertility evaluation with an abnormal semen analysis report before an extensive female partner workup has been performed. Additionally, a man is usually considered fertile based only on seminal parameters without a physical exam. This behavior may lead to a delay in both the exact diagnosis and in possible specific infertility treatment. Moreover, male factor infertility can result from an underlying medical condition that is often treatable but could possibly be life-threatening. The responsibility of male factor in couple's infertility has been exponentially rising in recent years due to a comprehensive evaluation of reproductive male function and improved diagnostic tools. Despite this improvement in diagnosis, azoospermia is always the most challenging topic associated with infertility treatment. Several conditions that interfere with spermatogenesis and reduce sperm production and quality can lead to azoospermia. Azoospermia may also occur because of a reproductive tract obstruction. Optimal management of patients with azoospermia requires a full understanding of the disease etiology. This review will discuss in detail the epidemiology and etiology of azoospermia. A thorough literature survey was performed using the Medline, EMBASE, BIOSIS, and Cochrane databases. We restricted the survey to clinical publications that were relevant to male infertility and azoospermia. Many of the recommendations included are not based on controlled studies.

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.

Cost effectiveness of contraceptives in the United States

BACKGROUND

The study was conducted to estimate the relative cost effectiveness of contraceptives in the United States from a payer's perspective.

METHODS

A Markov model was constructed to simulate costs for 16 contraceptive methods and no method over a 5-year period. Failure rates, adverse event rates and resource utilization were derived from the literature. Sensitivity analyses were performed on costs and failure rates.

RESULTS

Any contraceptive method is superior to "no method". The three least expensive methods were the copper-T intrauterine device (IUD) (US$647), vasectomy (US$713) and levonorgestrel (LNG)-20 intrauterine system (IUS) (US$930). Results were sensitive to the cost of contraceptive methods, the cost of an unintended pregnancy and plan disenrollment rates.

CONCLUSION

The copper-T IUD, vasectomy and the LNG-20 IUS are the most cost-effective contraceptive methods available in the United States. Differences in method costs, the cost of an unintended pregnancy and time horizon are influential factors that determine the overall value of a contraceptive method.

Medical Barriers to Effective Contraception

Medical barriers to contraception can prevent women from obtaining, initiating, and continuing their contraceptive method of choice. The barriers include lack of appropriate counseling, delaying initiation for menses or laboratory tests, inappropriate contraindications or mandated warnings, untrained clinicians, and financial or regulatory barriers preventing access by low-income, undocumented, or adolescent women. These barriers may partially explain why almost half of pregnancies in the United States are unintended and occur predominantly in the small proportion of sexually active women not using contraception.

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.

The use of URYX for reversible vasectomy in a rabbit model

URYX is a biocompatible polymer of ethylene vinyl alcohol dissolved in a dimethyl sulfoxide (DMSO) carrier to allow injection of a very low-viscosity fluid into tissue. Once the material comes into contact with body tissue or fluid, the DMSO rapidly dissipates from the polymer, which results in a precipitate of a coherent solid mass. The purpose of the present study was to determine whether URYX can effectively occlude the vas deferens and whether patency can be restored by redissolving the URYX in vivo using the solvent DMSO. Eight male New Zealand White rabbits (age range, 25-41 weeks; mean age, 33.9 +/- 7.5 weeks; mean weight, 4.0 +/- 0.2 kg) were used in 2 experiments (E1 and E2). In E1, 3 rabbits underwent unilateral vasectomy, and the contralateral vas was injected with either 0.05 or 0.10 mL of URYX, to determine the amount of URYX required to cause obstruction. Two animals underwent bilateral vasectomy, to serve as controls. In E2, 3 animals underwent bilateral URYX injection and were compared with the bilateral vasectomy control rabbits used in E1. After 1 month of initial bilateral URYX treatment, all animals in E2 underwent attempted unilateral reversal with 1.5 mL of DMSO injected into 1 occluded vas deferens. Two end points were evaluated-a clinical end point assessed by semen analyses and a pathological end point assessed by histological analysis of treated tissues, to assess for safety. A 1.5-cm infrapubic incision was made to expose both vasa in anesthetized rabbits. The vasal injection of URYX was performed with a 30-gauge needle. Vasectomy was performed by excision of a 1-cm segment of the vas deferens and subsequent ligation with a 6-0 prolene suture. Semen was collected using an artificial vagina 2-3 times/wk before and 1 month later, after injection treatments and vasectomy. Manual sperm counts were performed. All animals were sacrificed, and tissues (distal vas, injection site, proximal vas, cauda epididymis, caput epididymis, and testis) were harvested and examined for the presence of URYX. The inflammatory response of the wall and adventitia of the vas deferens was given a score (0-15) based on the sum of grades (0 = none, 1 = mild, 2 = moderate, and 3 = severe) for the following categories: foreign body giant cell reaction, granulation tissue, lymphocytes, eosinophils, and scarring, as evaluated by a single pathologist (J.M.). Vasal injection with 0.05 mL of URYX was not sufficient to cause occlusion. Both animals injected with 0.1 mL of URYX were effectively occluded. The injection of occluded vasa with DMSO did not dissolve the URYX plug in the vas lumen. There was no significant difference in vasal inflammatory response scores between vasal units treated with URYX only and vasal units in the vasectomy model. Vasal units subjected to URYX followed by DMSO demonstrated greater inflammatory response scores than vasal units treated with URYX followed by normal saline, URYX alone, or vasectomy. Epididymal and testicular histology remained unaffected in all vasal units in E1. The vasal units in E2 subjected to URYX followed by normal saline showed no histological abnormalities of the epididymis and testis. However, those vasal units subjected to URYX followed by DMSO in E2 showed evidence of adhesions, necrosis, and degenerating cells in the epididymis and a focal foreign body giant cell reaction in the testis. The bilateral vasal injection of URYX can result in azoospermia in the rabbit model. Reversal with subsequent DMSO injection was not achieved. A minimal inflammatory response of the vas deferens was observed with URYX injection alone; however, DMSO following URYX injection resulted in increased vasal inflammation, in addition to epididymal and testicular changes.

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.

Combined local-propofol anesthesia with noninvasive positive pressure ventilation in a vasectomy patient with sleep apnea syndrome

A vasectomy patient with sleep apnea syndrome, who requested general anesthesia and day surgery, was given sole propofol infusion with airway maintenance by noninvasive positive-pressure ventilation. Surgery was performed with additional local anesthesia. Because this patient was treated successfully, this anesthetic technique may also be applicable to other normal patients.

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.

Psychological correlates of vasectomy

OBJECTIVE

To examine the thoughts and concerns of men contemplating vasectomy before speaking to a physician as well as their partner's role in reaching this decision.

DESIGN

A questionnaire analysis using response rates, ANOVA, and regression analyses.

SETTING

A large Midwestern teaching hospital.

PATIENT(S)

Visitors to the urology clinic of the hospital.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

[1] Questionnaire designed by authors. [2] Measures of self-concept, relationship satisfaction, and problem-solving abilities.

RESULT(S)

[1] Subjects had been considering vasectomy for an average of 1 year and were fairly certain of their decision. [2] Anxiety about vasectomy surgery was mostly driven by fear about pain and fear of the unknown. [3] Concerns about the finality of the procedure did not emerge as a big concern. [4] There is confusion about the reversibility of the procedure. [5] Subjects are better problem solvers and have a higher self-concept than people in general.

CONCLUSION(S)

Our findings demonstrate the need for adequate prevasectomy counseling, particularly in the area of postoperative expectations, as well as reversibility of the procedure.

Safety and effectiveness of vasectomy

OBJECTIVE

To recommend further research on vasectomy based on a systematic review of the effectiveness and safety of vasectomy.

DESIGN

A systematic MEDLINE review of the literature on the safety and effectiveness of vasectomy between 1964 and 1998.

MAIN OUTCOME MEASURE(S)

Early failure rates are <1%; however, effectiveness and complications vary with experience of surgeons and surgical technique. Early complications, including hematoma, infection, sperm granulomas, epididymitis-orchitis, and congestive epididymitis, occur in 1%-6% of men undergoing vasectomy. Incidence of epididymal pain is poorly documented. Animal and human data indicate that vasectomy does not increase atherosclerosis and that increases in circulating immune complexes after vasectomy are transient in men with vasectomies. The weight of the evidence regarding prostate and testicular cancer suggests that men with vasectomy are not at increased risk of these cancers.

CONCLUSION(S)

Publications to date continue to support the conclusion that vasectomy is a highly effective form of contraception. Future studies should include evaluations of the long-term effectiveness of vasectomy, evaluating criteria for postvasectomy discontinuation of alternative contraception for use in settings where semen analysis is not practical, and characterizing complications including chronic epididymal pain syndrome.

Sterilization and its consequences

The purpose of this review is to analyze critically the two techniques of sterilization (bilateral tubal ligation [BTL] and vasectomy) so that a physician may provide informed consent about methods of sterilization. A MEDLINE search and extensive review of published literature dating back to 1966 was undertaken to compare preoperative counseling, operative procedures, postoperative complications, procedure-related costs, psychosocial consequences, and feasibility of reversal between BTL and a vasectomy. Compared with a vasectomy, BTL is 20 times more likely to have major complications, 10 to 37 times more likely to fail, and cost three times as much. Moreover, the procedure-related mortality, although rare, is 12 times higher with sterilization of the woman than of the man. Despite these advantages, 300,000 more BTLs were done in 1987 than vasectomies. In 1987, there were 976,000 sterilizations (65 percent BTLs and 35 percent vasectomies) with an overall cost of $1.8 billion. Over $260 million could have been saved if equal numbers of vasectomies and BTLs had been performed, or more than $800 million if 80 percent had been vasectomies, as was the case in 1971. The safest, most efficacious, and least expensive method of sterilization is vasectomy. For these reasons, physicians should recommend vasectomy when providing counseling on sterilization, despite the popularity of BTL.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader will be able to predict the failure rates and likelihood of successful reversal of tubal ligation and vasectomy; to recall the difference in cost between the two sterilization procedures, and to describe the short-term and long-term complications associated with each of the two methods of sterilization.

Vasectomy in the United States, 1991 and 1995

OBJECTIVES

This study sought to assess whether the controversy surrounding publications linking vasectomy and prostate cancer has had an effect on vasectomy acceptance and practice in the United States.

METHODS

National probability surveys of urology, general surgery, and family practices were undertaken in 1992 and 1996.

RESULTS

Estimates of the total number of vasectomies performed, population rate, and proportion of practices performing vasectomy were not significantly different in 1991 and 1995.

CONCLUSIONS

This study provides no solid evidence that the recent controversy over prostate cancer has influenced vasectomy acceptance or practice in the United States. However, the use of vasectomy appears to have leveled off in the 1990s.

Clinical aspects of vasectomies performed in the United States in 1995

OBJECTIVES

Currently, no surveillance system collects data on the numbers and characteristics of vasectomies performed annually in the United States. This study provides nationwide data on the numbers of vasectomies and the use of no-scalpel vasectomy, various occlusion methods, fascial interposition, and protocols for analyzing semen after vasectomy.

METHODS

A retrospective mail survey (with telephone follow-up) was conducted of 1800 urology, family practice, and general surgery practices drawn from the American Medical Association's Physician Master File and stratified by specialty and census region. Mail survey and telephone follow-up yielded an 88% response rate.

RESULTS

In 1995, approximately 494,000 vasectomies are estimated to have been performed by 15,800 physicians in the United States. Urologists performed 76% of all vasectomies, and nearly all (93%) urology practices performed vasectomies in 1995. Nearly one third (29%) of vasectomies in 1995 were no-scalpel vasectomies, and 37% of physicians performing no-scalpel vasectomies taught themselves the procedure. The most common occlusion method in 1995 (used for 38% of all vasectomies) was concurrent use of ligation and cautery. In 1995, slightly less than half (48%) of all physicians surveyed interposed the fascial sheath over one end of the vas when performing a vasectomy. Protocols for ensuring azoospermia varied: 56% of physicians required one postvasectomy semen specimen; 39% required two, and 5%, three or more.

CONCLUSIONS

No-scalpel vasectomy, used by nearly one third of U.S. physicians, has become an accepted part of urologic care. Physicians' variations in occlusion methods, use of fascial interposition, and postvasectomy protocols underscore the need for large scale, controlled, and statistically valid studies to determine the efficacy of occlusion methods and fascial interposition, as well as whether azoospermia is the only determination of a successful vasectomy.

[Efficacy and complications associated with vasectomies in two clinics in the Quebec region]

OBJECTIVE

To compare the efficacy of, and complications associated with, vasectomies performed in two medical clinics.

DESIGN

Retrospective cohort study.

SETTING

A private medical clinic and a family planning clinic at a teaching hospital in the Quebec City region, where one doctor performs all surgery.

PARTICIPANTS

The 1223 men who underwent a first vasectomy between January 1994 and February 1996.

INTERVENTIONS

Isolations of the vas deferens through the scrotum was performed using the no-scalpel technique in both clinics. At the private clinic (n = 775), vasectomy was performed by ligature with tantalum clips. At the family planning clinic (n = 448), a combination of cauterisation of the abdominal end of the vas deferens, leaving the testicular end open, and fascial interposition with a clip was used.

MAIN OUTCOME MEASURES

Rate of postoperative complications (painful granuloma; noninfectious inflammation of the vas deferens, epididymis, and testes; hematoma; infection; undiagnosed pain) and rate of recanalization (early and late).

RESULTS

At the private clinic, 39 patients (5.0%) consulted for postoperative complications, compared with 55 patients (12.3%) at the family planning clinic (chi (2)1 = 21.0; P < 0.001). Of the patients who underwent semen analysis, 15 (2.8%) at the private clinic and 4 (1.2%) at the family planning clinic experienced early or late recanalization (chi (2)1 = 2.2; P < .14).

CONCLUSION

The rate of consultation for postoperative complications was lower at the private clinic than at the family planning clinic, but the efficacy of the procedure appeared to be higher at the family planning clinic. The surgical techniques used at the two clinics might partially explain these differences.

Voluntary vasectomy: Medico-legal aspects

In Italy, although voluntary sterilisation was decriminalised with act No. 194/78, which abrogated section 552 of the criminal code, there is no regulation as yet ratified by law. The authors refer to the trend shown by some sentences, the most important of which is No. 438 of 18.03.1987 (Court of Cassation), highlighting some aspects of physical and psychic health and “informed” consent. The surgical technique of male sterilisation and possible complications are dealt with, as well as the unresolved medico-legal aspects concerning the irreversibility of the operation or vice versa, failure of reversal. The possible judicial implications of claims for compensation for damages caused by malpractice, negligence or imprudence are also discussed. In conclusion, it is hoped that a law regulating this matter will soon be passed, while in the meantime a protocol to avoid legal liability is suggested.