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Vasectomy

Created: 24/5/2005
Updated: 13/6/2007

 

VASECTOMY

Introduction

  • 33 million couples in USA / UK
  • The most reliable method of birth control
  • Reproducible results
  • Can be performed under LA and in the community

Controversies

  • Failure rate exists
  • Early post-op problems
  • Late post-op problems
  • Reversibility is not guaranteed
  • High risk for litigation

Patient types [1]

  • Young couples
  • 2 or less children
  • Social class 3 or above
  • Seldom African / Asian
  • ‘Less traditional’
  • Female partner is ‘anxious or neurotic’
  • Financial or emotional stress

Operation

  • LA or GA
  • Number of incisions:
    • Single
    • Double
    • No incision (Li technique)
  • Remove a 1 cm segment of vas
  • Ligate, cauterise, clip or do nothing to free ends
  • +/- fascial interposition

Follow-up

  • Semen analysis at 10 –12 weeks
  • Require 2 consecutive ‘negative’ samples
  • Dead sperm may be seen
  • Medicolegally not evidence of sterility
  • ‘Special clearance’ sanctions discontinuation of other forms of contraception despite the persistance of scanty (< 10,000 immotile spermatazoa / ml) sperm in 2 consecutive samples at least 7 months post-vasectomy
  • Re-explore if motile sperm seen as considered a sign of failure

Published Series

Philp, 1984 [2]

  • 16,796 patients (Oxford)
  • 72 early failures (0.4%)
    • 69 had positive samples
    • 3 became fathers (no samples)
  • At re-exploration 12 were found to have patent vas (i.e. missed)
  • Excluding these cases, early re-canalisation rate was 0.51% ligation and 0.28% diathermy
  • 6 late failures despite azoospermia (diagnosed by partners pregnancy)
  • Operator experience relevant
    • Failure rate 0.14% if >1000 procedures
    • Failure rate up to 1.40% if < 200 procedures
  • Absent vas in 1 in 400 cases
  • Duplicate vas in 1 in 16,000

Barnes 1983 [3]

  • 1000 patients (Margaret Pyke Centre – London)
  • Early failure rate of 0.6%
  • At re-exploration: Recanalisation (5) third vas (1)
  • One late failure
  • Operator-dependent

Complications

  • Haematoma, wound infection, epididymitis up to 5%
  • Acute pain     
  • Post vasectomy pain syndrome/chronic orchalgia <10% (Christiansen CG. J Androl 2003)
  • Sperm granuloma 10 – 15% - Epididymal tubal damage causes sperm granuloma and time-dependant secondary epididymal onbstruction

Rarer problems
Fourniers
Cardiac arrest

Counselling/Consent

General Aspects

Accurate information about risks and benefits prior to procedure is vital
Approx 10% of patients state that they regretted having vasectomy

  • Ideally discussed with own GP
  • Written consent by patient
  • Specific reference to points discussed
  • Written information
  • Period between consent and surgery
  • Partners consent useful
  • Copy of consent to patient

Contraceptive aspects

  • Should be considered irreversible
  • Has a low complication rate but risks should be explained
  • Vasectomy failure-
    • Risk of early recanalisation is <1%
    • Risk of late recanalisation extremely rare but may occur
    • Despite documentation of azoospermia paternity has been reported
  • Alternative contraception
  • Success rates of reversal

Surgical aspects

  • Bruising
  • Haematoma
  • Infection
  • Acute and chronic orchalgia
  • Sperm granulomas

Techniques

  • Fascial interposition
  • Li ‘no-incision’ technique
    • Difference in access rather than technique, fewer haematomas
  • Cautery of vas
  • Ligation of vas
  • Percutaneous vas occlusion
  • Operator experience is single most important factor

NB Sokal, D and Barone, MA. Investigator study group - RCT. BMC Urol 2004.
Fascial interposition and cauterisation appears to have a higher efficacy

Persistent spermatazoa

Davies 1990 [4]

  • Follow-up of 151 men with ‘special clearance’
    • (i.e. more than 7 months / <10,000/mL motile sperm)
  • No pregnancies
  • However, most urologists will perform repeat vasectomy for motile sperm due to risk of pregnancy or medico-legal recourse

Azoospermia and pregnancy

NB Reports exist for paternity (with DNA confirmation) in azoospermic fathers
NB Non-motile sperm can still produce pregnancy in ICSI techniques

Other Health Implications

  • No link for testicular cancer
    • UK Testicular Cancer Study Group 1994
  • No link for myocardial / atherosclerotic disease
  • No evidence for link with prostate cancer
    • Bernal-Delgado, E. Systematic review of literature. Fertil Steril 1999.

Vasectomy reversal

  • Approximately 1 –3 % of men
  • Reasons commonly cited
    • Remarriage
    • New partner keen for children
  • Commonly < 35 years old at vasectomy
  • Undertook vasectomy at time of emotional or financial crisis

NB Microsurgical vasectomy reversal is low-risk and cost-effective when compared to assisted fertilisation techniques

Methods

  • Vaso-vasostomy
    • One-layer
    • Two-layer
    • End-to-end
    • Side-to side
  • Vaso-epididymostomy
    • Secondary epididymal obstruction (increases with time after reversal)
    • > 9 years since vasectomy
    • No sperm in non-watery fluid from vas

Results

Wide range of success rates published - up to 90%
Sucess depends on

  • Time after vasectomy
  • Type of vasectomy (open-ended or sealed)
  • Type of reversal
  • Whether reversal unilateral or bilateral

NB The consensus is that microsurgical techniques should be used

NB For vasovasostomy patency rates are superior to pregnancy rates

  • Most series up to 90%
  • Little difference between techniques
  • Stents – no improvement
  • Vaso-epididymostomy better if
    • Granulomas present (associated with secondary epididymal obstruction)
    • > 7 – 9 years post-vasectomy
    • Turbid fluid from testicular side (indicates epididymal obstruction)

Paternity rates: Belkir et al. Vasovasostomy study group (1991) J Urol

  • Sperm count rises slowly for 6 months
  • Directly correlates with time post-vasectomy
  • Patency and paternity rates
    • Up to 3 years 97% & 76%
    • 3 – 8 years 88% & 53%
    • 9 – 14 years 79% & 44%
    • More than 15 years 30%
  • 50:50 chance overall

Difference between patency and paternity

  • Methodological factors
  • Immotile sperm
  • Partner infertile
  • New partner
  • Anti-sperm antibodies

Failed vasectomy reversal

  • Re-explore if no sperm or transient appearance in ejaculate
  • Causes of failure:
    • Stenosis of anastamosis
    • Sperm granulomas
    • Epididymal blockage
    • Anti-sperm antibodies
    • Cessation of spermatogenesis

1. Howard, G., Motivation for vasectomy. Lancet, 1978. 1(8063): p. 546-548.

2. Philp, T., I. Guillebaud, and D. Budd, Complications of vasectomy: review of 16000 patients. Br J Urol, 1984. 56: p. 745-748.

3. Barnes, M., et al., One thousand vasectomies. BMJ, 1973. 4: p. 216-224.

4. Davies, A., et al., The long-term outcome following "special clearance" after vasectomy. Br J Urol, 1990. 66(2): p. 211-212.


ArticleDate:20050524
SiteSection: Article
 
   
    
                                            



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