Vasectomy

Vasectomy is a minor surgical procedure that is arguably the safest and most effective form of permanent contraception for couples.  Simply put, the procedure involves division of the vas deferens, the tube that carries sperm from the testes to the ejaculate, on both sides (for men with two testes.)  It takes about 20-30 minutes to accomplish and can be done under local anesthesia or with mild sedation.  The expected result of a vasectomy is that no sperm appear in the ejaculate, whereas sexual experience, erections, and the ejaculate volume is essentially unaffected because most of the ejaculate comes from the seminal vesicles and prostate gland, that are deep within the pelvis and unaffected by a vasectomy.  The failure rate after vasectomy (chance of pregnancy) is less than 0.1%, and further lowered if patients have the requested evaluation of a semen analysis 2-3 months after the procedure.

The process of a vasectomy is pictorial shown here: https://cdn.jamanetwork.com/ama/content_public/journal/jama/937282/jpg180016fa.png?

From an article by Fainberg et al ( Fainberg J, Kashanian JA. Vasectomy. JAMA. 2018;319(23):2450.)

Vasectomy can be done in a series of different ways; we use the most effective and safest approach to accomplish this procedure.  This is referred to as a no-scalpel approach.  No-scalpel refers to the fact that only the vas is approached with the procedure.  The vas is isolated using a specific instrument that can accept only the vas and overlying skin.  This approach is distinct from a standard approach to vasectomy, where an incision is made in the scrotum, and the scrotum is searched to isolate the vas deferens.  The incisional approach leads to higher risks of bleeding and possibly post-procedural pain, as the incision leads to more work around the blood vessels and nerves that go to the testis.

Figure: The vas is isolated with the no-scalpel instrument to limit risks of the procedure.

The no-scalpel approach limits the risk of complications such as bleeding or pain, as it focuses on the vas deferens and overlying skin.  The procedure requires some experience to use the specific instruments needed for the procedure.  Of note, Dr. Schlegel has used his experience to teach dozens of other urologists how to perform these procedures.  For procedures done under local anesthesia, Dr. Schlegel also uses a “jet-injector”, allowing the skin to be numbed at the site of the procedure, rather than starting the procedure by piercing the scrotum with a needle.  We also seek to make the procedure easier by giving men numbing medicine in the form of an ointment to place of the upper front of the scrotum and base of the penis to help numb the skin.  We also use celecoxib, an anti-inflammatory medication that helps to prevent pain after procedures, starting the medication before the procedure, and taking the medication twice a day thereafter for one week to prevent pain.  Dr. Schlegel has reported in carefully done trials that celecoxib is highly effective in preventing post-procedural pain ( doi: 10.1016/j.juro.2013.04.058 ).

Before a vasectomy, men should consider all options for contraception including temporary forms of contraception (condoms, birth control pills or implantable devices, diaphragm, etc) as well as other permanent forms of contraception (tubal ligation for a woman.)  Since vasectomy is considered a permanent form of contraception, men should consider that they may change their mind about having children in the future, including the possibility of having a child with a future partner, since nearly 6% of men who have a vasectomy will request reversal or interest in fertility after vasectomy.  

Risks of a vasectomy are rare, with bleeding the most concerning risk.  Re-operation for bleeding after vasectomy occurs in about 1 in 1,000 procedures.  Chronic pain after a vasectomy can occur, that appears most commonly related to damage to a nerve outside of the vas deferens – with risks potentially limited by using the no-scalpel approach.  

After a vasectomy, sterility may take several months to be achieved.  In an effort to decrease the time period to achieve sterility, Dr. Schlegel typically flushes out the vas deferens to remove sperm from the reproductive system.  Still, contraception should be used until a semen analysis is done 2-3 months after the procedure to confirm that no live sperm persist in the ejaculate.  Also, men should avoid ejaculating within a week of the procedure.  Overall, it is reported that up to 1% of men need to have a vasectomy repeated because of failure, although Dr. Schlegel has not yet seen a patient where he needed to a repeat a vasectomy after he performed a no-scalpel vasectomy procedure with division of the vas and burning the inside of the vas deferens tube, with a surgical clip typically placed on the vas as well.

Consultation prior to vasectomy is recommended with a brief exam to assure normal anatomy for the man.  In New York City, it is required that another individual (can be my nurse, your partner, or another person) confirm that we have had a consent discussion that reviewed the procedure, discussed risks, benefits and alternatives to vasectomy – documented at least 30 days prior to the procedure.

In discussion of vasectomy and followup, Dr. Schlegel seeks to follow the current American Urological Association guidelines for vasectomy ( doi: 10.1016/j.juro.2012.09.080. )  Of note, the AUA has asked Dr. Schlegel to chair a panel to review and update these guidelines.