Vasectomy: a "seminal" analysis.

Abstract: 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.

Key Words: contraception, male sterilization, postvasectomy semen analysis, vasectomy

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Vasectomy is among the most reliable and cost-effective methods of contraception. Approximately 15% of the estimated 500,000 vasectomies are performed each year by family physicians in the United States. (1) A survey in 1998 by the American Association of Family Physicians suggested that 29.2% of family physicians offered vasectomy in their offices. Since the no-scalpel vasectomy (NSV) technique authored by Li was introduced to the United States in 1988, it has gained in popularity, and has been found superior to other conventional techniques, both in the ease of performance and in outcomes. (2), (3) Other studies have shown no improvement, (4), (5) however, suggesting that any technique performed by an experienced surgeon yields similar good results. NSV accounted for 29% of vasectomies in 1995, and 37% of physicians performing NSV taught themselves the procedure. (6)

However, certain questions remain unresolved: selection of patients, techniques of managing the vasal ends, the need for postvasectomy semen analysis, matters relating to compliance of patients with semen analysis, relationship of vasectomy to the development of subsequent comorbidities, and whether resident physician training in this procedure has any impact on postoperative morbidity. The fact that the procedure is so widely performed and so permanent lends to unethical practices, with significant and permanent consequences. Hence, there is a need for informed consent from prospective patients. In this article, an effort will be made to describe the evolution of vasectomy as a contraceptive procedure; review some variations in technique; and assess issues associated with preoperative counseling, resident physician training in this procedure, postvasectomy care, and compliance with postprocedural instructions and follow-up and long-term consequences. A description of the procedure is deliberately avoided, as this is well covered in the general literature.

The Evolution of Vasectomy

The vas deferens was a misnomer coined by Berengarius of Capri (1470-1530), an anatomist at Bologna and Padua, under the misconception that sperm passes down from the vas. (7) Sir Astley Cooper (1768-1841), in his treatise Observations on the Structure and Functions of the Testis, presented a comprehensive study of the normal anatomy of the testis (including the vas), followed by a description of the pathology and treatment of its diseases. (8) The Viennese psychologist Eugen Steinach (1861-1944) suggested that vasoligation, through enhancing testosterone production, delayed aging. (9) This resulted in a vasectomy boom in the early 1900s as a form of rejuvenation.

The increasing populations in prisons and mental health facilities in Europe prompted some to label people with mental illness, developmental disabilities, antisocial personality traits, communicable diseases, and drug addiction as "socially inadequate"; vasectomy was seen as the perfect solution to limit their procreation. (7) Albert John Ochsner (1858-1925) introduced this eugenic attitude into the United States and advocated vasectomy as a means of preventing habitual criminals from siring children, suggesting that the procedure caused little physical harm while protecting the community from the predatory instincts of their descendants. In an article published in the Journal of the American Medical Association in 1899, Ochsner (10) advocated vasectomy as a method "to keep undesirables such as habitual criminals, chronic inebriates, imbeciles, perverts and paupers" from reproducing. Eventually, 29 states had statutes permitting sterilization of these groups, though ultimately many such laws were overturned. Eugenic sterilizations, however, continued until the 1960s, with the most recent application occurring in the "aid to families with dependent children" program. (11)

Vasectomy has been used for symptomatic relief of benign prostatic hypertrophy and, more recently, as an adjunct to transvesical prostatectomy to prevent epididymitis. (12) Procreation was not an issue in the age group needing prostatectomies, as retrograde ejaculation follows prostatectomy, the semen being passed subsequently in the urinary stream. This practice continued until the use of antibiotics was found to minimize epididymitis. More recently, vasectomy has been widely advocated as a means of "family planning," especially in populous countries like India, where family planning camps were held, and payments were made in cash and kind to encourage patients to consent to the procedure. (13)

Counseling Issues

Discussion of the procedure, alternative forms of contraception, aftercare, and complications constitutes the first step in patient preparation. Although sperm banking is an option for some individuals, (14) the permanence of the procedure should be emphasized, and, if patients desire future procreation, their suitability is in question. Advantages over tubal ligation (ease of performance, office procedure, more cost-effective, less major morbidity, success checked easily by a semen analysis rather than through a pregnancy) should be highlighted. (3) Many patients prefer to have counseling, evaluation, and the procedure done at a single visit. (15) Another approach is to have the counseling and evaluation on a day before the surgical procedure. Medicaid regulations in many states require a 30-day waiting period between patient consent and procedure. Structuring the counseling process ensures a well-informed and satisfied patient, minimizing the risk of subsequent litigation.

Counseling is also important to minimize the potential for regret, particularly in younger age groups, even though the incidence remains low. (16) Age and number of living children are not medical reasons to restrict access to vasectomy according to the World Health Organization Medical Eligibility Criteria. (17) However, these are important considerations for the counseling process, as men who request vasectomy reversal are typically younger at the time of sterilization. (18) Other factors that have been associated with regret are remarriage or a change in partner, death of one or more children after the procedure, improvement in financial status, childless marriage, unstable relationship, pressure by partner to undergo vasectomy and, more rarely, psychological problems with infertility or comorbid illness. (19)

Technical Advances/Variation. Fear of the procedure, especially of anesthetic administration, remains a barrier to increased acceptance of vasectomy. A "no-needle anesthetic," in which lidocaine is injected using a jet injection device that penetrates the skin to a depth of 4 mm anesthetizes both the skin and the underlying vas adequately in most instances (90%). (20) A double-blind, prospective study showed that the application of EMLA cream significantly decreased the pain associated with lidocaine injections. (21)

Technical variations exist in managing the ends of the vas after excision, each calculated to reduce morbidity and risk of recanalization and to enhance the permanence of the procedure. Options include ligation, clipping, cautery, proximal fascial interposition, and open-ended techniques (Table 1).

In a series of 1,224 vasectomies after removal of a 2- to 3-cm section, the ends of the vas were looped and tied with absorbable polyglycolic acid (termed the excision-ligature technique). (22) Semen analyses were performed 3 months postvasectomy and monthly thereafter until two consecutive azoospermic specimens were obtained, the criterion used to document success. Ten percent of patients had complications, most of them minor, with less than 1% failures. Ligatures, however, are said to cause ischemia and transmural necrosis of the muscle wall of the vas, sloughing of the end distal to the tie, and sperm leakage, increasing the incidence of both sperm granulomas and spontaneous recanalization. (23)

Placement of surgical clips has been advocated as an easy method of sealing the vasal ends. Clipping before transection avoids the risk of retraction of the inguinal and scrotal ends and potentially avoids the complications of vasal necrosis, sperm granuloma, and recanalization. Placement of one clip at each end has a failure rate of 1 to 1.5%. (24) Using two clips reduces this significantly. (25) Clips are, however, difficult to apply accurately without crushing the vas, creating the potential for vasocutaneous fistula. Clips become dislodged frequently due to the natural tendency of the cut ends to retract. (26) Their retention in superficial tissues can lead to chronic pain. However, in a series of 500 outpatient vasectomies performed using bilateral scrotal incisions and metal clips to occlude the vas deferens, no failures and no sperm granulomas were encountered and complications were rare, including a single scrotal hematoma and six minor infections. (27)

Both electrocautery and a handheld cautery have been used to seal the ends of the vas. The cautery end is inserted 3 to 4 mm into the lumen and gradually withdrawn, causing necrosis of the mucosal and muscle layers of the vas, resulting in scarring and occlusion. Granuloma formation is minimal. (23) Electrocautery has the potential to spark through the wall of the vas, creating a full-thickness burn, not evident during surgery. (28) Care should be taken to keep the tip away from gauze pads, in view of its flammable potential. (29)

An analysis of 2,500 patients using electrocautery showed a failure rate of 0.24%. Other undesirable sequelae were low (hematoma, 3%; infection, 2%; sperm granuloma, 1%). (24) This technique also covered the distal end of the vas with surrounding tissue (distal fascial interposition) and so it is difficult to ascribe its success entirely to the scarring resulting from cauterization. To permit closure by scarring, the patients were asked to abstain from ejaculating for 1 week.

Proximal fascial interposition, by contrast, involves closure of the fascial sheath over the prostatic cut end of the vas in a purse-string fashion. The theory behind fascial interposition is that it ensures the discontinuity of the vasal sheath, which is considered critical to the long-term success of the procedure. (30) Continuity of the sheath may serve as a channel for recanalization. A multicenter, randomized, controlled trail including 1,200 men comparing vasectomy with and without fascial interposition showed that interposing the fascia led to a more rapid decrease in sperm counts, though this was confined to men younger than 35 years of age. (31) Compared with clipping, fascial interposition caused fewer failures (0.3 versus 8.7%), though complications were more, probably due to the increased dissection associated with the technique. (32)

Leaving the testicular end of the vas open is found to cause less congestive epididymitis and, if anything, decrease the incidence of both sperm granuloma and resultant failure. (33), (34) This, combined with cauterizing the inguinal end and interposing fascia, seals the proximal end for a distance of 10 mm and separates the ends of the vasa into different fascial planes, minimizing recanalization. (35) It also improves the success of vasal reanastomosis, should it be attempted in the future. This technique has minimal morbidity (Table 1), and in a series of 1,354 open-ended vasectomies, only 2 failures were reported. (35)

A "minimally invasive" technique without segmental excision or ties around the vas, or disruption of its mesentery, is described. The vas sheath is disrupted and both inguinal and scrotal ends cauterized, using a handheld cautery. Analysis of 158 consecutive cases showed complete azoospermia on two follow-up semen analyses, with no pregnancies. (36) Excision of any segment of the vas is said to be unnecessary, require more dissection, and reduce the success of reversal. (37), (38)

In spite of the divergent views expressed above, cautery of the vasal ends combined with fascial interposition approaches perfection both in minimizing complications and in long-term failure. Analysis of a series of 257 consecutive vasectomies performed in this fashion showed one failure (0.5%), no pregnancies, and a negligible minor complication rate (2.5%). (34)

Irrigation of the distal cut end of the vas deferens with sterile water during vasectomy does not seem to accelerate the clearance of spermatozoa. A randomized controlled trial showed no statistically significant differences in the mean time to clearance, proportion clear at 16 weeks (29% versus 21%), or proportion with lingering sperm at 40 weeks (22% versus 26%). (39)

Some difference of opinion exists also regarding vasectomy closure techniques. It has been the authors' practice to leave the scrotal wound open unless there is active bleeding at the incision site that cannot be controlled by pressure. The rugosity of the scrotal skin approximates the edges and seals the wound rapidly. The major advantage of not using sutures routinely is that this avoids the pain, infection, and drainage resulting from tissue necrosis caused by postoperative edema and the need for suture removal, which is also a painful procedure. In a letter to the editor published in the American Family Physician it is stated that leaving the scrotal incision open, or lightly approximating the skin with a hemostat, may be superior or at least equal to closure with suture. (40) The savings of time and money, and possibly a lower complication rate, make a "no-suture" vasectomy closure worth considering.

Aftercare and Outcome

Many patients return to their physician's office for rechecks because of complications or the need for reassurance regarding events associated with normal healing. Use of telephone follow-up increases patient satisfaction and benefits physician practice by curtailing unnecessary follow-up visits. (41)

Publications to date continue to support the conclusion that vasectomy is a highly effective form of contraception. A systematic MEDLINE review of the literature on the safety and effectiveness of vasectomy between 1964 and 1998 revealed early failure rates to be less than 1%, the success and complication rates varying with experience of surgeons and surgical technique. Complications, including hematoma, infection, sperm granulomas, epididymoorchitis, and congestive epididymitis, occur in 1 to 6% of men undergoing vasectomy. Incidence of epididymal pain is poorly documented and perhaps higher. (42) NSV is a minimally invasive procedure, which reduces the fear of incision encountered in men and results in significantly fewer complications. An analysis of 4,253 procedures showed that the complication rates with NSV were surprisingly low: two small hematomas (0.047%), three painful nodules (0.07%), three wound infections (0.07%), and two vasal fistulae. The mean surgical time of NSV was 9.5 minutes. (43)

An outcomes analysis conducted on 470 patients to determine the incidence of long-term complications (mean, 4.8 years) found scrotal pain to be most common (18.7%), which adversely affected the quality of life in very few (2.2%). The majority (71.4%) were satisfied with their decision, and the rest were ambivalent or were dissatisfied. (44) Another study evaluating long-term satisfaction and new counseling possibilities found that over 93% of the responding men were satisfied with vasectomy when asked after 2 years and 95% reported satisfaction 5 years later. Problems mentioned concerned sexual performance, long-lasting pain, and the desire to procreate in new relationships. (45)

There are no standardized guidelines in the follow-up of these patients to assess the efficacy of vasectomy. A survey of urologists and general surgeons in the United Kingdom indicated that there is a wide range of strategies used to follow patients after vasectomy. Most do not appear to be evidence-based. (46) One semen sample taken 16 weeks postvasectomy, and further samples taken only if motile sperms are seen, is considered to be both prudent and cost-effective. Nonmotile sperm is not an indication for checking further semen samples. (46)

The failure rate after a negative initial semen analysis is low. In one study, 20 of 1,000 men had a positive semen analysis during a 3-year follow-up period, with sperm counts being less than 10,000/ml. None of them reported an unwanted pregnapncy, and 14 showed azoospermia when re-tested 1 month later. (47) The risk of pregnancy occurring in the presence of nonmotile sperm was estimated to be less than the established risk of late recanalization. This survey offered both logical and medicolegal support for issuing a "special clearance" to men with few persistent nonmotile sperm after vasectomy, provided that the risks of pregnancy are properly discussed and documented. (48) Persistence of motile sperm, however, requires repeating the vasectomy. (48)

All ejaculates contain potentially fertile spermatozoa immediately after vasectomy, and patients should continue with contraceptive precautions. (49) A few studies have demonstrated rapid immobility of spermatozoa, often within a few days of vasectomy, and usually by 3 weeks. (50) Guidelines developed by the British Andrology Society suggest that patients have at least 24 ejaculations and preferably wait at least 4 months before submitting a first semen sample for examination. (51) This reduces the number of false-positives, minimizing both patient inconvenience and repeat laboratory assessment. (52) Recommendations were also made as to how the semen sample should be collected. Patients should not have ejaculated for 48 hours prior and should have an abstinence period of no longer than 7 days. Semen should be collected by masturbation directly into the container. Condoms should be avoided and the semen should be delivered for analysis within an hour of collection. (51) The World Health Organization suggests that after 12 weeks of 15 ejaculations, one or two sperm-free analyses should be performed to confirm success. (53) The complete disappearance of spermatozoa after vasectomy takes longer than is generally believed and the mean time to azoospermia is 6.36 months, with reappearance of nonmotile sperm being found in up to one-third of the patients 12 weeks after vasectomy. (54)

To determine the rate of recanalization, semen analyses performed after 2,563 vasectomies over a 4-year period were analyzed. (55) Seventy-nine percent of patients submitted a semen sample for analysis and 15% contained sperm. The subjects then provided additional samples until azoospermia. Thirty-six patients underwent reoperation, yielding a calculated recanalization rate of 1.4%. (55) Rate of recanalization could not be associated with the experience of the operating surgeon. As sperm can persist early after vasectomy, reoperation should be performed on a conservative basis and solely in subjects in whom repeated semen analysis has failed to provide evidence of azoospermia. (48) Recanalization and consequent paternity can occur at any time after bilateral vasectomy and does not depend on the surgical procedure or criteria for sterility. Because of the medicolegal and psychosocial implications of paternity after vasectomy for both patient and physician, accurate information about the possibility of recanalization should be given before the procedure. (56) There appears to be no association between the length of vas excised and the risk of recanalization. (57)

To determine the postoperative instruction compliance rate, the records of 1,892 consecutive patients who underwent vasectomy were reviewed and revealed that only one-third had returned for two consecutive semen analyses, one-third had only one sample, and the rest did not come for follow-up. (58) Only 6% submitted to yearly semen analyses, which was part of the protocol. (58) Another retrospective study concluded that compliance was good if patients were required to submit only one sample for analysis but decreased significantly when they were asked to provide a second sample. (59) This study also found that the percentage of patients with azoospermia stabilized after 3 months, and the authors concluded that azoospermia proven on a single semen analysis at 3 months was sufficient grounds for discontinuing other methods of contraception. A third study showed a compliance rate of 70% with semen analyses and suggested that the strict requirement of two consecutive azoospermic postvasectomy semen specimens may be unjustified, leading to a high level of noncompliance and causing unnecessary delay in confirming success of the procedure. (60)

Vasectomy and Subsequent Comorbidity

Vasectomy does not increase arteriosclerosis but does cause a transient increase in circulating immune complexes. (61) The preponderance of evidence suggests that men with vasectomy are not at increased risk of either prostate or testicular cancer. (42) A national population-based case-control study of 923 new cases of prostate cancer among men aged 40 to 74 years from the New Zealand Cancer Registry concluded that vasectomy has no effect on the risk of prostate cancer, even after 25 years or more. (62) It is associated with a twofold increased risk for urolithiasis in men younger than 46 years of age, which may persist for up to 14 years postvasectomy. (63) It does not change the volume of semen, as the seminal vesicles and the prostate contribute 95% of the semen, nor does it result in organic impotence. The case for psychogenic impotence following vasectomy can be made, though the association is tenuous at best, being more related to poor acceptance. (64) A decrease in frequency of intercourse and sexual desire and changes in sexual behavior during intercourse have also been reported. (65)

Impact of Physician Training. One potential drawback in training resident physicians to acquire the requisite skills in office surgical procedures is worsening complication rates. The success of procedures is proportional to the skill with which it is performed, and proctors must take additional precautions to ensure that the risk of complications is minimized, when training residents with minimal surgical expertise. If significantly worse sequelae were discovered, a need to reexamine the training modalities of resident physicians in this procedure would be indicated. Resident physicians are routinely trained on the assumption that the presence of a proctor and judicious intervention will successfully achieve this goal. To our knowledge, there have been few studies comparing outcomes of resident-performed or resident-assisted vasectomies with those performed by trained physicians. An estimate of the complication rate and morbidity of no-scalpel vasectomy done in a family practice residency, where one family physician directly attended all cases and supervised resident trainees, showed an absence of major hematoma, a minor infection rate of 1.4%, and a failure rate of 0.7%, comparable to other published reports. (66) It has also been shown that the Li vasectomy (NSV) can be learned and practiced under routine conditions by residents in training with the same effectiveness and the same rate of complications as standard vasectomy with bilateral incision. (5)

Conclusions

Vasectomy is a highly cost-effective, permanent sterilization procedure causing minimal morbidity with a high success rate and rare long-term consequences of significance. Care in patient selection is paramount, and steps should be taken to identify those who are at an increased risk of regretting the procedure and suffering subsequent adverse psychological consequences. A physician may become facile with any technique of vasectomy over time and should be adept at choosing the technique best suited to individuals. The authors believe that though individual techniques of managing the vasal ends and closure have their proponents, most techniques practiced long enough yield excellent results. For the beginner or the "occasional vasectomist," the case for NSV with cauterization of the ends and fascial interposition is compelling with regard to both the ease of training and its demonstrated superiority through minimizing sequela. We think that though excision of a segment of the vas does not contribute to its eventual success, it helps ratify through histologic evaluation that the appropriate organ was transected, particularly in those patients with persistent sperm in postvasectomy semen specimens. The process of following patients by telephone interview and documenting their postsurgical course is both efficient and informative. Delivery of a fresh sample of semen at 16 weeks after surgery for analysis enhances the documentation of success and minimizes anxiety. We feel that asking patients to wait any longer may defeat the biggest benefit of the procedure, the discontinuation of other contraceptive measures. Although rare, long-term consequences of the procedure such as testicular pain or psychogenic impotence may engender dissatisfaction and affect the quality of life. Resident physicians may easily be trained in vasectomy through observation and assistance of an experienced supervisor, with little impact on the sequelae, though further studies are necessary to confirm this.

If I had to live my life again I would have made a rule to read some poetry and listen to some music at least once a week; for perhaps the parts of my brain now atrophied could thus have been kept active through use.

--Charles Darwin

Table 1. Techniques of vasal occlusion and sequelae

                              Complication rate
                            (hematoma, infection,    Failure
Technique                     sperm granuloma)     rate (a) (%)

Ligation                     Higher (10.6%) (b)        1-2

Surgical clips                      Low                1-2

Cauterization                       Low                0.24

Cauterization with fascial          Low                0.2
  interposition

Open ended vasectomy                Low                0.5

(a) Failure rates vary in different series. Best results depicted in the
table.
(b) Majority were minor complications.

From the Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK.

Reprint requests to Kalyanakrishnan Ramakrishnan, MD, Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, 900 N.E. 10th Street, Oklahoma City, OK 73104. Email:[e-mail]

Accepted January 28, 2003.

Copyright [c] 2004 by The Southern Medical Association 0038-4348/04/9701-0054

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RELATED ARTICLE: Key Points

* Physician training probably has little impact on the morbidity of vasectomy, but further studies are required to corroborate this.

* To ensure a well-informed, satisfied patient and minimize the potential for regret and adverse sequelae, proper patient selection and counseling are mandatory.

* All techniques of vasectomy yield excellent results in experienced hands. For the beginner, no-scalpel vasectomy with cauterizing the vasal ends and fascial interposition is recommended.

* Patients should be followed up to document morbidity and ensure compliance with semen analysis. Analysis of a single fresh sample of semen at 16 weeks is sufficient, with further analyses only if motile sperm are seen.

Gerald A. Amundsen, MD, and Kalyanakrishnan Ramakrishnan, MD