Vasectomy, the sterilization procedure for men, is simpler and safer than female sterilization and is usually performed in a doctor's office or a clinic. A vasectomy takes approximately 20 minutes, is almost 100 percent effective, has few complications, and is permanent. Some 500,000 vasectomies are performed each year.
The term "vasectomy" means cutting the two vasa deferentia, the sperm ducts, that carry sperm from the testicles to the penis. A small portion of each duct is usually removed and the cut ends are closed off. This procedure effectively prevents sperm from getting into the semen that is ejaculated during sex. Although it is possible to reverse a vasectomy, a reversal procedure requires difficult microsurgery. Under the best conditions, the reversal succeeds only about 50 percent of the time (a pregnancy is viewed as success), and it is very expensive.
A vasectomy does not influence a man's virility, nor does it have any negative impact on his overall health. It does not lead to premature aging, and the most recent studies find that it does not increase the chance of prostate cancer. After a vasectomy, a man still produces male hormones, has erections and orgasms, and ejaculates. Even the amount of fluid that he ejaculates is virtually unchanged,
IN A NUTSHELL
Vasectomy is a permanent form of birth control for men. The tubes that carry the sperm from the testicles to the penis are cut and the cut ends are closed off. This prevents sperm from getting into the semen that is ejaculated during sex.
This method of birth control is highly effective and has few complications. It is faster, simpler, and less expensive than female sterilization.
A vasectomy does not change your virility or strength or increase your chance of prostate cancer. You still produce male hormones, have erections, and ejaculate.
A local anesthetic is injected near the sperm tubes in the testicles. A tiny incision is made. Each tube is pulled through the incision, cut, and tied off. The whole operation takes about 20 minutes. The incision is so small it does not need stitches.
Vasectomies are done as outpatient procedures at doctor's offices, clinics, and hospitals.
A vasectomy does not protect either partner against STDs, including AIDS.
since sperm contribute only a small amount—3 to 5 percent—to the total volume.
The only change that takes place is that the semen contains no sperm, so it cannot cause a pregnancy. In fact, some men report an increase in sexual desire after having a vasectomy, because they are no longer worried about the possibility of an unwanted pregnancy.
After your vasectomy you will still be fertile for a while, until all the sperm that were present when the surgery was performed have been ejaculated or have died. This process takes between 2 and 4 months—or about 20 ejaculations. Meanwhile, you or your partner should use another contraceptive method until two consecutive specimens of semen are found to be free of sperm.
A vasectomy does not protect either partner against AIDS or other sexually transmitted diseases.
The standard vasectomy technique uses a tiny incision; the "no-scalpel" method utilizes a puncture.
The vasa deferentia that carry sperm from the testicles to the pe-
nis can be felt just under the skin of the scrotum. The outer, muscular wall of each sperm duct is thick and less flexible than the nearby blood vessels, which are soft and pliable to the touch (Figure 13.1). The physician doing the vasectomy uses his or her fingers or a special clamp to hold one vas firmly under the skin while injecting a local anesthetic, usually lidocaine. (The injection hurts for several seconds.) Some practitioners apply a second injection just above the vasectomy site to act as a nerve block for more complete protection against pain.
When the area is numb, the doctor uses a surgical clamp to hold the skin tightly over the vas, making a tiny (1/4 to 1/2 inch) incision through the skin and the thin layer of muscle tissue. When the duct is accessible, a very small forceps or similar instrument is used to pull it gently up through the incision. Although the site of the surgery itself is anesthetized, you may still feel a pulling sensation on the upper part of the duct.
Many clinicians prefer to make an incision directly over each duct, but some make a single incision halfway between them and
E Each end is tied by suture and skin is closed
FIGURE 13.1 Standard Vasectomy Procedure
FIGURE 13.1 Standard Vasectomy Procedure draw each duct over to the opening to snip it. After each vas has been severed and its cut ends closed, it is returned to the scrotum. The incision is closed with an absorbable suture—some incisions are so small they need no suture.
To sever the vas, the surgeon may snip through it with scissors and then remove a short bit of tube to make certain the two cut ends will not join again accidently. Because the human body has such a strong tendency to repair itself, most physicians today seal the cut ends with electrocautery, employing a technique similar to the one used in female sterilization to close the fallopian tubes. A quick touch of high-frequency electric current causes the inside of the duct to scar into a permanent seal. Other methods include folding and suturing each severed end back on itself, or suturing a bit of the outside sheath of the duct over the end to close it.
Sperm will still be produced by the testicle and may build up behind the closed end of the duct that carries them from the testicle. Accumulated sperm sometimes—rarely—can be painful. Fortunately, they have a short life cycle and soon die off and are absorbed by the body.
Some surgeons may leave open the end of the duct that carries sperm from the testicle—the epididymis—closing only the section that connects with the penis. This allows sperm to spill and not accumulate in the delicate epididymis. A vasectomy that leaves the epididymis portion of the vas open avoids the possibility of the epididymis being harmed by pressure from accumulated sperm. Regardless of where sperm go, however, they are absorbed. Although a vasectomy that closes off only one end of the dissected vas may be more reversible, it also has a somewhat greater chance of failing.
A vasectomy usually takes about 20 minutes. After a brief recovery period at the clinic, it is advisable to rest in bed at home for 24 hours to allow the incisions to heal. You may experience a dull, aching pain and some bleeding for a few days. You can take a painkiller, preferably one that does not contain aspirin, such as acetaminophen, because aspirin reduces the blood's ability to clot. Men who do physical labor generally are advised to wait a week before going back to strenuous work, in order to encourage healing and avoid bleeding complications. All men who have had vasecto-
mies should wear an athletic supporter or jockey shorts for four to six weeks to support the scrotum until it is completely healed.
A vasectomy procedure that is growing in popularity is the no-scalpel method, which was developed in China in the 1970s. It is called the "no-scalpel" method because a puncture instead of an incision is made in the scrotum to reach the sperm ducts. A puncture instead of an incision greatly reduces the risk of accidently cutting into a blood vessel. The approach takes only about 10 minutes and causes considerably less soreness, bleeding, and bruising afterward. Furthermore, the chance of infection or a hematoma (a collection of blood) is much less.
As in a standard vasectomy, some clinicians are using the anesthesia technique that is basically a nerve block. A small amount of local anesthetic is injected at the site in the scrotum where the puncture will be made and then, with the same needle, additional anesthetic is injected near the vasal nerve above the vasectomy site. The anesthetic takes effect almost immediately. When the area is numb, a sharp instrument is used to pierce the skin of the scrotum and the vas sheath where the duct is most prominent and accessible beneath the skin. The same instrument is then used to spread apart the opening. Each vas deferens is pulled, in turn, through this tiny opening, cut, and closed off according to usual vasectomy practice (Figure 13.2). After each duct is closed, it is put back in place in the scrotum. No stitches are required to close the wound. The puncture contracts and becomes almost invisible. Antibiotic ointment is applied and the area covered with a small gauze bandage that is held in place with the help of a snug pair of undershorts or an athletic supporter.
Vasectomy is highly effective and should not be considered a reversible method. Although it is possible to repair the occluded sperm ducts, this requires delicate surgery and does not always succeed.
FIGURE 13.2 No-Scalpel Vasectomy
A typical first-year failure rate for vasectomy is 0.5 to 1.0 percent. A true failure of the technique can take place only when a closed duct opens or reconnects, or when a structure other than the duct—such as a blood vessel—is mistakenly cut and closed off instead of the vas. Such events are very rare.
Pregnancies can occur if you have unprotected intercourse before your reproductive tract has been totally emptied of the sperm that were present when the surgery was performed. In a few extremely rare cases, men who had at least two negative sperm counts after a vasectomy fathered children.
Like tubal occlusions in women, vasectomies sometimes can be reversed successfully. The success of a reversal procedure depends largely on the skill of the surgeon. The diameter of the inner canal of the vas deferens has been described as being approximately the diameter of a pinpoint. To achieve a clear connection between the two severed ends of the duct, the surgeon must use a microscope while rejoining the ends of these almost invisible tubes. Because this operation is major surgery, it calls for the use of general anesthesia, is expensive, and requires a long recovery time.
If the epididymis has been damaged, the injured area of this fine, tightly coiled tube must be bypassed by suturing the end of the vas to the nearest healthy part of the epididymis. Since the epididymis is even more delicate than the inner canal of the vas, this sort of repair often fails. Moreover, it may take months or even years before an epididymis long dilated by sperm buildup finally returns to normal functioning.
Pregnancy rates following a reversal procedure vary widely, from 16 percent to 79 percent, with the majority of clinics achieving a success rate close to 50 percent of couples who passed a screening process for possible success. For all practical purposes, vasectomy should be viewed as a permanent form of contraception.
Complications after vasectomy occur only in a small fraction of the procedures. They include:
Hematoma. The most common complication from a vasectomy is a hematoma, a mass of clotted blood, caused by damage to a blood vessel during the surgery. Normally, blood drains from the incision, but occasionally the blood accumulates instead of draining, and within 24 hours the scrotum becomes enlarged and painful. Draining this may require a brief hospitalization. Although unpleasant, hematomas generally do not cause permanent harm. They may be prevented if you spend the first 24 to 48 hours off your feet, preferably in bed. Any upright activity, even walking, increases pressure on the blood vessels and the likelihood of a hematoma. In a review of almost 25,000 vasectomies, hematomas occurred in 1.6 percent.
Infection. An infection occasionally develops near the site of the incision. It should be treated immediately with antibiotics. Infections occur in 1.5 to 3.4 percent of vasectomies.
ARE YOU A GOOD CANDIDATE FOR VASECTOMY?
Vasectomy is an excellent contraceptive option for the man who is in a stable relationship and has all the children he wants. Men whose partners have health problems that may make a pregnancy unsafe frequently turn to vasectomy as the most reliable form of birth control. Similarly, couples who are at risk for passing on a hereditary disease or disability often choose sterilization—and vasectomy is the safer and less expensive form.
If you are young, are not sure about having children, or are considering sterilization in the hope that not having to worry about birth control might steady your relationship, you are not a likely candidate for vasectomy. If you are thinking of storing your sperm in case you may want children in the future, vasectomy is probably not for you at this time. (Sperm banking is expensive and not always successful.) Finally, if you have any reservations at all about vasectomy or if you are under any pressure to have the procedure, postpone the decision.
Epididymitis. Acute inflammation of the epididymis occasionally follows vasectomy surgery. It is treated with heat, support of the scrotum to relieve discomfort, and antibiotics. Epididymitis occurs in approximately 1.4 percent of vasectomies.
Sperm Granulomas. A painful nodule or lump can develop at the site of the vasectomy or in the epididymis. This is a sperm granuloma (a localized inflammatory reaction), usually caused by the presence of sperm that have leaked from one of the severed ducts. The lumps rarely become painful—only if the lump touches a nerve. This problem occurs in about 0.3 percent of vasectomies and only needs treatment if it is painful. Treatment may require having the vas deferens on that side removed so sperm will no longer reach the granuloma. The lump then is absorbed by the body and stops causing pain.
HAVING A VASECTOMY
Because it is difficult to reverse a vasectomy successfully, choosing it should be given long, careful thought.
Before undergoing this operation, it is essential that you feel comfortable with the fact that a vasectomy is permanent. If you have any doubts, postpone the operation until you are more certain of your feelings, and have gotten all the information you feel you need. Other men who have had vasectomies can provide you with useful insights and advice. Family planning clinics may do much better than individual physicians in providing information and counseling. Do not hesitate to ask a lot of questions.
Urologists, family physicians, and general surgeons perform vasectomies. Your own family health care provider or your partner's gynecologist are good places to start making inquiries. In addition, most hospitals have at least one physician on staff—usually a urologist—who is experienced in both the standard and no-scalpel procedures. If medical resources are scarce in your area, get in touch with a local family planning clinic, Visiting Nurse Association, health department, or county medical society. (Family planning clinics often are listed in the Yellow Pages.) Or contact the Association for Voluntary Surgical Contraception, 79 Madison Avenue, New York, N.Y. 10016 (212-561-8000). The association is an especially helpful resource if you are interested in the no-scalpel vasectomy and finding a practitioner who has experience with it.
No matter which technique is used, some men find vasectomy painful. Before the surgery, make certain you understand exactly how your physician plans to perform the procedure and what he will do to minimize the possibility of pain and discomfort. Pain tends to be magnified when it is unexpected, so knowing every detail of the operation goes a long way toward making the surgery more comfortable. A sedative beforehand also makes things easier. As mentioned earlier, an additional injection of anesthetic above the site of the incision or puncture may be more effective in blocking pain along the vasal nerve, which carries sensation to the vasa deferentia. This approach is worth discussing with your doctor.
Your doctor will conduct a physical examination beforehand that will take into account the existence of any local infections, hernias, and the present condition of your testicles and penis. A vasectomy is more difficult if you have an undescended testicle, a hernia or a repaired hernia, or some other abnormality. A health history will note any condition that may affect the surgery and its outcome, such as past operations and illnesses, as well as allergies to local anesthetics and pain medications.
Make arrangements to have someone drive you home afterward, and to avoid all exertion for 24 to 48 hours after the vasectomy. Also get an ice pack to use later. Before the surgery, use scissors to trim the hair around your penis and scrotum to about 1/4 inch, so this does not have to be done in the doctor's office. (You do not need to cut or shave the pubic hair above your testicles and penis.) Then shower or bathe to get rid of the loose hair and wash your testicles and penis thoroughly with soap.
Bring an athletic supporter or a snug pair of briefs with you to wear after the operation. (Briefs are likely to be softer and less irritating than a supporter.) This will hold the dressings in place and, by supporting the testicles, protect the incision area from strain and discomfort. Your physician can help you put on the supporter and briefs. Even after the incision or puncture no longer needs a bandage, you should continue to wear the support until you are completely healed.
If possible, schedule the operation for a Thursday or Friday so you will have the weekend for recuperation. The less active you are for a few days after the vasectomy, the lower your risk of having a complication.
Get the telephone number and name of the person to call if you have any questions at any time later on or if you experience unusual discomfort. Check with the physician or nurse about how often to change the dressing. Gauze pads can be bought at drugstores, or your vasectomist may provide you with a supply. Keep a bandage on the wound for as long as your doctor indicates.
Once at home, spend most of that day and the next with your feet up—literally. Periodically put the ice pack on your scrotum for the first day to reduced the chance that the incision area will swell or bleed. If necessary, take a non-aspirin, over-the-counter pain reliever such as acetaminophen. Check your choice of medication and the dosage with your physician before you leave the office or clinic.
Avoid strenous physical activity—any hard exertion that will strain or put pressure on your groin or scrotum.
It is normal to have some pain, swelling, and discoloration in the immediate area of the incision or puncture for a few days, or sometimes longer. This is less likely to occur, however, if you have had the no-scalpel procedure. A small amount of blood or clear fluid may ooze from the incision for a day or two. The gauze bandage will absorb this and protect the incision from being irritated by your clothes. If a single pad does not seem to be enough, use several. If these symptoms grow worse, get in touch with the practitioner who performed the vasectomy or with your regular physician.
AFTER-VASECTOMY DANGER SIGNS
Call your physician immediately if you experience any of these symptoms:
• Fever—a temperature over 100.4 degrees F—within a week after the operation.
• Swelling near the incision that is larger than a quarter, or pus or continual bleeding from the incision or puncture.
• Pain in the area of incision or in the scrotum that gets worse or does not go away in a day or two.
To keep the incision dry for the first couple of days, do not shower or take a bath or go swimming. When you do bathe or shower, wash the incision area gently but thoroughly.
In the rare instance that the sutures were not the absorbable type, you will need an appointment to have the stitches removed.
The rule for having intercourse after a vasectomy is to wait until it feels comfortable, anywhere from a few days to a week or two. If your scrotum is still sore, you can reduce the vigor of your lovemaking.
After the operation there is still stored-up sperm in the semen for some time, so you or your partner need to use some kind of birth control until at least two tests of your semen show no sperm are present. Do not skip these tests: most vasectomy failures show up (as pregnancies) in the first year afterwards.
Some men also have pain in the scrotum, as testicular fluid and sperm build up behind the surgical obstruction before being absorbed by the body. The chance of this occurring may be reduced by leaving the cut ends of the vas open. Regardless of which method is used, the congestion goes away after a few months.
A vasectomy costs between $350 and $1,000, depending on where you live and who performs it. As a rule, this cost includes two or three postoperative visits for testing your semen for sperm. Sometimes this charge includes the first consultation, but often the first visit is billed separately, because a substantial number of men who have a consultation do not go on to have the surgery. Many health insurance plans, HMOs, and Medicaid pay for vasectomies.
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