In the United States, vasectomy emerged as a popular method of permanent contraception during the 1960s. Within a decade, 750,000 men were undergoing vasectomies each year. Vasectomy rates markedly declined in the 1990s and have now leveled off at about 500,000 a year. Worldwide, millions of couples use vasectomy as a method of permanent birth control.
The procedure works by surgically interrupting the route that the sperm take from the testicles (where they are produced) to the penis. After vasectomy, the testicles still continue to generate sperm, but their movement is blocked at the site of the vasectomy. Eventually the sperm die, and the patient's body absorbs them. During sex, semen is produced in the same amount as before vasectomy, but this fluid does not contain sperm.
Vasectomy should not be confused with castration. It has no noticeable impact on a man's ability to perform sexually, or on his sensation of orgasm and pleasure. It does not affect the balance of male hormones, male sex characteristics, or sex drive. Testosterone continues to be produced in the testes and delivered into the bloodstream. Sperm form a very small portion of semen, so patients notice no difference in the amount of semen produced during orgasm.
The male reproductive tract performs three functions:
The Traveling Sperm. The sperm's journey through the male body -- from the testes (the testicles) to the final stage (the orgasm) -- is long and complex:
The decision to have a vasectomy should be made only after serious consideration. The surgery is intended to be permanent. The great majority of men who seek a vasectomy have been married for 10 years or more. Not all are good candidates, however. It is important that both the woman and the man completely agree that they no longer want to have children. They should also agree that permanent birth control is the right decision for them. Ideally, the couple should view the operation as a mutual commitment to an already successful marriage or relationship. Vasectomy generally is not a good idea if the couple's relationship is under great stress. It is not a cure for emotional or sexual problems between a man and woman.
Single men, some of them younger, may also choose to have a vasectomy. Physicians may refuse to perform the procedure depending on how young person is, or ask these men to wait for a year or even more.
After deciding that permanent birth control is the best solution, a couple still has the option of either vasectomy for the male or tubal ligation (female sterilization) for the female. Female sterilization is performed three times as often as vasectomy, but vasectomy is a less complicated and less expensive procedure, and poses fewer risks for complications.
Vasectomy is very safe and is nearly 100% effective for preventing pregnancy. It does not protect against sexually transmitted diseases (STDs). Condoms remain the best method of STD prevention for sexually active people.
The decision to have a vasectomy should be carefully considered. A reversal procedure can be performed, but it is a major operation that does not guarantee restored fertility. In addition, these reversal procedures (vasovasostomy and vasoepididymostomy) are much more complicated surgeries than vasectomy.
Surveys indicate that the vast majority of men are satisfied with vasectomy and that this satisfaction persists. Most men who have vasectomies feel relieved that the worry about pregnancy is over, and most couples respond well to their new-found contraceptive freedom.
Vasectomy does not affect a man's hormonal levels and does not impair sexual potency, desire, or satisfaction. Some men may go through a brief period of self-consciousness, wondering whether others notice some difference in their masculinity. For most men, this tentativeness passes quickly. Some couples may experience difficulties, which manifest in sexual dysfunction such as erectile dysfunction, premature ejaculation, or painful intercourse. In such cases, the underlying cause is usually unresolved emotional issues, not the vasectomy itself.
Vasectomies may be right for:
Vasectomies may not be right for:
Sperm banking can be used in conjunction with vasectomy or vasectomy reversal surgery. Sperm banking involves freezing (cryopreservation) and storage (cryobanking) of sperm. It is usually performed before a vasectomy, or during or after reversal surgery. If a man later desires to have children, the sperm can be used for assisted reproductive technologies, usually intracytoplasmic sperm injection used in combination with in vitro fertilization.
Sperm banking is no guarantee for successful conception and pregnancy. Sperm can be frozen for many years, but even after 6 months not all sperm cells remain fertile after being unfrozen. In addition, sperm banking is typically not covered by health insurance plans and costs should be considered.
Although most men who have a vasectomy never use their banked sperm, it is understandable if some men are emotionally reassured by the idea that they have sperm preserved "just in case." Still, men who are considering vasectomy should not view sperm banking (or vasectomy reversal) as a guaranteed option if they later change their minds. It is best to undertake vasectomy as a permanent sterilization procedure. If future fathering of children seems a possibly desirable scenario, it is wise to reconsider whether vasectomy is the right decision to make.
Vasectomy is a minor operation that takes about 15 - 30 minutes and is usually performed with local anesthesia in a doctor's office or a family planning clinic. Most insurance policies will cover vasectomies performed as a minor outpatient procedure, but will not cover vasectomies performed as major surgery in an operating room. If a Vasclip procedure is performed, there may be an additional cost for this device.
A conventional vasectomy procedure is performed as follows:
A method of vasectomy called no-scalpel vasectomy (NSV) that does not require the use of a scalpel was developed in China in 1974. NSV is now used in a third of all vasectomies.
The technique takes about 10 minutes and is performed in a doctor's office or a family planning clinic. The no-scalpel vasectomy differs from a conventional vasectomy in the method of accessing the vasa deferentia:
When performed correctly, NSV works just as well as conventional vasectomy, takes less time, and causes less bleeding, infection, and pain. Current research indicates that NSV is the safest type of vasectomy procedure. NSV is difficult to perform, however, and most surgeons must do about 15 - 20 procedures in order to be proficient. NSV is becoming a popular alternative to standard vasectomy, but it is important to select a doctor who is experienced with this procedure.
A simpler method of NSV, called percutaneous vasectomy, is now also being used. Recent research suggests that it works as well as standard NSV and is easier to perform. Percutaneous vasectomy uses the same instruments as no-scalpel vasectomy, but with a different surgical technique. The hemostat is used to first puncture the skin (instead of spearing the vas and lifting it out). The ringed clamp is then passed through the incision and used to enclose the section of the vas that is then pulled out for closure. This avoids the need for the difficult wrist maneuver in NSV.
Vasclip. The Vasclip is a recent alternative to conventional vasectomy. The procedure does not involve cutting the vas deferens. Instead, a very small rice-sized plastic clip is locked around the vas deferens to stop the flow of sperm. Some studies have reported fewer post-surgical complications than with standard vasectomy, including infection and swelling. However, studies have also reported that the Vasclip is less effective than no-scalpel vasectomy for reducing sperm count. To date, there is insufficient evidence that the Vasclip is better than standard vasectomy. Some insurance companies consider this procedure to be investigational and will not pay for it.
Vasectomy is a low-risk procedure, and complications, which occur in about 10% of patients, are usually easy to control. There are generally fewer complications with no-scalpel vasectomy. Pain or soreness typically lingers for a few days after the procedure, but this is normal and usually does not require a return visit to the doctor. No deaths resulting from vasectomy have ever been reported in the United States.
Nearly all men recover completely in a few days. The following are some guidelines after the operation to help recovery:
Although rare, more serious complications may occur soon after surgery. They include:
Bleeding . Frequently, blood may seep under the skin, so that the scrotum and penis appear to be bruised. If there is no dangerous swelling, this painless problem usually disappears without treatment within 1 - 2 weeks. If the patient bleeds excessively in the days after the operation and requires more than two or three gauze changes per day, he should call his doctor.
Hematoma . In a small percentage of cases, bleeding inside the scrotum can cause a painful swelling known as a hematoma. In these cases, the scrotum swells up shortly after vasectomy. The doctor should be called immediately.
Infection . Infection can occur after vasectomy. The incision site may become infected, causing redness and swelling around the incision. Antibiotics, antimicrobial creams or ointments, or both, along with hot baths several times a day will usually clear the infection in a few days. Severe infections are extremely rare.
After the vasectomy procedure, there are always some active sperm left in the semen for several months, so the risk for pregnancy persists. The patient is considered sterile only when there are no live or moving (motile) sperm in his semen.
It takes, on average, around 3 months to clear the viable sperm from the reproductive system, but it may take some men as long as 6 months to become sterile. The doctor will perform a semen analysis at around 12 weeks after vasectomy to verify that no live sperm remain in the semen. It is essential that the patient and his partner continue to use other methods of birth control until his sperm count is zero.
About 25% of men who have vasectomies never bother to return for follow-up sperm testing (semen analysis). Without a follow-up test, men do not know whether the vasectomy was successful. Until test results verify that there are no sperm in the semen, men are at risk of fathering unwanted pregnancies.
Vasectomy Failure and Unexpected Pregnancy . Pregnancy rates after a vasectomy are very low, about 1 in 1,000. There are two main reasons for an unexpected pregnancy:
Recanalization and Sperm Granulomas . The primary reason for vasectomy failure is recanalization-- when the cut ends of the vas deferens spontaneously reconnect. Recanalization in some cases may be due to sperm granulomas. These are tiny balls of debris that form from sperm, scar tissue, and white blood cells at the incision site. Cells lining the inside of the vas deferens grow through the scar tissue and form a new channel through which the sperm can now move. In general, surgeons can reduce the risk for recanalization by leaving a gap between the two cut ends.
This natural vasectomy reversal can occur after any vasectomy surgical procedure, but it is uncommon. When recanalization does occur, sperm counts are almost always very low and pregnancies are still rare. Most cases of recanalization develop within several months after the operation. In very rare cases, sperm have reappeared a year or even longer after vasectomy.
Epididymitis . Epididymitis occurs when an inflammation at the site of the vasectomy causes swelling of the epididymis. This rare condition usually occurs within the first year and is treated with heat and anti-inflammatory medications. It usually clears up within a week.
Anti-sperm Antibodies . Sperm continue to be produced after vasectomy but are disposed of in the body. In some men the immune system mistakes these sperm as foreign proteins (antigens) and produces anti-sperm antibodies that are designed to target and interfere with sperm's motility (ability to move). Infections in the genital tract, such as orchitis or sexually transmitted diseases, increase the risk for anti-sperm antibodies. The anti-sperm response itself appears to be a problem only if a man wishes to reverse the vasectomy.
Chronic Pain . Some men develop testicular pain following vasectomy. If this pain lasts longer than 3 months, it is referred to as postvasectomy pain syndrome (PVPS). The causes of PVPS are unclear. It may be due to obstruction and resulting contraction of the epididymal duct, or inflammation and formation of fibrous tissue after rupture in the duct, which can cause nerve damage. Sperm granuloma has also been discussed as a possible cause, although their role remains controversial.
PNVS is first treated conservatively, with heat or cold therapy, rest, scrotal support, and nonsteroidal anti-inflammatory drugs (NSAIDs). Most patients are successfully treated with conservative therapies. If these methods do not work, other drug therapies, (including injections of local anesthetics or steroids), may be tried. Transcutaneous electrical nerve stimulation is another method that has been used with good results. If all options fail, surgical interventions, [including removal of the epididymis (epididymectomy), granuloma excision, or vasectomy reversal surgery], may be required.
Cancer Concerns . Because testosterone levels remain higher for a longer period in men who had vasectomy, there have been concerns raised as to whether vasectomy can increase the risk of developing prostate cancer. Men with a family history of prostate cancer can discuss the risks and benefits of vasectomy with their doctors, although the weight of evidence to date indicates there is no link between vasectomy and prostate cancer. There have also been some concerns that vasectomy could increase the risk of testicular cancer. Studies have not identified any significant associations between the two.
Although men should consider vasectomy a permanent decision, reversal procedures can restore fertility in some men who change their minds. The main reasons for requesting a vasectomy reversal are remarriage or the death of a child.
Vasectomy reversal can also sometimes provide pain relief for some of the small number of men who suffer post-vasectomy pain, but these patients should first be treated with pain management therapies. For men who desire a vasectomy reversal for psychological reasons, counseling is a better option.
There are two types of vasectomy reversal surgical procedures:
These procedures help restore sperm flow so that sperm can be ejaculated out of the urethra. Both types of procedures are performed on an outpatient basis and the patient can return home the same day.
It is not possible to know in advance which procedure will be performed. The surgeon will make the decision whether to use vasovasostomy or vasoepididymostomy based on a fluid sample taken at the start of the operation. The fluid is removed from the vas end closest to the testicle and examined for its appearance and the presence of sperm.
If sperm are present or the fluid is clear, it indicates that there is no blockage in the epididymis, and a vasovasostomy can be performed. No sperm, or a creamy, thick appearance of fluid, is a sign of blockage, and the vasoepididymostomy surgical approach to bypass the blockage should be used. Other factors may also determine the surgeon's choice of reversal surgical procedure. In some cases, a combination of the two surgeries may be used, with vasovasostomy performed on one side and vasoepididymostomy on the other side.
Vasovasostomy . Vasovasostomy uses several different surgical approaches. Usually a microsurgical technique is used, in which a microscope helps magnify the surgical area. Vasovasostomy takes 2 - 3 hours to perform. The patient is given local anesthesia and a mild sedative.
Vasoepididymostomy. Vasoepididymostomy is a more complex microsurgical technique. To appreciate the difficulty of this operation, one should realize that the epididymis is 1/300th of an inch wide with a wall thickness of 1/1000th of an inch. Microscopic techniques are critical for the success of this procedure and require a surgeon who specializes in them. Vasoepididymostomy takes up to 4 hours to perform. The patient is given either general anesthesia or an epidural block.
Pain after reversal surgery is usually not severe and can be controlled with mild analgesics such as acetaminophen (Tylenol). A cold pack placed on the scrotum area can help relieve swelling. Your doctor may recommend that you wear a jockstrap for a few weeks to help provide compression and to keep the surgical incisions in place. Most patients can return to work and resume normal non-strenuous activities within a week, but patients may need to refrain from heavy lifting and other rigorous physical activities for up to 4 weeks following surgery. Patients should wait 2 - 4 weeks before having sex.
The doctor will perform a semen analysis every 2 - 3 months after reversal surgery to check your sperm count. It generally takes around 2 months for sperm to reappear following vasovasostomy, and around 3 - 15 months following vasoepididymostomy. Either a stabilized sperm count, or pregnancy, indicates successful reversal surgery.
If reversal surgery is not successful, a repeat surgery can be performed. However, the success rates for repeat reversals are lower than for an initial reversal.
Vasectomy reversal restores sperm production in about 80 - 90% of men. On average, around 50% of couples achieve a pregnancy within 1 - 2 years after reversal surgery. Microsurgical techniques appear to help produce higher quality grade of sperm and better pregnancy rates than macrosurgical techniques. Several other factors determine the likelihood of a successful outcome. The experience of the surgeon is one critical factor. The time interval between the original vasectomy and the reversal procedure is another important factor. The closer the time between vasectomy and reversal, the better the chances for fertility.
Sperm removed during vasovasostomy can be frozen and used for assisted reproductive technologies in case of unsuccessful reversal surgery. If reversal surgery is not successful, a doctor may also be able to retrieve sperm from the testes or epididymis using various sperm retrieval techniques such as testicular fine needle aspiration, microsurgical epididymal sperm aspiration, percutaneous epididymal sperm aspiration, or testicular sperm extraction.
The best assisted reproductive technology procedure for men who have had vasectomies or failed reversal surgery is intracytoplasmic sperm injection (ICSI). The procedure involves injecting a single sperm into an egg. The fertilized egg is then implanted in the woman using in vitro infertilization (IVF).
Some men may consider pursuing ICSI in place of vasectomy reversal surgery. Even though the introduction of ICSI has helped improve pregnancy rates after vasectomy, reversal surgery is usually still a better choice for most men who want children. Reversal surgery costs less than ICSI and men have the potential to achieve long-lasting fertility. ICSI is performed a limited number of times, and the success rates are best if the women is younger than age 37. ICSI/IVF also increases the chance for multiple births, which can pose risks to the mother and babies. However, ICSI may be more effective than reversal surgeries in men whose vasectomies were performed at least 15 years earlier.
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