Vasectomy

 DSC_0050.jpgOverview 
Vasectomy is a minor surgical procedure to cut and close off the tubes (vas deferens) that deliver sperm from the testes; it is usually performed as a means of contraception. The procedure typically takes about 30 minutes and usually causes few complications and no change in sexual function. About 500,000 vasectomies are performed annually in the United States. A vasectomy is less invasive than a tubal ligation (i.e., the procedure used to prevent a woman’s eggs from reaching the uterus) and more easily reversed. An increasing number of couples choose it as a means of permanent birth control.

Male Reproductive System 
To understand a vasectomy, it is helpful to understand the male reproductive system and how it functions. The testicles, or testes, are the sperm- and testosterone-producing organs. They are located in a sac at the base of the penis called the scrotum. Each testicle is connected to a small, coiled tube called the epididymis, where sperm are stored for as long as 6 weeks while they mature. The epididymes are connected to the prostate gland by a pair of tubes called the vas deferens. The vas deferens are part of a larger bundle of tissue, blood vessels, nerves, and lymphatic channels called the spermatic cord. During ejaculation, seminal fluid produced by the prostate gland mixes with sperm from the testes to form semen, which is ejaculated from the penis.

Preparation 
Surgeons typically require men to do 4 things before vasectomy:

  1. Shave and wash the scrotum (to prevent infection and to allow easier access)
  2. Bring a pair of tight-fitting underwear or athletic supporter (to support the scrotum and minimize swelling)
  3. Arrange for a ride home (to minimize exertion and movement that exacerbates swelling)
  4. Avoid anti-inflammatory drugs, such as ibuprofen and aspirin, before surgery (they thin the blood and can cause excessive bleeding)

Procedure 
A urologist performs a vasectomy on an outpatient basis, frequently in the office. The procedure takes about 30 minutes. The patient typically remains clothed from the waist up and lies on his back. The scrotum is numbed with one or more injections of local anesthetic (lidocaine), the vas deferens is gathered under the skin of the scrotum, and a small incision (usually 1 centimeter or less) is made. The vas deferens is then pulled through the incision, cut in two places, and a 1-centimeter segment is removed. Each end of the vas deferens is surgically tied off or clipped, and placed back in the scrotum. The incision is sutured and the procedure is repeated on the other side of the scrotum.  The incisions are dressed and most men go home immediately after the procedure.

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No-scalpel Vasectomy 

In the no-scalpel vasectomy, a surgical clamp is used to hold the vas deferens while a puncture incision (instead of a cut) is made with special forceps. The forceps are opened to stretch the skin, making a small hole through which the vas deferens is lifted out, cut, sutured or cauterized, and put back in place. The puncture incision does not require suturing. Some urologists recommend the no-scalpel method because they find it is quicker and minimizes postoperative discomfort and the risk for bleeding and infection. Recently, as encouraging studies are reported, more vasectomies are being performed using this approach.

Postoperative Care 
Rest and limited mobility are required for 2 to 3 days following the procedure to reduce swelling and to allow the vas deferens to heal. Most men lie on their back with their feet elevated. Although it is not necessary to remain immobile, excessive motion, lifting, and excessive walking increases the chance for inflammation and bleeding in the scrotum. Moderate discomfort is normal for a week or more. Anti-inflammatory drugs and prescription painkillers may be used. Ice packs applied 15 minutes on and 15 minutes off can minimize swelling. Strenuous exercise and lifting should be avoided for a few days or longer if it causes pain or discomfort. The degree of discomfort should dictate activity, as overexertion can postpone healing and a return to normal routine. It may take a week before erection and ejaculation is comfortable.

It may be necessary to keep the incisions dressed for a few days to control bleeding from the healing incisions. Showering is usually allowed, but soaking and swimming should be avoided until the sutures have dissolved.

Additional postoperative information 

Sterility 
Vasectomy does not result in immediate sterilization. Sperm may live for more than a week in the vas deferens, between the sutured ends and the ejaculatory ducts that lead to the penis. For most men, it takes 10 to 14 ejaculations before the ducts are free of sperm. Usually, one semen sample is produced and collected for analysis 8 weeks after the procedure. When sperm count is zero, the man is sterile. Men who undergo any sterilization procedure (e.g., vasectomy, no-scalpel vasectomy) should use another form of birth control until semen analysis confirms sterility.

After sterility, semen is still ejaculated, but it lacks sperm. The testes continue to produce sperm, but sperm are prevented from reaching the prostate because they are blocked in the tied-off vas deferens, where they die and are absorbed into the body. Because semen is about 5% sperm, there is no discernible difference in the amount of semen ejaculated after vasectomy. The procedure does not affect testosterone production or libido.

Complications 
Serious complications are rare. Up to 10% of men experience more pain, bleeding, or inflammation than others, and discomfort may persist longer than expected. This may be caused by a temporary buildup of pressure within the vas deferens. In rare cases, sperm is present in the semen for up to a year after surgery. This may be the result of poor sperm migration out of the vas deferens after surgery, or it may indicate that the severed ends of the vas deferens have reattached, a condition called recanalization. The solution to this problem is repeat vasectomy. Occasionally, a condition called sperm granuloma develops, in which residual sperm make their way out of the tied ends of the vas deferens, producing irritation and a small nodule. These usually heal in time, although surgical removal is occasionally required.

There is no evidence that vasectomy increases a man’s chance for prostate cancer. Nevertheless, as a precaution, the American Urological Association (AUA) recommends that men over 40 who had a vasectomy more than 20 years previously should have an annual test for prostate cancer. Annual exams are recommended for all men age 50 to 70.

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