Patient education: Vasectomy (Beyond the Basics)

INTRODUCTION — Vasectomy is a safe, effective, and permanent method of birth control for men. It is also the most cost-effective form of birth control, costing half as much as a tubal ligation (having a woman's "tubes tied"). In the United States, one out of five men over the age of 35 has had a vasectomy.

This topic reviews recommendations for men who are considering vasectomy, including the success and failure rates, as well as how the procedure is done. Topics discussing other methods of birth control are available separately. (See "Patient education: Permanent birth control for women (Beyond the Basics)" and "Patient education: Hormonal methods of birth control (Beyond the Basics)" and "Patient education: Long-acting methods of birth control (Beyond the Basics)" and "Patient education: Barrier and pericoital methods of birth control (Beyond the Basics)".)

VASECTOMY DEFINITION — Sperm are produced in the testicles and then move into the epididymis, which sits on the upper surface of each testicle. Sperm are stored in the epididymis, where they mature and become capable of fertilization.

At the time of ejaculation, seminal fluid and sperm move from the epididymis through the vas deferens and are then expelled from the penis. The vas deferens are long, thin tubes that start in the scrotum and run behind the bladder and then return forward to empty into the urethra inside of the prostate gland; the urethra is the tube inside the penis that carries urine and semen.

When a vasectomy is performed, each vas deferens is cut and cauterized (sometimes sutured closed) to prevent sperm from leaving the epididymis (figure 1). This way, no sperm are expelled from the penis at the time of ejaculation. (See "Vasectomy".)

WHO SHOULD CONSIDER A VASECTOMY? — Vasectomy is for men who want ALL of the following from their birth control method:

●Permanent, not meant to be reversed

●No preparation before or during sex

●A high success rate and low risk of complications

●No other biological children

Men who are not sure that vasectomy is right for them can consider a number of other contraceptive options. (See "Patient education: Birth control; which method is right for me? (Beyond the Basics)" and "Patient education: Permanent birth control for women (Beyond the Basics)".)

VASECTOMY SUCCESS RATES — Vasectomy is successful in more than 99 percent of men. A second method of birth control is necessary until testing is done to confirm that there are no sperm in the semen.

The sperm count is checked, usually three months after the procedure, to ensure that no sperm remain in the ejaculate. A man needs to have ejaculated at least 20 times after vasectomy to clear the ducts of sperm before the follow-up sperm count.

A sperm count requires that the man give a semen sample, usually obtained by masturbation. A man who continues to have sperm in the ejaculate requires a second sperm count, usually performed two months later.

If the follow-up check shows sperm that do not move, there is a small chance that a partner may become pregnant. Another method of contraception should be continued until "special clearance" is given by the doctor.

VASECTOMY PROCEDURE

Consultative visit — Men who are considering a vasectomy usually have a consult visit before the procedure. At this visit, the doctor will explain the procedure and answer any questions.

Men frequently have a great deal of anxiety about vasectomy. Much of the anxiety is related to a fear of pain or damage to the penis or scrotum. The consult visit is an excellent opportunity to discuss the procedure, risks, and potential complications. It is preferable for the man to bring his partner to this visit.

The procedure — Most vasectomies are performed in a physician's office and take about 30 minutes. (See "Vasectomy".)

●A local anesthetic is injected under the skin (not into the testicle) using a very small needle or a jet injector ("puff of air"). Only the area around the vas deferens (vas or sperm duct) becomes numb. The injection of the local anesthetic will sting briefly.

●Once the area is numb, some men will still feel a pulling and/or cramping sensation during the procedure. The physician finds the vas deferens by feeling through the skin of the scrotum.

●To expose the vas, a small puncture is made using the no-scalpel technique. A small incision can also be used. A loop of vas is brought to the surface, and a small segment is usually removed (up to about 1 cm). One or both of the cut surfaces of the vas are then either cauterized (treated with heat), tied off, or clipped. Once the procedure is complete on one vas deferens, the other side is treated. Often, the second vas can be treated through the same initial puncture or incision.

●In the no-scalpel technique, the skin puncture does not require sutures. If an incision is made, the skin edges are closed with stitches.

●Tight underwear or an athletic supporter (jock strap) is used to hold a bandage in place and apply pressure to the scrotum.

After the procedure — The man may go home a few minutes after the vasectomy is completed but should have someone available to accompany him and assist with tasks (driving, heavy lifting, etc).

●The most important factor in a smooth recovery is rest. It is best to take it easy for two to three days after the procedure.

●Applying an ice pack intermittently on top of the underwear helps minimize discomfort and swelling.

●Patients should be asked to limit their activities for about five days. Strenuous exercise or lifting should be avoided for a total of seven days.

●Patients should not bathe or swim for 24 to 48 hours after the procedure.

●Sexual intercourse can be resumed after a week, but a backup method of birth control is necessary until testing is done to confirm that sperm are no longer present in the ejaculate (usually at three months after the procedure).

●Men need to ejaculate at least 20 times to clear the ducts of sperm before the three-month check. (See 'Vasectomy success rates' above.)

PAIN CONTROL FOLLOWING VASECTOMY — After the vasectomy, there may be some cramping and discomfort of the scrotum. This can be relieved by ice pack application and with a pain medication such as acetaminophen (Tylenol). Ibuprofen and aspirin should be avoided for at least one week because these medications may increase the risk of bruising or bleeding around the incision. For more severe pain, a stronger pain medication may be prescribed. Most men find that they do not need the stronger medication.

VASECTOMY COMPLICATIONS — Vasectomy is a relatively simple procedure to perform. Complications are unusual, although possible.

●Bleeding – Excessive bleeding occurs in fewer than 5 percent of men who undergo vasectomy. Most bleeding problems occur within the first 48 hours after the procedure. Bleeding within the scrotum can lead to a hematoma, which is an expanding mass of blood within the tissues around the vas. This can grow to a large size if not treated promptly.

Men can help to prevent bleeding by avoiding aspirin, ibuprofen, and other nonsteroidal anti-inflammatory drugs (NSAIDs) for at least one week prior to surgery and by following the instructions regarding rest and limited activity after surgery.

●Infection – Infection occurs in up to 4 percent of men who undergo vasectomy. This typically involves the scrotal skin around the incision. Occasionally, the epididymis will become swollen after a vasectomy. This is usually treated with a short course of oral antibiotics.

●Sperm granuloma – A sperm granuloma occurs in 15 to 40 percent of men who undergo vasectomy. A sperm granuloma is a mass that develops over time as a result of the body's immune reaction to sperm leaking from the cut end of the vas. It is typically treated with an anti-inflammatory medication, such as ibuprofen. The mass is not dangerous. There are rare instances, however, in which a sperm granuloma causes significant scrotal discomfort. This may be treated by surgically removing the granuloma.

●Post-vasectomy pain syndrome – This condition is thought to result from buildup of fluid in the epididymis leading to a chronic dull ache in the testes. There is some controversy as to how commonly this condition occurs. Historically, rates for post-vasectomy pain syndrome have been reported as very low (<1 percent). However, surveys have found that the incidence of "troublesome" post-vasectomy pain is reported by approximately 15 percent of men, with pain severe enough to affect quality of life in 2 percent. However, survey respondents may not have been representative of all men who have had a vasectomy. The preferred therapy for post-vasectomy pain syndrome is NSAIDs, such as ibuprofen (sample brand names: Advil, Motrin) or naproxen (sample brand name: Aleve), and warm baths. If these measures are not enough to relieve pain, local nerve blocks or steroid injections may be performed by a pain specialist. Cases that do not respond to therapy may require surgery, including possibly a vasectomy reversal.

HEALTH EFFECTS OF VASECTOMY

Sex drive — Having a vasectomy will not affect testosterone (male hormone) levels, sex drive, or the ability to have an erection.

Risk of cancer — Although there have been some concerns regarding a link between vasectomy and prostate and testicular cancer, several large studies show that there is no increased risk of any cancer following vasectomy [1-5].

Heart disease — Similar to the situation with cancer, there have been some concerns about a link between vasectomy and heart disease; however, studies have found no such link.

CHILDREN AFTER VASECTOMY — A man should not have a vasectomy unless he is sure that he does not want to be able to biologically father children in the future. However, about 5 percent of men who have a vasectomy eventually decide that they would like to have it reversed.

Sperm antibodies develop in 40 percent of men after a vasectomy. These are formed when leaked sperm cells interact with the body's immune system. These antibodies cause no harm to the man but can make sperm cells less effective if the vasectomy is reversed.

Vasectomy reversal — Vasectomy reversal is called a vasovasostomy. This is a microsurgical technique that reconnects the vas deferens. The success rate of this procedure depends upon the condition of the vas. As more time elapses from the time of the vasectomy, vasovasostomy is less likely to be successful (ie, result in pregnancy) [6,7]. In one study, vasovasostomy resulted in pregnancy about 76 percent of the time when performed three years or less from the time of the vasectomy, but pregnancy resulted in 30 percent when the vasectomy was performed 15 years or more before reversal [6]. If sperm antibodies have developed, fertility after vasovasostomy is further reduced. In the United States, vasectomy reversal is not covered by most insurance plans.

Sperm banking — Sperm banking involves storing a collected sample of sperm with a preservative at a very low temperature. Sperm banking can be accomplished prior to vasectomy, or collection of sperm from the ducts can be done at the time of vasectomy reversal surgery. The initial cost of storing sperm is about $500, with annual storage costs between $300 and $1000 per year.

BIRTH CONTROL AFTER VASECTOMY — If the three-month check shows no evidence of residual sperm in the ejaculate, a second form of birth control (eg, condoms) is no longer needed to prevent pregnancy. However, vasectomy does not protect against sexually transmitted diseases (STDs) such as HIV. Men who have more than one sexual partner and men whose partner has other partners should consider using condoms to reduce the risk of STDs.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Vasectomy (The Basics)
Patient education: Choosing birth control (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Permanent birth control for women (Beyond the Basics)
Patient education: Hormonal methods of birth control (Beyond the Basics)
Patient education: Long-acting methods of birth control (Beyond the Basics)
Patient education: Barrier and pericoital methods of birth control (Beyond the Basics)
Patient education: Birth control; which method is right for me? (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Contraception: Counseling and selection
Vasectomy

The following organizations also provide reliable health information:

●National Library of Medicine

     (https://medlineplus.gov/healthtopics.html)

●Planned Parenthood Federation of America

     (www.plannedparenthood.org)

●Managing Contraception

      (https://managingcontraception.com)

●Vasectomy Information

      (www.vasectomy-information.com)

[1-4,6]

ACKNOWLEDGMENTS — The editorial staff at UpToDate would like to acknowledge Christopher Cutie, MD, and Theodore J Ongaro, MD, who contributed to earlier versions of this topic review.