Vasectomy

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Vasectomy is • Before Vasectomy • Methods • After Vasectomy • Risks • Limitations • Advantages • The Technique of Dr. Hussain • Instructions Before Vasectomy • Instructions Following Vasectomy • Fees • FAQs • Special Message for Young Men with Fewer than Two Children

Vasectomy is...

Before Vasectomy...

Sperm are made in the testes. From each testis, sperm move through a long curled-up tube behind the testis (the epididymis) wherein they become mature. From there, they swim up a foot-long tube (the vas) which guides them up to the channel (urethra) through which men urinate and ejaculate. Just before entering the urethra, the left and right vas tubes are enlarged, and it is here, behind the bladder, where many sperm are stored between ejaculations. The easiest place to access the vas tubes is just above the testes where the vas tubes are just beneath the thin scrotal skin, easy to feel and very mobile.

Methods... (Our preferences are below)

Anesthesia: An anesthetic solution can be injected with a tiny needle to numb the scrotal skin and the vas tubes, or a pressure spray applicator can be used to numb the skin and vas tubes without using any needles.

Access: During conventional vasectomy, one or two 1/2-inch scrotal incisions are made to gain access to the vas tubes. These incisions are later closed with sutures, which remain in place for about 5 days until they dissolve or are removed. During no-scalpel vasectomy (NSV), special instruments are used to perform the procedure through a single tiny access-opening on the front side of the scrotum. The 1/4-inch slit usually seals within hours, so no stitches are needed.

Blocking the vas tubes: Whichever technique of accessing the vas tubes is used, each vas (left & right) is divided about one inch above each testis, where it is just beneath the thin scrotal skin and very easy to reach. What is done with the ends of the divided vas tubes depends on the preference of the person performing the vasectomy. Some operators remove a piece of vas; others don't. Some tie off one or both vas ends using permanent or absorbable sutures or the small clips used to stop bleeding blood vessels during other types of surgical procedures; others cauterize the ends so that they will seal by scarring. Still others simply place the divided ends out of alignment, by closing the vas sheath between the 2 ends with a suture or tiny clip so the ends won't grow back together.

After Vasectomy...

The portions of the vas tubes within the pelvis still contain live sperm until they are all released. About 98% of men are sperm-free after 20 ejaculations and 12 weeks. In 5% of men, the semen may still contain some sperm (usually few in number and not active) for months, so it is important to have a semen sample checked (Post-Vasectomy Semen Analysis - PVSA) and to use other forms of birth control until it is confirmed by microscopic examination that the semen is sperm-free.
Sperm are still made by the testes but can no longer pass up through the vas tubes (anatomy diagrams). So the body adjusts: white blood cells ingest and digest the retained sperm, recycling the proteins back into the system for use in other body functions. Men usually notice:

• No change in the semen
  
• No change in sex drive
  
• No change in climax sensation
  
• No change in the testes or scrotum
  
• No change in erections

 In fact, a recent study concluded that vasectomy positively impacts the sexual satisfaction of couples because there is less fear of a accidental pregnancy.

Risks...

Bleeding can occur during or after vasectomy by either method, but it is less common with NSV. If this occurs within the scrotum, drainage of a scrotal hematoma (blood clot) in a hospital operating room could be necessary. Smaller hematomas do not require surgical drainage, but tender swelling can last for 2 to 4 weeks. Both large and small hematomas are very rare. If the scrotal skin bleeds at the vasectomy access site, the scrotum can become discolored (black and blue) for about a week; this is more common than swelling, but painless.

Infection is also a rare complication. 

Delayed Lightheadedness (feinting) with bodily injury can occur hours after vasectomy even in men who feel great when they leave the office. If a man is driving when this occurs, he could injure himself or others. If he is standing, he could fall and injure himself. We offer all patients a soft drink with caffeine and sugar to decrease the likelihood of this occurring, and we strongly recommend that men come and leave with a driver. Although we have never had a patient sustain an injury from this, delayed feinting and bodily injury should be considered a risk because it has occurred in other practices.

Sperm granuloma is a pea-sized (sometimes tender) lump on the vas tube at the vasectomy site, almost never requiring treatment. Some consider sperm granulomas beneficial, as they may increase the likelihood of success with vasectomy reversal. Periodic tenderness usually responds to an anti-inflammatory medication like ibuprofen, but over the past 20 years and 40,000 vasectomies, 5-10 men been so troubled by chronic tenderness that they chose to undergo removal of the lump, an office procedure performed under local anesthesia similar to the original vasectomy.

Congestion, tender buildup of sperm and white blood cells upstream from or at the vasectomy site, can occur anytime after vasectomy, but usually goes away with use of an anti-inflammatory drug such as aspirin or ibuprofen. About one in 2000 patients will experience chronic post-vasectomy discomfort (PVPS or Post-Vasectomy Pain Syndrome) severe enough that he will seek vasectomy reversal or neurolysis (division of the sensory nerves coming from the testes). A larger percentage (the medical literature says 1-15%)  may have milder forms of chronic pain that can affect quality of life but not severely enough to seek surgical therapy.

Re-canalization is the development of a channel for sperm flow between the two cut ends of the vas. If this happens during the healing process (early), the semen never becomes sperm-free until the vasectomy is repeated. If re-canalization happens late (months or years after a man's semen has been examined and declared sperm-free), an unplanned pregnancy could result; but the odds of this occurring is far less after vasectomy than the odds of pregnancy with any other form of birth control including birth control pills and tubal ligation (female sterilization). Failure rates of vasectomy vary with the technique used to obstruct sperm flow through the vas tubes. The early failure rate is about one in 2500 and the late failure rate is one in 3500 .

There are no proven long-term health risks (neither cancer nor cardiovascular disease) associated with vasectomy.

The risks of NOT having a vasectomy are all borne by the partners of men who choose to avoid vasectomy. And they are considerable!

* - Since reversal attempts often do not lead to pregnancy, vasectomy should be considered an irreversible form of contraception. Statistics show that men who undergo vasectomy in their 20's are more likely to seek vasectomy reversal than men who have vasectomies later in life. In fact, men in their 20's and with fewer than 2 children should read our Special Message for young men. Before choosing vasectomy, couples, especially couples in their 20's with fewer than 3 children, should consider all other forms of reversible contraception including birth control pills, shots, patches, and implants ; the IUD (intrauterine device); and barrier methods such as the condom and diaphragm. A nice review of these options is in the Planned Parenthood website. Couples using barrier methods should also be aware that, for those occasions when they are just unintended, EC (emergency contraception, or the "morning after pill") is readily available at most women's health services sites such as private primary care and gynecology offices and Planned Parenthood clinics. EC is effective at preventing pregnancy for up to 72 hours (perhaps longer) after the "careless" encounter (visit www.not-2-late.com for a list of EC providers in your area).

Men should not proceed with vasectomy if they feel they are being pressured to do so, if their private lives are temporarily unstable due to marital discord, or if they have not considered all reversible alternatives. For many stable men, circumstances change, and all men, especially younger men, should consider sperm storage as insurance against regret over vasectomy in the event of a major life change. If you have never caused a pregnancy, how do we know that you even need a vasectomy ... or what we should expect if you ever opt for vasectomy reversal? Please see our Special Message for Men Who Have Never Caused a Pregnancy.

The Technique of Dr. Hussain:

No-scalpel ... and no-needle!

Dr. Hussain use the no-scalpel technique as shown in the YouTube video provided above, exposing each vas in turn through a tiny opening in the front scrotal wall under local anesthesia. Since the opening is so small, it is easy to apply anesthesia without the use of needles. A spray applicator (MadaJet®) delivers a stream of anesthetic so fine that it penetrates the skin and diffuses to a depth of about 3/16 of an inch, enough to surround and anesthetize each vas tube in turn as it is lifted into position beneath the skin. Most, about 99%, of patients require no more anesthetic than this for completion of the procedure itself without pain. Some, about 1%, of patients do require injection of a little more anesthetic, but since the skin and vas are already partially numb, injection of more anesthetic with a fine needle rarely causes more than the slightest sensation. The tiny opening in the dime-sized area of numb skin is made with a pointy hemostat: one tip makes a pinpoint opening, then the two tips are used to spread and enlarge the opening to about 1/4 of an inch. Since blood vessels in the skin are spread apart rather than cut, bleeding is less than when a scalpel is used, no stitches are required, and the opening is usually sealed closed (often barely visible) by the next day.

Once each vas tube is lifted through the small skin opening, it is divided under direct vision with fine surgical scissors. Nothing is removed; the ends of the divided vas are placed out of alignment and kept from rejoining by applying a tiny clip to the sheath surrounding the vas so that one end stays inside the sheath, the other outside. While extremely effective (failure rate less than 1 in 2000), the technique provides for easier reversal (less scarring than when sutures are used) in men who choose reversal later in life. Procedure time is about 15 minutes. Most men say it hurts less than having a blood sample drawn. Many have called it painless. (In an e-mail, one patient recounted his experience step-by-step here.) A scrotal support (jockstrap) is applied and should be worn overnight and reapplied, after a next-morning shower, when up and around for the next 2 days. Ice-packs are not necessary. Men are advised to recline on the evening of the vasectomy, light activity the next day, sex and full activity 2 days after the vasectomy. After vasectomy about half of men will take non-prescription pain pills (Tylenol or ibuprofen), often just to prevent expected discomfort; the other half don't take any pain pills. About 1 in 1000 men will have enough discomfort to request a prescription pain medication. Semen samples can be brought or mailed (we provide the mailers) to the office twelve (12) weeks after the procedure to see if all stored sperm have been passed. Ninety-eight percent of men are sperm-free after 12 weeks and 20 ejaculations, some sooner, and a few men will not be sperm-free for 5 or 6 months. Evaluation of semen samples is included in the price. A copy of our vasectomy instructions and consent is available below and here as a PDF file.

Fees

ABC Healthcare does not have contracts with any insurance companies and therefore cannot collect from these entities. Two hundred dollars is collected at the first clinic appointment as a consult fee. This is then deducted from the $ 690 for the vasectomy. This accomplishes a few things:

1. Fewer "no-show" appointments that could have been filled by another patient

2. No need for our office to "over-book" to compensate for no-shows

3. You're honestly less likely to back out because you've put some money down

4. Our practice is small but efficient because we do no have to struggle with the bureaucracy of a insurance company 

We will provide you a form to help you get re-imbursed from your insurance company but this is not a guarantee

The cost may seem like a lot but here is the cost of diapers alone from one site :

Diaper Facts

Cost of raising a child from birth to 17 years of ago can run more than $200,000.

https://www.investopedia.com/articles/personal-finance/090415/cost-raising-child-america.asp

Frequently Asked Questions about Vasectomy

Pointy Hemostat

Ring Clamp

No-scalpel vasectomy instruments, used in China since the mid-70's and introduced into the United States in 1989, are simply a very pointy hemostat, used initially to make a tiny opening into anesthetized skin of the scrotal wall, and a ring clamp, used initially to secure each vas tube in turn beneath this opening. The pointy hemostat is then used to spread all layers (the vas sheath) down to the vas tube itself and to then deliver a small loop of the vas through the opening as the ring clamp is released. In turn, the ring clamp is used to hold the vas, while the pointy hemostat spreads adherent tissue and blood vessels away from the vas under direct vision, so that the vas can then be divided with a fine surgical scissors and the upper end cauterized with a hand-held cautery unit so that it will seal closed.

Traditionally, a local anesthetic has been injected into the skin and alongside each vas tube with a very fine needle, as small as diabetics use to inject themselves with insulin. One could feel a tiny poke in the skin, then a bit of a squeeze as the anesthetic was applied to each vas tube. However, most people do not like needles of any size ... especially there!

The spray penetrates to
about 3/16", enveloping
the vas.

A MadaJet® is a spray applicator which delivers a fine stream of liquid anesthetic at a pressure great enough to penetrate the skin to a depth of about 3/16", deep enough to envelop the vas tube held snugly beneath the skin. Each vas is positioned in turn beneath the very middle of the front scrotal wall and given two or three squirts. That numbs the skin and both vas tubes adequately for 99% of men. The other 1% (usually men who have thick skin or scarring due to prior surgical procedures in the area) will require a bit more anesthetic delivered with a fine needle, usually with no pain at all because of the partial anesthesia achieved with the MadaJet.

Is this a "laser" vasectomy?

How are the ends prevented from rejoining?

 

Hemoclip

After the vas is divided, the upper (abdomenal) end is cauterized and allowed to slide back into its sheath, while the lower (testicular)  end is held outside the sheath. A tiny hemoclip (the size of a grain of rice) is then used to close the empty portion of the sheath between the 2 ends. It would be like making a lengthwise opening in a wire's insulation, reaching in and dividing the wire, lifting one cut end out through the insulation, then putting a clip on the empty portion of the insulation, thereby holding one end outside and one end inside, the insulation itself serving as a barrier between the two ends. Most hemoclips are made of titanium, a non-ferromagnetic metal used for many types of implanted medical devices such as dental implants, heart valves, and joint replacement.

There have been no clip-related problems in the 38,000 or so men who have undergone vasectomy by Dr. Stein since he began using this method in 1990, and no reports of problems in the medical literature of which we are aware. Surgeons have used hemoclips for many years to occlude bleeding blood vessels during many operations in the abdomen and chest, sometimes over 50 clips in a single procedure. Hemoclips have been used by vasectomists for decades. In fact, during vasectomy reversal procedures, as many as 5 clips can be discovered on each side, clips of which the patient was unaware and which could not be felt by the surgeon before the reversal. Most hemoclips are made of medically inert titanium, the same metal used for dental implants, many artificial joints, and mechanical heart valves. Not ferromagnetic, titanium will not interfere with MRI studies and the small amounts used in hemoclips and dental implants do not set off metal detector alarms.

45% of men took no pain medication following their vasectomies, not even the Tylenol that was provided. They had so little discomfort that they saw no need to take anything.
15% of men took pain medication (the Tylenol that was provided or home supplies of ibuprofen) one time "just in case", that is, as a precaution to prevent expected discomfort, not because they needed it.
29% of men took pain medication one time for discomfort, then did not need any additional doses.
11% of men took pain medication more than one time (two or three times), though at least 4 of these 11 men said that they had taken it more to prevent expected pain than because they were actually having discomfort.
0% of these men felt that they needed something stronger than Tylenol or ibuprofen, but we are asked for a prescription medication by about 1 in 500 men.

The previously common technique of removing a section of the vas tube (1/4 to 1/2 inch) and cauterizing the ends with a hand-held hot-wire cautery unit. Three patients (of about 1500) experienced early failure. That is, the vas tubes grew back together during the healing process, the men did not become sperm-free, and the vasectomies had to be repeated. Recognized early, the problem was corrected before an unintended pregnancy could occur. Since use of hemoclips to divert the vas ends out of alignment and only 7 anatomically normal men (of about 42,000 vasectomy cases, or one in 6000) have experienced early failure. Again, no pregnancies occurred because the men never became sperm-free and the vasectomies were successfully repeated without incident. Delayed failure, or late recanalization, presents as (1) a pregnancy after the semen has been confirmed to be sperm-free by microscopic examination, AND (2) documentation of a return of sperm to the semen by microscopic examination OR DNA documentation of paternity if the presumed father has no visible sperm in his semen (the veritable "one got through"). Delayed failure is also exceedingly rare.  By contrast, the failure rate of birth control pills is 3% per year!

The expression "open-end" or "open-ended" refers to a vasectomy technique in which the lower (testicular) end of the vas is not occluded with a stitch, hemoclip, or electrocautery. The internet contains many web pages that laude the benefits of the open-end technique. The theory is that if the lower end is occluded, in effect "slamming the door" on the normal egress of sperm from below, there may be a sudden increase in pressure within the epididymis and the portion of the vas tube below ("upstream") from the vasectomy site, potentially causing an increase in the level of inflammation normally required for the resorption of sperm. This exaggerated inflammatory response, so the theory goes, increases the likelihood of post-vasectomy discomfort and decreases the likelihood of reversal success, should the individual ever opt for vasectomy reversal in the future. After an open-ended vasectomy, a sperm granuloma may form at the vasectomy site with a transfer of the inflammatory sperm-resorption process to the vasectomy site, thereby sparing the upstream tubules (epididymis and vas) from this inflammation, decreasing the likelihood that they will become scarred and secondarily occluded, and enhancing the chances of reversal success.

Are there any long-term health risks associated with vasectomy? 

The February 17, 1993 issue of the Journal Of The American Medical Association contained 2 studies (by the same research group) that suggest that vasectomy was associated with a small increased risk of prostate cancer in their study groups (almost 30,000 patients in 1 study and almost 40,000 patients in the other study). Because the question was initially raised by 2 studies back in 1990, the World Health Organization convened a 1991 meeting of 23 international experts to review all research regarding vasectomy and prostate cancer. They concluded that there was no plausible biologic mechanism for a relationship between vasectomy and prostate cancer. Some medical researchers interpreted the small increased risk noted in the 1993 studies as a weak association that may be due to chance or bias. A systematic review of the medical literature in 1998 (Fertility & Sterility, 70: 191) further documented the lack of a significant relationship between vasectomy and prostate cancer. Additional convincing evidence of no relationship has been published in the Journal of Urology in June 1999 (161: 1848-1853), in the Journal of the American Medical Association in June 2002 (287:3110-3115), in the Journal of Urology in October 2002 (168: 1408-1411), and in Fertility and Sterility in November 2005 (84:1438-1443). A more recent study in 2014 raised the question once again, and once again, careful analysis of all available research data showed no association of vasectomy with prostate cancer. Studies as recent as 2016, show no increased risk of prostate cancer after vasectomy. The official position of the American Urological Association is that the association between vasectomy and prostate cancer risk is so weak that it need not even be discussed as part of routine pro-op counseling (see AUA Guidelines, pages 14-15). There are greater increases in the risk of prostate cancer (and mortality) associated with consuming milk/dairy products (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8255404/), meat (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8859108/#:~:text=Consumption%20of%20processed%20meat%20might,not%20with%20advanced%20prostate%20cancer) and alcohol (https://pubmed.ncbi.nlm.nih.gov/27842506/) or even having multiple sexual partners and not ejaculating often enough (https://pubmed.ncbi.nlm.nih.gov/30122473/).

The question of an association between vasectomy and subsequent cardiovascular disease was raised back in 1978 and 1980 by two studies which reported an increase in atherosclerosis (hardening of the arteries) in vasectomized laboratory monkeys. The last article listed above (Cancer and cardiovascular disease after vasectomy: an epidemiological database study. Fertility and Sterility 84:1438-1443, November 2005) provides an excellent bibliography of studies showing no association in humans as well as its authors' own data comparing 24,773 vasectomized men with 159,480 non-vasectomized men as a control group. Their findings "strengthen the evidence that vasectomy is not followed by an increased risk of myocardial infarction [heart attack], coronary heart disease as a whole, or stroke. In particular, we add strong support to the evidence that there is no elevation of risk of cardiovascular disease in men after long periods after vasectomy."

My office has copies of these and other research studies, available to any patient upon request. 

Federal programs (Medicaid and Title10) that provide financial coverage or assistance for sterilization procedures require only that the candidate "is at least 21 years old and appears mentally competent". There are no laws forbidding vasectomy for certain age groups, though individuals under 18 require parental consent for any elective surgery. We will not provide vasectomy for a childfree man under 21 years of age unless (1) there are profound extenuating circumstances such as a hereditary disease or obvious inability to care for a child, as might be the case in someone with a cognitive disability, or (2) he presents documentation of sperm storage. We have provided vasectomy for men younger than 21 who have had 2 or more children. Other vasectomy providers may follow a different or more restrictive set of guidelines, as is their prerogative.