Vasectomy follow-up: Clinical significance of rare nonmotile sperm in postoperative semen analysis

U.S. Selected Practice Recommendations for Contraceptive Use, 2024

The 2024 U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR) addresses a selected group of common, yet sometimes complex, issues regarding initiation and use of specific contraceptive methods. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25-27, 2023. The information in this report replaces the 2016 U.S. SPR (CDC. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR 2016;65[No. RR-4]:1-66). Notable updates include 1) updated recommendations for provision of medications for intrauterine device placement, 2) updated recommendations for bleeding irregularities during implant use, 3) new recommendations for testosterone use and risk for pregnancy, and 4) new recommendations for self-administration of injectable contraception. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.

Patient Portal Engagement Affects Postvasectomy Semen Analysis Completion

OBJECTIVE

To identify factors that affect completion of postvasectomy semen analysis (PVSA) in men receiving telehealth prevasectomy counseling. Telehealth visits have become increasingly common for prevasectomy consultations. Prior studies have shown that men prefer telehealth vasectomy consultations over in-person options. Postvasectomy semen testing should be completed to confirm sterilization.

METHODS

Three hundred and seventy-one men aged 19 and older who saw a single physician for a telehealth prevasectomy consultation and completed an in-office vasectomy were included in the study. Demographic information such as age, patient relationship status, and distance from the clinic were accessed via electronic medical record. Patients were assessed based on their engagement with electronic preprocedure instructions, and the primary outcome measured was completion of PVSA.

RESULTS

45.6% of men completed a PVSA. There was no significant difference in completion of the PVSA between those who opened their electronic instructions before their vasectomy and those who did not (46.1% vs 44.4%, P = .77). Of those who messaged the clinic for any reason at least once after their consultation, 62% completed their PVSA; 41% who did not contact the clinic completed the PVSA (P = .0009).

CONCLUSION

While there was no difference in completion of PVSA in patients who opened their instructions vs those who did not, patients with a higher level of engagement with the patient portals were more likely to complete their semen test. By understanding factors influencing patient compliance with postvasectomy semen testing, healthcare professionals can develop targeted interventions to ensure safe and successful outcomes.

[Male contraception]

CONTEXT

Contraception is a major global health issue, which is still dominated by female contraception. Developments in male contraception could help redistribute the contraceptive burden.

METHODS

A literature search was carried out to review the existing options and the criteria for optimal contraception, to establish the principles of a male pre-contraception consultation, and to review the various research avenues with their advantages and disadvantages.

RESULTS

The new male contraception options are detailed, whether hormonal (androgen therapy, combination of progestins and testosterone) or non-hormonal, particularly thermal, with current results and avenues for improvement. Condom use and vasectomy remain the only 2 validated options. The recent development of minimally invasive vasectomy without the need for a scalpel and of occlusion techniques has simplified the procedure, minimised the risk of complications (pain, haematomas, post-vasectomy pain syndrome) and improved efficacy. The issues of regret and the possibility of repermeabilisation are also raised.

CONCLUSION

The question of male contraception will become increasingly important in consultations with urologists. The urologist will have to inform the patient, as required by law, before the vasectomy is performed, and provide the best possible advice on the technique, which will often be minimally invasive without the need for a scalpel. New reversible options should also broaden the range of options available on a routine basis, with a view to gradually moving towards contraceptive equity.

[Recommendations of the Committee of Andrology and Sexual Medicine of the AFU concerning the management of Vasectomy]

OBJECTIVES

To answer the main clinical questions asked by practitioners and men consulting for a vasectomy request.

METHOD

The CPR method was used. The clinical questions were formulated according to the PICO methodology. A Pubmed literature search for the period 1984-2021 identified 508 references, of which 79 were selected and analyzed with the GRADE grid.

RECOMMENDATIONS

Vasectomy is a permanent, potentially reversible contraception. It is a safe procedure. A second vasectomy is necessary in only 1 % of cases. Surgical complications (hematoma, infection, pain, etc.) are rare. The frequency of prolonged scrotal pain after vasectomy is about 5 %, and less than 2 % describe a negative impact of this pain on their quality of life. Vasectomy does not have negative consequences on sexuality. The only contraindication to vasectomy is the minor patient. Patients at increased risk of remorse are single, divorced or separated men under the age of 30. Sperm storage may be particularly appropriate for them. Whatever the reason, the law allows the surgeon to refuse to perform the vasectomy. He must inform the patient of this at the first consultation. The choice of the type of anesthesia is left to the discretion of the surgeon and the patient. It must be decided during the preoperative consultation. Local anesthesia should be considered first. General anesthesia should be particularly considered in cases of anxiety or intense sensitivity of the patient to palpation of the vas deferens, difficulty palpating the vas deferens, or a history of scrotal surgery that would make the procedure more complex. Concerning the vasectomy technique, 2 points seem to improve the efficiency of the vasectomy: coagulation of the deferential mucosa and interposition of fascia. Leaving the proximal end of the vas deferens free seems to reduce the risk of post-vasectomy syndrome without increasing the risk of failure or complications. No-scalpel vasectomy is associated with a lower risk of postoperative complications than conventional vasectomy. Regarding follow-up, it is recommended to perform a spermogram at 3 months post-vasectomy and after 30 ejaculations. If there are still a few non-motile spermatozoa at 3 months, it is recommended that a check-up be performed at 6 months post-vasectomy. In case of motile spermatozoa or more than 100,000 immobile spermatozoa/mL at 6 months (defining failure), a new vasectomy should be considered. Contraception must be maintained until the effectiveness of the vasectomy is confirmed.

Risk of vasectomy failure by ligation and excision with fascial interposition: A prospective descriptive study

OBJECTIVE

To evaluate the occlusive failure risk of ligation and excision with fascial interposition vasectomy technique. There are doubts about the effectiveness of this technique largely used in Asia and Latin America.

STUDY DESIGN

We conducted a prospective longitudinal observational descriptive study among men who underwent a vasectomy performed under local anesthesia in a clinic specializing in sexual and reproductive health services in Bogotá, Colombia. Three urologists used the Percutaneous No-Scalpel Vasectomy technique to isolate the vas deferens. They then ligated the vas, excised a 1 cm segment between ligations, and ligated the fascia on the prostatic end to cover the testicular end. We requested all patients to submit a semen sample three months after the vasectomy. We defined probable and confirmed vasectomy failure as 1-4.9 million sperm/ml and 5 million sperm/ml or more or any number of motile sperm observed on the last semen sample available, respectively.

RESULTS

Among 1149 participants, 581 (51%) had at least one post-vasectomy semen analysis. The overall failure risk was 5.2% (30/581; 95% confidence interval [CI] 3.6%-7.3%) with probable and confirmed failure risk of 1.9% (11/581; 95% CI 1.1%-3.4%) and 3.3% (19/581; 95% CI 2.1%-5.1%), respectively. Older men and one urologist had statistically significant higher risk of overall failure.

CONCLUSION

Our study confirmed that the ligation and excision with fascial interposition vasectomy technique is associated with an unacceptable risk of failure.

IMPLICATIONS

Surgeons who use the ligation and excision with fascial interposition vasectomy technique and countries with large vasectomy programs in Asia and Latin America that still recommend this technique should consider adopting alternatives to reduce the failure risk to below 1% as recommended by the American Urological Association.

CUA guideline: Vasectomy

<p>Vasectomy is a safe and effective method of birth control. Although it is a simple elective procedure, vasectomy is associated with potential minor and major complications. The early failure rate of vasectomy (presence of motile sperm in the ejaculate at 3‒6 months post-vasectomy) is in the range of 0.3‒9% and the late failure rate is in the range of 0.04–0.08%. The no-scalpel vasectomy technique is associated with a lower risk of early postoperative complications and the use of cautery or fascial interposition will reduce the risk of contraceptive failure. As such, detailed preoperative counselling and careful assessment of the post-vasectomy ejaculate (for presence of sperm) is imperative. Failure to provide and document adequate information and counselling to patients may lead to litigation.</p><p>The focus of this guideline is the management of men presenting for vasectomy. Specifically, the topics covered include: preoperative counselling, vasectomy efficacy and complications, technical aspects of vasectomy, post-vasectomy semen testing, and interpretation-communication of post-vasectomy semen results. By performing an extensive literature review, we have generated an evidence-based consensus on the management of these men. The objective of this guideline is to help standardize the treatment of men presenting for vasectomy.</p>

Optimizing outcomes in vasectomy: how to ensure sterility and prevent complications

Vasectomy provides a long-term effective sterilization for men and is performed on nearly 500,000 men annually in the United States. Improvements in technique have led to a decreased failure rate and fewer complications, although significant variations in technique exist. Use of cautery occlusion with or without fascial interposition appears to have the least failures. A no-scalpel approach lowers risk of hematoma formation, infection and bleeding post-operatively. A patient can be considered sterile when azoospermia is achieved or the semen analysis shows less than 100,000 non-motile sperm per milliliter. Incorporating these principles may allow the physician to optimize outcomes in vasectomy.

2016 Laboratory guidelines for postvasectomy semen analysis: Association of Biomedical Andrologists, the British Andrology Society and the British Association of Urological Surgeons

Post-vasectomy semen analysis (PVSA) is the procedure used to establish whether sperm are present in the semen following a vasectomy. PVSA is presently carried out by a wide variety of individuals, ranging from doctors and nurses in general practitioner (GP) surgeries to specialist scientists in andrology laboratories, with highly variable results.

Key recommendations are that: (1) PVSA should take place a minimum of 12 weeks after surgery and after a minimum of 20 ejaculations. (2) Laboratories should routinely examine samples within 4 h of production if assessing for the presence of sperm. If non-motile sperm are observed, further samples must be examined within 1 h of production. (3) Assessment of a single sample is acceptable to confirm vasectomy success if all recommendations and laboratory methodology are met and no sperm are observed. Clearance can then be given. (4) The level for special clearance should be <100 000/mL non-motile sperm. Special clearance cannot be provided if any motile sperm are observed and should only be given after assessment of two samples in full accordance with the methods contained within these guidelines. Surgeons are responsible both preoperatively and postoperatively for the counselling of patients and their partners regarding complications and the possibility of late recanalisation after clearance. These 2016 guidelines replace the 2002 British Andrology Society (BAS) laboratory guidelines and should be regarded as definitive for the UK in the provision of a quality PVSA service, accredited to ISO 15189:2012, as overseen by the United Kingdom Accreditation Service (UKAS).

[European Association of Urology guidelines on vasectomy]

CONTEXT

The European Association of Urology presents its guidelines for vasectomy. Vasectomy is highly effective, but problems can arise that are related to insufficient preoperative patient information, the surgical procedure, and postoperative follow-up.

OBJECTIVE

These guidelines aim to provide information and recommendations for physicians who perform vasectomies and to promote the provision of adequate information to the patient before the operation to prevent unrealistic expectations and legal procedures.

EVIDENCE ACQUISITION

An extensive review of the literature was carried out using Medline, Embase, and the Cochrane Database of Systematic Reviews from 1980 to 2010. The focus was on randomised controlled trials (RCTs) and meta-analyses of RCTs (level 1 evidence) and on well-designed studies without randomisation (level 2 and 3 evidence). A total of 113 unique records were identified for consideration. Non-English language publications were excluded as well as studies published as abstracts only or reports from meetings.

EVIDENCE SYNTHESIS

The guidelines discuss indications and contraindications for vasectomy, preoperative patient information and counselling, surgical techniques, postoperative care and subsequent semen analysis, and complications and late consequences.

CONCLUSIONS

Vasectomy is intended to be a permanent form of contraception. There are no absolute contraindications for vasectomy. Relative contraindications may be the absence of children, age <30 yr, severe illness, no current relationship, and scrotal pain. Preoperative counselling should include alternative methods of contraception, complication and failure rates, and the need for postoperative semen analysis. Informed consent should be obtained before the operation. Although the use of mucosal cautery and fascial interposition have been shown to reduce early failure compared to simple ligation and excision of a small vas segment, no robust data show that a particular vasectomy technique is superior in terms of prevention of late recanalisation and spontaneous pregnancy after vasectomy. After semen analysis, clearance can be given in case of documented azoospermia and in case of rare nonmotile spermatozoa in the ejaculate at least 3 mo after the procedure.

European Association of Urology guidelines on vasectomy

CONTEXT

The European Association of Urology presents its guidelines for vasectomy. Vasectomy is highly effective, but problems can arise that are related to insufficient preoperative patient information, the surgical procedure, and postoperative follow-up.

OBJECTIVE

These guidelines aim to provide information and recommendations for physicians who perform vasectomies and to promote the provision of adequate information to the patient before the operation to prevent unrealistic expectations and legal procedures.

EVIDENCE ACQUISITION

An extensive review of the literature was carried out using Medline, Embase, and the Cochrane Database of Systematic Reviews from 1980 to 2010. The focus was on randomised controlled trials (RCTs) and meta-analyses of RCTs (level 1 evidence) and on well-designed studies without randomisation (level 2 and 3 evidence). A total of 113 unique records were identified for consideration. Non-English language publications were excluded as well as studies published as abstracts only or reports from meetings.

EVIDENCE SYNTHESIS

The guidelines discuss indications and contraindications for vasectomy, preoperative patient information and counselling, surgical techniques, postoperative care and subsequent semen analysis, and complications and late consequences.

CONCLUSIONS

Vasectomy is intended to be a permanent form of contraception. There are no absolute contraindications for vasectomy. Relative contraindications may be the absence of children, age <30 yr, severe illness, no current relationship, and scrotal pain. Preoperative counselling should include alternative methods of contraception, complication and failure rates, and the need for postoperative semen analysis. Informed consent should be obtained before the operation. Although the use of mucosal cautery and fascial interposition have been shown to reduce early failure compared to simple ligation and excision of a small vas segment, no robust data show that a particular vasectomy technique is superior in terms of prevention of late recanalisation and spontaneous pregnancy after vasectomy. After semen analysis, clearance can be given in case of documented azoospermia and in case of rare nonmotile spermatozoa in the ejaculate at least 3 mo after the procedure.

Compact and light-weight automated semen analysis platform using lensfree on-chip microscopy

We demonstrate a compact and lightweight platform to conduct automated semen analysis using a lensfree on-chip microscope. This holographic on-chip imaging platform weighs ∼46 g, measures ∼4.2 × 4.2 × 5.8 cm, and does not require any lenses, lasers or other bulky optical components to achieve phase and amplitude imaging of sperms over ∼24 mm(2) field-of-view with an effective numerical aperture of ∼0.2. Using this wide-field lensfree on-chip microscope, semen samples are imaged for ∼10 s, capturing a total of ∼20 holographic frames. Digital subtraction of these consecutive lensfree frames, followed by appropriate processing of the reconstructed images, enables automated quantification of the count, the speed and the dynamic trajectories of motile sperms, while summation of the same frames permits counting of immotile sperms. Such a compact and lightweight automated semen analysis platform running on a wide-field lensfree on-chip microscope could be especially important for fertility clinics, personal male fertility tests, as well as for field use in veterinary medicine such as in stud farming and animal breeding applications.

Clearance after vasectomy: has the time come to modify the current practice?

OBJECTIVE

Vasectomy is a simple, reliable and effective form of permanent contraception. Clearance after vasectomy has been the subject of much debate among urologists. Poor compliance with postvasectomy semen analysis is well recognized, with rates as low as 36%. This can leave the partner at risk of an unplanned pregnancy and, consequently, the surgeon at risk of litigation. Although there is no consensus about the requirements for postvasectomy clearance, urologists usually tend to request at least two azoospermic postvasectomy semen samples (PVSSs) before labelling patients as sterile. This study investigated whether simplifying the criteria for postvasectomy clearance can result in improved compliance.

MATERIAL AND METHODS

Medline, Embase and Cochrane databases were searched for studies on postvasectomy clearance. The main focus of the search was on the timing and number of PVSSs, their impact on patients' compliance and the significance of the rare non-motile sperm (RNMS).

RESULTS

It has been found that patients' compliance decreases when more than one PVSS is requested. One azoospermic PVSS can be as indicative of sterility as two azoospermic samples. There have been calls for a uniform protocol recommending only one routine sperm sample taken 16 weeks postoperatively. This period will allow the vasa and seminal vesicles to become clear of spermatozoa. A significant proportion of men will have RNMS in their semen after vasectomy; only 1% will ultimately fail. Therefore, RNMS samples can, for practical purposes, be considered azoospermic and one PVSS, even if containing RNMS, should be considered sufficient for clearance.

CONCLUSIONS

Provided that patients are adequately warned about the risk of vasectomy failure and appropriate consent is obtained, a single azoospermic PVSS at 16 weeks is sufficient for clearance. Patients with RNMS should be practically considered azoospermic and further sampling should be abandoned. This approach should improve patients' compliance. Evaluation in a prospective setting will be required to validate this conclusion.

Vasectomy by epithelial curettage without suture or cautery: a pilot study in humans

Curettage of the epithelium of the vas deferens might be a safe and effective method of male sterilization. We conducted a pilot study of vasectomy by epithelial curettage with a novel microcurette called the Vas-X in 12 normal men requesting elective sterilization. Seminal fluid analysis was obtained monthly after the procedure for 6 months. Pain was assessed by questionnaire. Three months after the procedure, all men attained sperm concentrations of less than 0.2 million sperm per mL, and seven were azoospermic. Post-procedural pain was minimal. Nine men ultimately achieved and maintained azoospermia; however, 4 to 6 months after the procedure, sperm concentrations increased in three of the 12 subjects, necessitating repeat vasectomy. Microscopic examination of the vas deferens from these failures revealed re-canalization. Vasectomy by epithelial curettage can result in effective sterilization; however, 1/4 of the subjects were not effectively sterilized by the procedure due to re-canalization of the vas deferens. Epithelial curettage will require further refinement to determine if it is a viable form of vasectomy.

Vasectomy: A simple snip?

Vasectomy is one of the most common forms of permanent sterilization methods currently in use and has a failure rate of <1% in most reported series. Since failure of vasectomy may result in pregnancy, adequate counseling is essential. Couples are advised that an analysis of a semen specimen after vasectomy is required to confirm success before the use of alternative contraception is abandoned. However, measuring the success of vasectomy is complicated by a lack of consistency with regards to both the number and timing of tests and the end points accepted.

Determining the success of vasectomy

OBJECTIVES

To examine patient compliance, significance of rare nonmotile sperm (RNMS) and to determine the timing and number of semen analyses required to confirm sterility.

PATIENTS AND METHODS

From November 2001 to November 2004, 436 consecutive primary vasectomies were performed by one surgeon. All patients were instructed to submit two initial semen specimens for analysis (2 and 3 months after vasectomy) and additional samples (at 1-month intervals) if sperm were identified on the initial and subsequent analyses.

RESULTS

A quarter of the patients submitted no semen specimens and only 21% followed the full instructions to provide two consecutive negative semen analyses. Three-quarters of the patients provided a semen specimen at 8 weeks after vasectomy; of these, 75% were azoospermic and 25% contained sperm. At 12 weeks after vasectomy half the patients provided a semen specimen; of these, 91% were azoospermic and 9% contained sperm. Of the 83 patients with semen containing sperm at 8 weeks, 80 had RNMS and three had rare motile sperm (one of whom subsequently proved to have vasectomy failure). Of the 80 patients with RNMS, at 3, 4, 5, 6, 8, 10 and 11 months, 65, four, three, four, two, one and one, respectively were azoospermic.

CONCLUSIONS

The present results indicate that many patients are not compliant with the protocol after vasectomy. Provided patients have been adequately counselled, we think that one negative semen analysis at 3 months or one with RNMS at 2 months may be adequate to determine the success of vasectomy. This should reduce the number of semen analyses, including reducing the number of men who must undergo repeat testing, without sacrificing the accuracy of determining paternity. Simplifying the follow-up after vasectomy is important; not only would it be cost-effective but it may also improve patient compliance.