The Risk of Pregnancy After Vasectomy

Vasectomy incidence in the military health system after the reversal of Roe v. Wade

Dobbs v. Jackson Women's Health Organization (Dobbs decision) has already had profound impact on reproductive health care in the United States. Some studies have reported increased incidence of vasectomy after the Dobbs decision. The Military Health System (MHS) provides a unique opportunity to evaluate this relationship in a universally insured, geographically representative population. We conducted a retrospective cross-sectional study of vasectomies among all male beneficiaries in the MHS, ages 18 to 64, from 2018 to 2022. Beneficiaries receiving a vasectomy were identified via billing data extraction from the MHS Data Repository (MDR). Descriptive statistics of demographic factors of all those receiving a vasectomy in the study period were evaluated. Crude and multivariate logistic regression models were used to evaluate for differences in demographic variables in those receiving a vasectomy pre-Dobb's decision as compared to after the Dobb's decision. The total number of men receiving a vasectomy each month over the study period was analyzed, as were the numbers in a state immediately implementing abortion access restrictions (Texas), and one without any restrictions on abortion access (Virginia). Our analysis found that men receiving a vasectomy post-Dobbs decision were more likely to be younger, unmarried, and of junior military rank than prior to the Dobbs decision. In the months following the Dobbs decision in 2022 (June-December), there was a 22.1% increase in vasectomy utilization as compared to the averages of those months in 2018-2021. Further, it was found that the relative increase in vasectomy after the Dobbs decision was greater in Texas (29.3%) compared to Virginia (10.6%). Our findings highlight the impact of the Dobbs decision on reproductive health care utilization outside of abortion.

Probability and informed consent

In this paper, we illustrate some serious difficulties involved in conveying information about uncertain risks and securing informed consent for risky interventions in a clinical setting. We argue that in order to secure informed consent for a medical intervention, physicians often need to do more than report a bare, numerical probability value. When probabilities are given, securing informed consent generally requires communicating how probability expressions are to be interpreted and communicating something about the quality and quantity of the evidence for the probabilities reported. Patients may also require guidance on how probability claims may or may not be relevant to their decisions, and physicians should be ready to help patients understand these issues.

[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.

Male Contraception

Approximately 40 to 50% of pregnancies are unintended. Contraceptive use significantly reduces the risk of unintended pregnancy. Approximately 70% of couples' contraceptive use is female and 30% is male, attributable to the reliance on condoms and vasectomies. Unfortunately, many women cannot use currently available contraceptives due to medical contraindications or side effects. At the same time, men want additional safe and effective contraceptive methods. Because of this, work to develop novel, safe, and effective male contraceptives is underway. This review will briefly discuss the pros and cons of condoms and vasectomies, and then describe research into the development of novel methods of male contraception, by the mechanism of action of the contraceptive. First, we will discuss male contraceptives that block sperm transmission. Next, we will discuss male contraceptives that impair sperm production. Lastly, we will discuss male contraceptives that impair sperm function.

Telehealth Sterilization Consultation Does Not Impact Likelihood of Vasectomy: A Retrospective Institutional Analysis

OBJECTIVE

To evaluate if telehealth consultations would impact the likelihood of patients following through with vasectomies.

METHODS

We utilized electronic medical records from the past 5 years to retrospectively evaluate male patients undergoing a sterilization consult. Telehealth consultations have been offered since March 2020 due to the COVID-19 pandemic. Patients were stratified to in-office or telehealth consultation. We then utilized billing codes to determine if patients underwent a vasectomy. Percentages of patients who subsequently underwent vasectomy were compared using Chi-square analysis. Logistic regression was performed to identify factors associated with completing vasectomy.

RESULTS

There were a total of 369 patients who underwent a telehealth male sterilization consultation and 1664 patients who were seen in the office. We found that 66.9% of telehealth patients ultimately underwent a vasectomy (n.ß=.ß247) compared to 64.3% of patients who were seen via office assessment (n.ß=.ß1070) (X2 =.ß0.646, p.ß=.ß.724). Younger age was the only variable on univariate logistic regression that was associated with completing vasectomy (p.ß=.ß.002) via either an in-person or televisit, while body mass index, race, and ethnicity were not significant.

CONCLUSION

Only 2/3 of the men completing a vasectomy consult receive a subsequent vasectomy. Both in-office and telehealth consultations resulted in comparable rates of vasectomy. This is the first study to report on the likelihood of following through with a surgical procedure comparing in-office vs.ßtelehealth assessment in male sexual and reproductive medicine. As vasectomy consultations continue to rise, clinicians can be reassured by the effectiveness of telehealth consultations prior to vasectomy.

[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.

Vasectomy Regret or Lack Thereof

Background

Vasectomy is a procedure that results in permanent yet reversible sterility and remains a great contraceptive option for many. Previous research studies have highlighted frequency of vasectomy utilization, defining characteristics of individuals who opt for this method, various surgical techniques, and the risks and benefits associated with the procedure. What remains to be defined is why or why not individuals may experience post-vasectomy regret and whether the previous characteristics correlate.

Objective

The objective of this review is to synthesize information regarding reasons individuals may regret their vasectomy and seek reversal, what options exist for accomplishing the reversal, and patients' fertility prognosis post-vasovasostomy.

Methods

This review utilized a combination of secondary and tertiary data analysis across a wide scope of academic databases pertaining to the topic of interest.

Results

Typically, most males who have sought a vasectomy are satisfied with their decision, however, approximately 6% of this population seeks reversal. Key factors influencing vasectomy regret include age at the time of vasectomy, parental status, pre- and post-operative relationship status, unresolved physical and psychosexual problems, and development of chronic scrotal pain following the procedure. Few options exist for vasectomy reversal including microsurgical reconstructive vasectomy reversal (VR) and sperm extraction for in vitro fertilization. There is no guarantee that fertility will be restored in any case but a major predictive factor for success is the time interval prior to reversal.

Conclusion

Vasectomy is intended to be a permanent form of contraception; however, a minor chance remains that individuals may experience post-operative regret due to various factors. This warrants proper comprehensive counseling by the patient's provider regarding benefits and risks, procedural outcomes, opportunities for reversal, and fertility prognosis.

Post-Vasectomy Semen Analysis: Optimizing Laboratory Procedures and Test Interpretation through a Clinical Audit and Global Survey of Practices

PURPOSE

The success of vasectomy is determined by the outcome of a post-vasectomy semen analysis (PVSA). This article describes a step-by-step procedure to perform PVSA accurately, report data from patients who underwent post vasectomy semen analysis between 2015 and 2021 experience, along with results from an international online survey on clinical practice.

MATERIALS AND METHODS

We present a detailed step-by-step protocol for performing and interpretating PVSA testing, along with recommendations for proficiency testing, competency assessment for performing PVSA, and clinical and laboratory scenarios. Moreover, we conducted an analysis of 1,114 PVSA performed at the Cleveland Clinic's Andrology Laboratory and an online survey to understand clinician responses to the PVSA results in various countries.

RESULTS

Results from our clinical experience showed that 92.1% of patients passed PVSA, with 7.9% being further tested. A total of 78 experts from 19 countries participated in the survey, and the majority reported to use time from vasectomy rather than the number of ejaculations as criterion to request PVSA. A high percentage of responders reported permitting unprotected intercourse only if PVSA samples show azoospermia while, in the presence of few non-motile sperm, the majority of responders suggested using alternative contraception, followed by another PVSA. In the presence of motile sperm, the majority of participants asked for further PVSA testing. Repeat vasectomy was mainly recommended if motile sperm were observed after multiple PVSA's. A large percentage reported to recommend a second PVSA due to the possibility of legal actions.

CONCLUSIONS

Our results highlighted varying clinical practices around the globe, with controversy over the significance of non-motile sperm in the PVSA sample. Our data suggest that less stringent AUA guidelines would help improve test compliance. A large longitudinal multi-center study would clarify various doubts related to timing and interpretation of PVSA and would also help us to understand, and perhaps predict, recanalization and the potential for future failure of a vasectomy.

Outpatient Vasectomy: Safe, Reliable, and Cost-effective

Vasectomy is a safe, effective, and practical option for permanent contraception in men. Vasectomy is a surgical procedure used in men to disrupt and occlude the vas deferens, which delivers sperm from the testicles. By interrupting sperm transport, this procedure provides permanent sterilization. Vasectomies are typically done under local anesthesia in outpatient settings, and patients usually go home within an hour of the surgery. Surgical techniques used for vasectomy vary widely throughout the world, with limited evidence to guide the most effective approach. Current vasectomy guidelines largely rely on information from observational studies, with few controlled clinical trials.

Paternity seven years after a negative post-vasectomy semen analysis: a case report

BACKGROUND

Vasectomy is one of the permanent methods of contraception; however, the risk of conception still exists. Early failure, defined as a postoperative semen analysis showing persistent motile sperm, occurs in 1 in every 250 patients. Late failure, defined as the rejoining of the severed ends of the vas deferens, occurs in 1 in every 2000 patients.

CASE PRESENTATION

A healthy 37-year-old British male presented to our clinic because his wife had conceived seven years after he had undergone a vasectomy. The result of his semen analysis after the vasectomy was negative, and the histopathological report confirmed that the sample contained tissue from both the left and right vas deferens. His wife conceived seven years after the procedure, and semen analysis at that time confirmed a total of 0.5 million sperm per milliliter of semen in a total semen sample of 6.3 ml. The total number of motile sperm recorded was 2.5 million.

CONCLUSION

This case shows that late recanalization can occur up to seven years after a vasectomy. Patients should be informed prior to the procedure that late recanalization, although rare, may still occur. Post-vasectomy paternity necessitates further counseling to ensure that the patient and the patient's partner fully understand the implications and options available to them.

Contraception

Contraception counseling and provision are vital components of comprehensive health care. Unplanned pregnancy can be devastating to any woman but is particularly dangerous for those with chronic illness. Internal medicine providers are in a unique position to provide contraception, as they often intersect with women at the moment of a new medical diagnosis or throughout care for a chronic problem. A shared decision-making approach can engage patients and ensure that they choose a contraceptive method that aligns with their reproductive plans and medical needs.

Use of secondary contraception following vasectomy: insights from the Pregnancy Risk Assessment Monitoring System, 2007-2011

Background

To assess postpartum use of secondary contraception with vasectomy within Pregnancy Risk Assessment Monitoring System (PRAMS).

Methods

Secondary contraception and type of method used were assessed among married women reporting partner vasectomy 4 months after a recent live birth in female residents of 15 US states and New York City who participated in the 2007–2011 PRAMS.

Results

Between 2007 and 2011, 1,004 married women who had a recent live birth participating in PRAMS reported they and their partners relied on vasectomy for postpartum contraception. Among these couples, 57.8% reported not using additional forms of contraception postpartum. Of those reporting additional contraception, condoms were most commonly used (50.0%), followed by oral contraceptive pills (26.5%), and withdrawal (9.5%). Multivariable modeling showed that use of secondary contraception was twice as high among women reporting a second birth versus women reporting a fourth or higher birth [adjusted prevalence odds ratio (POR) =2.0 (1.1–3.2)]. No other sociodemographic characteristics (maternal age, maternal race, parental education, household income) were significantly associated with use of secondary contraception with vasectomy.

Conclusions

Most couples within PRAMS reporting partner vasectomy as postpartum contraception did not use secondary contraception in the months immediately after vasectomy, and, of those who did, most relied on less effective methods. Clinicians need to better understand reasons for limited use of secondary contraception with vasectomy to improve counseling strategies for reducing unintended pregnancy.

Vasectomy with vessel sealing device: comparison of different diameters

OBJECTIVES

Vasectomy is a popular and effective male surgical contraceptive method. Different techniques have been proposed to reduce failure rates and complications. In this study, we sought to compare vas deferens occlusion rates using both standard occlusion techniques and LigaSure (LSVS) for vasectomy.

MATERIAL AND METHODS

A total of nine patients underwent open radical retropubic prostatectomy at our institution. During the procedure, a total of 125 fresh vas deferens samples were obtained and divided into four groups as follows: Group 1: ligation (n = 22), Group 2; ligation and electrocauterization (n = 18), Group 3; 5 mm LSVS (n = 44), Group 4; 10 mm LSVS (n = 41). All specimens were harvested during surgery and subsequent histopathological assessments were performed to assess the luminal status of the vas deferens.

RESULTS

Histopathological evaluation revealed that the majority of vas lumens with LSVS (79.5% of Group 3 and 89.4% of Group 4) were totally occluded. With standard techniques, however, the majority of vas lumens (86.4 and 77.8% of Groups 1 and 2, respectively) maintained a tiny patency.

CONCLUSIONS

On histopathological review, the application of LSVS resulted in better occlusion rates, compared to standard ligation methods. These findings suggest a higher occlusive role for LSVS for vasectomy. Further clinical studies are needed to confirm the clinical efficacy and safety of this technique.

Microdenervation of the spermatic cord for post-vasectomy pain syndrome

OBJECTIVE

To evaluate the outcomes of patients who underwent microdenervation of the spermatic cord (MDSC) for post-vasectomy pain syndrome (PVPS) at our institution.

METHODS

A retrospective study of all patients who underwent MDSC for PVPS by a single surgeon between March 2002 and October 2016 was performed. Pain was documented using the numerical rating scale (NRS). Spermatic cord block (SCB) was performed on all patients, and success was defined as NRS score ≤1 for >4 h. All patients had failed medical therapy prior to MDSC. All previous procedures for PVPS had been performed elsewhere. Surgical success was defined as a postoperative NRS score of ≤1.

RESULTS

A total of 27 patients with 28 scrotal units underwent MDSC for PVPS. The median (1st quartile; 3rd quartile) follow-up was 10 (2; 16.5) months. The median (range) duration of pain prior to surgery was 57 (8-468) months. Pain was bilateral in 14 (52%), left-sided in eight (30%) and right-sided in five patients (19%). Data on SCB were available for 23 patients, with a success rate of 96%. The median (range) preoperative pain NRS score was 7 (2-10). The median (range) pain score after SCB on the NRS scale was 0 (0-5). The median (range) postoperative pain score on the NRS was 0 (0-9). Overall success was achieved in 20 of 28 testicular units (71%). Patients with involvement of multiple structures in the scrotum (i.e. testis, epididymis, spermatic cord) had a success rate of 81% and were more likely to have a successful surgery (P < 0.001). Five patients had failed a prior epididymectomy and three had failed a vaso-vasostomy for PVPS; this had no correlation with the success of MDSC (P = 0.89).

CONCLUSION

The MDSC procedure is a reasonably successful, durable and valuable approach for PVPS, especially when pain involves multiple structures in the scrotum (testis, epididymis, spermatic cord). MDSC was equally efficacious in patients who had previously failed a procedure for PVPS. No patient had a worsening NRS score after MDSC. This is the largest study to date evaluating MDSC for the treatment of PVPS.

Micro-Denervation of the Spermatic Cord for Post-Vasectomy Pain Management

INTRODUCTION

Post-vasectomy pain syndrome (PVPS) is a challenging problem for the practicing urologist because of its unclear pathophysiology and no clearly established protocol for evaluation or treatment. PVPS is defined as at least 3 months of chronic or intermittent scrotal content pain after a vasectomy procedure once other etiologies for the pain have been ruled out.

AIM

To systematically review the current literature on the effectiveness of micro-denervation of the spermatic cord (MDSC) for PVPS.

METHODS

A systematic literature search using PubMed, Scopus, Medline, Embase, and Cochrane databases for all reports pertaining to PVPS using the Medical Subject Heading terms post vasectomy pain syndrome and micro-denervation of spermatic cord through February 2017.

MAIN OUTCOME MEASURES

Scrotal content pain after MDSC for PVPS.

RESULTS

There were nine retrospective studies evaluating MDSC for chronic testicular pain. After omitting repeated series, there were 213 patients who underwent MDSC for chronic orchialgia. Only one study specifically reviewed the outcomes of patients who underwent MDSC for PVPS. In this study, 17 patients underwent MSDC for PVPS, with 13 (76.5%) reporting complete relief of pain at their first follow-up visit. The other four patients had significant improvement in pain and were satisfied with the results. Long-term follow-up data were not available for this study.

CONCLUSION

MDSC remains a valuable approach with high success rates and should be considered for PVPS that is refractory to medical therapy. MDSC appears to have the most success for patients who experience a temporary relief from a cord block and can significantly improve the patient's quality of life and ability to return to daily activities. Tan WP, Levine LA. Micro-Denervation of the Spermatic Cord for Post-Vasectomy Pain Management. Sex Med Rev 2018;6:328-334.

Post-vasectomy pain syndrome: diagnosis, management and treatment options

Vasectomy is the most effective form of sterilization for men. With approximately 500,000 vasectomies performed each year in the United States, 1-2% of these patients will experience chronic testicular pain for greater than three months after the procedure. Post-vasectomy pain syndrome (PVPS) is diagnosis of exclusion, and may be caused by direct damage to spermatic cord structures, compression of nerves in the spermatic cord via inflammation, back pressure from epididymal congestion, and perineural fibrosis. Treatment should begin with the most noninvasive options and progress towards surgical management if symptoms persist. Noninvasive therapies include acupuncture, pelvic floor therapy and pharmacologic options. Ultimately, management of PVPS requires a multimodal approach. Thorough understanding of the potential etiologies of PVPS along with the therapeutic options currently available is important to improve quality of life.

Vasectomy and risk of prostate cancer: population based matched cohort study

OBJECTIVE

 To determine the association between vasectomy and prostate cancer, adjusting for measures of health seeking behaviour.

DESIGN

 Population based matched cohort study.

SETTING

 Multiple validated healthcare databases in Ontario, Canada, 1994-2012.

PARTICIPANTS

 326 607 men aged 20 to 65 who had undergone vasectomy were identified through physician billing codes and matched 1:1 on age (within two years), year of cohort entry, comorbidity score, and geographical region to men who did not undergo a vasectomy.

MAIN OUTCOMES MEASURES

 The primary outcome was incident prostate cancer. Secondary outcomes were prostate cancer related grade, stage, and mortality.

RESULTS

 3462 incident cases of prostate cancer were identified after a median follow-up of 10.9 years: 1843 (53.2%) in the vasectomy group and 1619 (46.8%) in the non-vasectomy group. In unadjusted analysis, vasectomy was associated with a slightly increased risk of incident prostate cancer (hazard ratio 1.13, 95% confidence interval 1.05 to 1.20). After adjustment for measures of health seeking behaviour, however, no association remained (adjusted hazard ratio 1.02, 95% confidence interval 0.95 to 1.09). Moreover, no association was found between vasectomy and high grade prostate cancer (adjusted odds ratio 1.05, 95% confidence interval 0.67 to 1.66), advanced stage prostate cancer (adjusted odds ratio 1.04, 0.81 to 1.34), or mortality (adjusted hazard ratio 1.06, 0.60 to 1.85).

CONCLUSION

 The findings do not support an independent association between vasectomy and prostate cancer.

An overview of the management of post-vasectomy pain syndrome

Post-vasectomy pain syndrome remains one of the more challenging urological problems to manage. This can be a frustrating process for both the patient and clinician as there is no well-recognized diagnostic regimen or reliable effective treatment. Many of these patients will end up seeing physicians across many disciplines, further frustrating them. The etiology of post-vasectomy pain syndrome is not clearly delineated. Postulations include damage to the scrotal and spermatic cord nerve structures via inflammatory effects of the immune system, back pressure effects in the obstructed vas and epididymis, vascular stasis, nerve impingement, or perineural fibrosis. Post-vasectomy pain syndrome is defined as at least 3 months of chronic or intermittent scrotal content pain. This article reviews the current understanding of post-vasectomy pain syndrome, theories behind its pathophysiology, evaluation pathways, and treatment options.

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).

[Male contraception]

Contraception allows within a heterosexual couple to have a more fulfilling as possible sexuality while protecting against the occurrence of unintended pregnancy. In a majority of couples, contraception is assumed by women. Currently, male contraceptive methods most commonly used are the male condom and vasectomy. Many other strategies, including hormonal contraceptive regimens, have been proposed and evaluated. The purpose of this review is to present an overview of the various current and future male contraceptive methods.

Contraceptive failure in the United States

This review provides an update of previous estimates of first-year probabilities of contraceptive failure for all methods of contraception available in the United States. Estimates are provided of probabilities of failure during typical use (which includes both incorrect and inconsistent use) and during perfect use (correct and consistent use). The difference between these two probabilities reveals the consequences of imperfect use; it depends both on how unforgiving of imperfect use a method is and on how hard it is to use that method perfectly. These revisions reflect new research on contraceptive failure both during perfect use and during typical use.

Vasectomy and vasectomy reversal: An update

Vasectomy is an elective surgical sterilization procedure for men that is intended to obstruct or remove a portion of both vas deferens, thereby preventing sperm from moving from the testes to the ejaculatory ducts. Although intended for permanent sterilization, vasectomy can be reversed in most men seeking to restore their fertility due to a change in marital status or reproductive goals. The purpose of this document is to provided a synopsis of the latest techniques used in vasectomy and reversal.

Vasectomy: the other (better) form of sterilization

Male sterilization (vasectomy) is the most effective form and only long-acting form of contraception available to men in the United States. Compared to female sterilization, it is more efficacious, more cost-effective, and has lower rates of complications. Despite these advantages, in the United States, vasectomy is utilized at less than half the rate of female sterilization. In addition, vasectomy is least utilized among black and Latino populations, groups with the highest rates of female sterilization. This review provides an overview of vasectomy use and techniques, and explores reasons for the disparity in vasectomy utilization in the United States.

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.

Racial differences in vasectomy utilization in the United States: data from the national survey of family growth

OBJECTIVES

To explore whether health care, socioeconomic, or personal characteristics account for disparities observed in the utilization of vasectomy. More than 500,000 vasectomies are performed annually in the United States. The safety and efficacy of vasectomy make it a good family planning option, yet the factors related to use of male surgical sterilization are not well understood. In this analysis, we examined differences in vasectomy rates according to factors such as race and socioeconomic status.

METHODS

We analyzed data from the male sample of the 2002 National Survey of Family Growth to examine the use of vasectomy among the sample of men aged 30-45 (n = 2161). Demographic, socioeconomic, and reproductive characteristics were analyzed to assess associations with vasectomy.

RESULTS

About 11.4% of men aged 30-45 years reported having a vasectomy, representing approximately 3.6 million American men. Although 14.1% of white men had a vasectomy, only 3.7% of black and 4.5% of Hispanic men reported undergoing vasectomy. On multivariate analysis, a significant difference in the odds of vasectomy by race/ethnicity remained, with black (odds ratio = 0.20, 0.09-0.45) and Hispanic men (odds ratio = 0.41, 0.18-0.95) having a significantly lower rate of vasectomy independent of demographic, partner, and socioeconomic factors. Having ever been married, fathering 2 or more children, older age, and higher income were the factors associated with vasectomy.

CONCLUSIONS

After accounting for reproductive history, partner, and demographic characteristics, black and Hispanic men were less likely to rely on vasectomy for contraception. Further research is needed to identify the reasons for these race/ethnic differences and to identify factors that impede minority men's reliance on this means of fertility control.

Effectiveness of vasectomy techniques

The effectiveness of various vasectomy techniques is reviewed, with a focus on methods used for vas occlusion. Spontaneous recanalization of the vas is more common than generally recognized and is often transient. Simple ligation and excision has an unacceptably high risk for failure. Techniques that include cautery seem to have a lower risk for failure than techniques that do not include cautery. There is insufficient evidence to recommend a particular standardized cautery technique, but adding fascial interposition to cautery seems to be associated with the lowest risk for failure.

Advances in male contraception

Despite significant advances in contraceptive options for women over the last 50 yr, world population continues to grow rapidly. Scientists and activists alike point to the devastating environmental impacts that population pressures have caused, including global warming from the developed world and hunger and disease in less developed areas. Moreover, almost half of all pregnancies are still unwanted or unplanned. Clearly, there is a need for expanded, reversible, contraceptive options. Multicultural surveys demonstrate the willingness of men to participate in contraception and their female partners to trust them to do so. Notwithstanding their paucity of options, male methods including vasectomy and condoms account for almost one third of contraceptive use in the United States and other countries. Recent international clinical research efforts have demonstrated high efficacy rates (90-95%) for hormonally based male contraceptives. Current barriers to expanded use include limited delivery methods and perceived regulatory obstacles, which stymie introduction to the marketplace. However, advances in oral and injectable androgen delivery are cause for optimism that these hurdles may be overcome. Nonhormonal methods, such as compounds that target sperm motility, are attractive in their theoretical promise of specificity for the reproductive tract. Gene and protein array technologies continue to identify potential targets for this approach. Such nonhormonal agents will likely reach clinical trials in the near future. Great strides have been made in understanding male reproductive physiology; the combined efforts of scientists, clinicians, industry and governmental funding agencies could make an effective, reversible, male contraceptive an option for family planning over the next decade.

“Oligozoospermia,” “azoospermia,” and other semen-analysis terminology: the need for better science

The Greek-based terms used to describe semen-analysis abnormalities (e.g., "oligozoospermia" and "azoospermia") are unscientific, have overlapping definitions, and are often misinterpreted. The best course is to abandon these vague and difficult labels and simply report semen analyses quantitatively.

Utility and drawbacks of continuous use of a copper T IUD for 20 years

This article examines interrelated questions concerning the extent of need for contraception in women 40 years and older and the degree to which that need can be served when use of collared T IUDs is initiated in women aged 25-35 years. Differentials in the impacts of intrauterine device (IUD) use on health issues in the second decade of contraception are also addressed. Although fertility of all women aged 40-44 years is below 100 per 1000 in all regions of the world today, the risk of pregnancy among married or cohabiting women who do not use contraception is estimated at 270-300 per 1000 or 27-30% per year. At ages 45-49 years, the annual risk of pregnancy to women in union who do not use contraception lies at or above 10% per year. Data from three studies show that users of collared copper IUDs who continued using the same device beyond the completion of 10 years experienced no pregnancies through the end of 15 years. A small number of women continued with the same IUD through 20 years and still experienced no pregnancies. Use of collared copper T IUDs beyond 10 years was not associated with intensification of side effects nor with an increase in the relative frequency of those effects, with the exception of the experience of perimenopausal symptoms and problems. Neither increased bleeding nor increased severity of pelvic disease was manifest in the second decade of continuous use of the same IUD, as compared with the first decade of such use. Under our current understanding of the duration of IUD effectiveness, only a small percentage of women complete 10 years of use. Even with revised understanding of the duration of effectiveness of long-acting copper devices, average annual continuation rates must be quite high in order that 20% of women aged 25-35 years initiate a second decade of continuous IUD use. Those who do so would find considerable protection against pregnancy and reasonable economic benefits in continuing to use the same device.

Outcome of vasectomies performed at a Turkish metropolitan maternity hospital

OBJECTIVE

To determine prospectively the outcome of vasectomies performed by two trained surgeons over a 9-month period at the Ministry of Health Ankara Etlik Maternity and Women's Health Teaching and Research Hospital Family Planning Centre.

METHODS

The demographic data, source of information concerning the method, sexual function before and after voluntary no-scalpel vasectomy, compliance with the post-vasectomy follow-up program of men applying for a vasectomy were analyzed. All patients were contacted by telephone and invited for follow-up visits for counseling, inquiry regarding sexual dysfunction, and performance of a semen analysis.

RESULTS

The patients were married men, mostly primary school graduates, with more than one child. Sources of information were health services and/or health personnel for 89% of the patients. Of the 279 men who underwent a vasectomy and who were later contacted by phone, 131 (47%) came for a follow-up assessment. There was only one post-vasectomy pregnancy (0.8%). The incidence of reported sexual problems did not change after the procedure. Vasectomy did not affect the sexual function of men in our study.

CONCLUSION

Compliance with follow-up after vasectomy, which is extremely important for assessment of its successful outcome, is low.

Vasectomy in the United States, 2002

PURPOSE

We estimated the number of vasectomies performed in the United States in 2002 and gathered information on the vasectomy procedures and protocols used. It follows similar studies done in 1991 and 1995.

MATERIALS AND METHODS

A retrospective mail survey with telephone followup was performed in 2,300 urologists, family physicians and general surgeons randomly sampled from the American Medical Association Physician Masterfile.

RESULTS

The response rate was 73.8%. An estimated 526,501 vasectomies were performed in 2002 for a rate of 10.2/1,000 men 25 to 49 years old. Overall 37.8% of physicians reported currently using no scalpel vasectomy and almost half of the vasectomies performed in 2002 were no scalpel vasectomies. Methods of vas occlusion varied in and among specialties with a combination of ligation and cautery being most common (41.0% of cases). Of the physicians 45.6% reported routinely performing fascial interposition, 94.4% reported removing a vas segment, 23.3% reported routinely folding back 1 or 2 ends of the vas and 7.5% reported using open-ended vasectomy. Followup protocols varied widely. Of respondents 53.5% reported charging $401 to $600 for vasectomy in 2002.

CONCLUSIONS

Although the estimated number of vasectomies performed in the United States during 2002 represents an increase from 1991 and 1995, incidence rates remained unchanged at approximately 10/1,000 men 25 to 49 years old. The percent of vasectomies performed using no scalpel vasectomy as well as the number of physicians who reported that they use no scalpel vasectomy increased substantially since 1995. Wide variation in surgical techniques and followup protocols were found.

An implantable ligation device that achieves male sterilization without cutting the vas deferens

OBJECTIVES

To determine whether the Vasclip implant procedure would (a) be equivalent to vasectomy in producing azoospermia, (b) produce greater patient satisfaction postoperatively, and (c) result in lower complication rates, postoperative pain, hematoma formation, spermatic granuloma, and surgical site infection when compared with historical controls.

METHODS

Sterilization and complications were studied in 124 consecutive patients.

RESULTS

Successful sterilization, defined by azoospermia at 10 to 14 months, was observed in 116 of 119 subjects. The effectiveness seemed to be equivalent to that of vasectomy. The incidence of postoperative pain and hematoma formation was similar to that with standard methods. The Vasclip procedure had similar infection rates and seemed to have lower rates of sperm granuloma when compared with vasectomy. In 3 subjects with persistent presence of sperm, histologic examination after traditional vasectomy indicated that misalignment of the device led to partial vas incision with recanalization. Patient acceptability was high: of the clinical study patients, 99% of survey respondents would recommend that other men considering a vasectomy have the Vasclip procedure.

CONCLUSIONS

The Vasclip implant procedure represents a new, effective, office-based alternative to vasectomy. Physicians' benefits can include reduced procedural time and reduction of postprocedural complications. Potential patients' benefits include reduced risk of postoperative infection and sperm granuloma formation.