Vasectomy & Vasovasostomy

Alternative Methods
As many as 40% of couples seeking vasectomy have experienced a failure with their previous method of nonpermanent birth control. Such failures can occur from misplacement of a diaphragm, an incorrectly implanted IUD, or noncompliance with an oral contraception regimen.

Some people contemplate vasectomy when use of a condom, diaphragm, or foam interferes with their enjoyment of sex. Freedom from distraction during sex is a secondary benefit of vasectomy, but should not be considered the primary motivation for the operation.

Can Vasectomies be reversed?
Although men should consider their vasectomy to be a permanent decision before undergoing the procedure, if they change their mind, there is a surgical procedure known as a vasovasostomy that may restore fertility. The main reasons for requesting a reversal are remarriage, the death of a child, or an improvement in finances. Reversal may also be performed to relieve postvasectomy pain, which occurs in a small percentage of men.

Causes of Vasovasostomy failure
The chances for pregnancy decrease the longer the duration between vasectomy and the reversal operation. The lower rates as time goes by is probably due to increasing chance for obstruction of the epididymis and the development of anti sperm antibodies. A successful reversal is more likely if the section removed during vasectomy was not long, if the original procedure was performed on straight sections of the vas, and if the joined pieces were of equal size.

Epididymis Obstruction
If the sperm count does not recover within a reasonable period after vasovasostomy, secondary blockage of the epididymis is most often the cause, which may be corrected with a second procedure. Auto antibodies
In the majority of cases, the reversal procedure reopens the epididymis, but fertility is not necessarily automatic. Autoimmunity is a condition in which the antibodies of the immune system attack specific cells in the body, mistaking them for micro foreign invaders. In the case of male infertility, such so–called auto antibodies target the sperm. Even if a procedure to reverse the vasectomy is performed, such antibodies often persist. Antibodies bind to specific parts of the sperm (e.g.., the head or tail) and cause problems depending on the site of attachment. Sperm may stick together (agglutinate), fail to interact with cervical mucous, or fail to penetrate the egg.

Other Vasectomy–Induced Anti fertility Factors
The important immune factors that trigger the autoimmune process are called leukocytes. Among their other harmful effects is the production of particles called oxygen–free radicals (also called reactive oxygen metabolites), which are particularly injurious to sperm. Vasectomy may also change other factors that affect fertility.

Failure
After a vasectomy, there is still a 1.5% chance of pregnancy usually due to either live residual sperm or operative failure. Some reasons for failure of a vasectomy include incomplete sealing of the vasectomy differentia and the development of openings in the tubes that allow sperm to pass through.

Residual Live Sperm. After the operation there are always some active sperm left in the semen for several months, so it is essential that the patient and his partner continue to use another method of birth control until his sperm count is zero. Fifteen to 20 ejaculations are required to clear the viable sperm from the reproductive system, usually it takes a few months before sterility is complete.

A semen analysis is done about six to twelve weeks after the surgery to ensure that no live sperm remain in the semen. The semen is usually collected at home in a small jar and delivered to the doctor’s office where it is examined under a microscope. A second semen analysis is usually performed again about four months after the vasectomy. The patient is considered sterile only when there is no live sperm in his semen. The presence of non-motile sperm presents no problem.

The primary reason for vasectomy failure occurs when the cut ends of the vas deferens reconnect through a process known as spontaneous recanalization. This is very rare but may occur if a sperm granuloma and its resultant interconnecting channels form a new route for sperm to move from one cut end of the vas deferens to the other. Recanalisation has been known to occur as soon as a man has achieved a zero sperm count and as late as 17 months after vasectomy, but the overall risk for recanalization is only about .025% or one in 4,000 vasectomies. This natural vasectomy reversal can occur regardless of the type of vasectomy surgical procedure. Men should have a follow-up examination a year after the procedure to be sure that there are no residual or new sperm.

Future Changes
Those considering vasectomy should consider whether recent changes or stresses (an illness, temporary financial crisis, death in the family, or birth of a child) rather than rational, long–term consideration, are influencing a decision about permanent contraception. Vasectomy should not be thought of as a way to cope with short–term problems. Experts recommend that couples wait for a while if they face such situations or that they seek marriage counseling or psychotherapy to be sure that they are not making a decision they will regret later.

Before deciding on a vasectomy, the patient and his partner should be clear about their reasons for going through with the procedure. The couple should consider all scenarios for possible future life changes. If the man changes his mind after a vasectomy, he will have to undergo a major operation to reverse the procedure with no guarantee of restoring his fertility. The couple needs to consider how they would feel if their current relationship ended, either by divorce or the wife’s death.

In such cases, the man might find a new partner who wanted a child by him. What would happen if one or more children died? If financial stress is triggering the decision for a vasectomy, would improved affluence make a difference in determining the desire for children? Age is also a factor, for many young men who still have many major life changes ahead of them, vasectomy is probably not a wise choice.

Is Vasectomy the Appropriate Choice?
Worldwide, more than 30 million couples use vasectomy as a method of birth control. The great majority of men who seek a vasectomy have been married for 10 years or more and have a stable relationship. Some reasons for a vasectomy include are having all the children the couple wants, not wanting or able to use other methods of contraception, a health problem in the woman that makes pregnancy unsafe, a genetic disorder, or a desire to enjoy sex without fear of unwanted pregnancy.

Even if all these factors are present, a couple must consider their options carefully before proceeding, and both partners should completely agree that they no longer want to have children. After deciding that permanent birth control is the best solution, the couple has the option of either vasectomy for the male or tubal legation for the female partner.

Studies indicate that between 5% and 10% of men have regrets after vasectomy. Men should not make the decision frivolously. Vasectomies may not be right for those who are unsure about having children in the future, whose current relationships are unstable or going through a stressful phase, who are considering the operation just to please their partners, or who are counting on having children later on either by storing sperm or surgical reversal of their vasectomies.

Long–Term Risks
Long–Term Testicular Pain. Research has indicated that up to a third of men have some pain that lasts longer than three months. The source of the pain is not fully known. Some experts believe there are two specific causes. scarring from the surgery and obstruction of part of the epididymis that causes another section to widen. Some believe that granulomas may cause more chronic pain than generally believed, but others point out that open–ended procedures, which actually stimulate granuloma production, result in less pain than closed–ended techniques.

It is not yet known if no–scalpel techniques will further reduce this complication. Many physicians believe that in most cases it is probably caused by pinched nerves. Surgery, including removal of the epididymis and surrounding tissue, may be required if more conservative measures fail. A surgical procedure that blocks nerves in the sperm cord can bring relief in severe cases. Surgery to reverse vasectomy also may relieve pain in men who have the procedure for this purpose.

Vasectomy & Prostate Cancer
Long–term high–normal levels of testosterone are associated with an increased risk for prostate cancer. Because testosterone levels remain higher for a longer period in men who had vasectomy, experts have been concerned that such men have a greater chance for developing the cancer. Studies investigating the relationship between vasectomy and prostate cancer have been conflicting. Research on the relationship with prostate cancer is continuing, although if any link is found, it is likely to be very weak. Men with a family history of prostate cancer should discuss the risks and benefits of vasectomy with their physicians.

Immune System Changes
Vasectomy is known to provoke immune system changes. Because sperm continue to be produced after vasectomy but disposed of in the body, the patient’s immune system may recognise them as foreign proteins and produce anti–sperm antibodies. Up to two–thirds of vasectomised men develop antibodies that get attach to the sperm and interfere with the sperm's motility (ability to move).

Infections in the genital tract, such as orchitis or sexually transmitted diseases, increase the risk for anti–sperm antibodies. Experts are concerned that changes in the immune system might cause damage in other parts of the body, including hardening of the arteries, blood clotting, kidney disease, and arthritis. Two major studies of large groups of men, however found no significant risk to a man’s overall health. Most medical experts, including special panels convened by the National Institute of Health and the World Health Organization, have concluded that vasectomy is a safe procedure.

Kidney Stones
Studies are indicating that men younger than their mid-forties who have vasectomies have twice the risk for kidney stones as their peers who have not had vasectomies. The increased risk persists for up to 14 years after the operation. Kidney stones are not life threatening but they can be extremely painful, and just to be on the safe side, men who have had vasectomies should drink plenty of fluids to help prevent them.

Osteoporosis
There has been some concern that vasectomies increase the risk for osteoporosis in men. One study, however, found no higher incidence of bone loss in vasectomised men.

Heart Disease
Animal research has suggested that heart disease accelerates after vasectomy, but one study on men who had vasectomies found no significant increase in risk for angina even over the long term.

Psychological Reactions and Long–Term Dissatisfaction. Most men who have vasectomies feel relieved that the worry about pregnancy is over, and most couples respond well to their new–found contraceptive freedom. About 30% of couples report that they have sex more often following vasectomy, enjoy it more, consider their marriages stronger, feel healthier and more relaxed, and have no regrets about the operation. Younger and older couples, with or without children, were all equally likely to have favorable reactions to vasectomies.

Some men go through a brief period of self–consciousness, wondering whether others notice some difference in their masculinity. About half of vasectomy patients keep their operations a secret. They may believe that the operation is tainted by the stigma of emasculation and that knowledge of it would degrade them in the eyes of their friends and family. For most men, this tentativeness passes quickly. In a few men, however, problems of poor self–image persist and require counseling. Some men may experience depressed and angry emotions similar to mourning over the loss of their reproductive ability. These negative feelings usually resolve over time as the patient moves on to the next stage of his life. A small percentage of couples experience serious difficulties with the adjustment. Their emotional distress most often manifests itself in sexual dysfunction, such as impotence, premature ejaculation, or painful intercourse. In such cases, however, the vasectomy is probably the catalyst but not the cause of such extreme reactions. Studies have indicated that men who experienced impotence after vasectomy were more likely to have female partners who were unable to accept the operation.

Other forms of Contraception
Contraceptives for Men
Withdrawal: Withdrawal before ejaculation is a form of natural contraception, but it is extremely risky and most people find it unsatisfactory Condoms. The only other form of male contraception currently available is the condom. The average rate of pregnancy for couples who rely on condoms for protection is 12%. Even for those who use a good–quality condom correctly, the annual risk for pregnancy is 3%. When the condom is used with spermicidal lubricants, either foams, creams, or jellies, protection is increased. The spermicidal lubricant also prevents tearing.

Condoms:Condoms made of latex rubber that are contoured for better fit and that contain a spermicide are effective but are less protective than if a man uses a condom and the women a spermicidal vaginal contraceptive. The condom should be put on before intercourse when the penis is erect, long before ejaculation, the male can discharge drops of semen that can cause pregnancy. Even with a vasectomy, men who are not in a monogamous relationship with an HIV–negative partner should always wear a latex condom during sex for protection against sexually transmitted diseases, vasectomy is not protective.

Implants:Implants of levonorgestrel (Norplant) offer another effective, long–term contraceptive option. Like Depo–Provera, levonorgestrel is a progestin and contains no estrogen. Six pellets containing the hormone are surgically implanted beneath the skin of a woman’s upper arm. (a newer system, Jadelle, uses two implants and may prove to be as effective as the Norplant system.) The pellets slowly release progestin, thereby preventing pregnancy even more effectively than oral contraceptive pills. The method has some distressing side effects but they are not common, and only 10% of women request removal. Implants provide 99% effective contraception for five years.

Intrauterine Device (IUD ):The intrauterine device (IUD) is a small T–shaped plastic device that is inserted into the uterus. An IUD’s contraceptive action begins as soon as the device is placed in the uterus and stops as soon as it is removed. It is 97% effective, although within a year some women expel them. They also increase the risk for infection and should be replaced every four years.

Psychological Implications
The word “Sterilization” has a deep emotional connotation for many people. Even though a couple may rationally accept the idea of a vasectomy, it is extremely important for each partner to be as open as possible about any negative feelings they might associate with the procedure. For instance, a woman might believe, incorrectly, that a vasectomy is emasculating, but she might not want to express this idea to her partner. On the other hand, some women may fear that vasectomy may make their partner more attractive to other women and encourage outside affairs.

Some studies have indicated that men with poor self–images, including concerns for their own physical health or sexual ability, are likely to have a difficult time adjusting psychologically to vasectomy. Men who have the operation only for the sake of their partner’s health and not because they want the procedure for their own reasons may also have difficulties. Such thoughts on the part of either partner can have devastating consequences on a relationship if they surface only after the procedure has been performed.

Re–operations after a failed Vasovasostomy
If pregnancy fails, in some cases, a repeat operation may be effective. Success rates depend on several factors, including the doctor's skill, complications from the original operation, the effects of anti–sperm antibodies, and the time elapsed since vasectomy. Even though tubes are open and sperm is restored in as many as 85% of men, pregnancy rates only average about 30%.

Damage to the epididymis occurs in about 75% of men who request a repeat operation after vasovasostomy failure. This requires an operation called vasoepididymostomy, which creates a bypass around the obstruction. To appreciate the difficulty, one should realize that the epididymis is 1/300 of an inch wide with a wall thickness of 1/1000 of an inch. Microscopic techniques are critical for the success of this procedure and require a surgeon who specializes in them. Success rates are higher for repairing obstructions closer to the testicles because the epididymis is wider in this area.

Assisted reproductive technologies (ART) or intrauterine insemination are available for men who want to conceive children after a vasectomy. For men who have failed vasovasostomy, however, a repeat procedure appears to be less expensive than embarking on fertility treatments at that time. One very effective fertilization technique for men who have had vasectomies or failed reversal surgery is called intracytoplasmic sperm injection (ICSI). In this procedure, sperm are usually taken from the epididymis using a technique called epididymal sperm aspiration (ESA). The procedure injects a single sperm into an egg with the aid of a powerful microscopic and robotic instruments. The fertilized egg is then implanted in the woman. In general, Pregnancy rates are round 20%. Damage in other ducts and small tubes are a major reason for vasoepididymostomy failure. Ultrasound before the operation may be valuable to determine if these abnormalities exist, which would make it unlikely that the procedure would be successful.

Fertility Treatments
Assisted reproductive technologies are the best approach at this time for men with evidence of anti sperm auto antibodies due to vasectomy or other causes. High doses of corticosteroids may be useful in conjunction with intrauterine insemination for infertile men who show antibodies to their own sperm, although their effectiveness is not proven. It should be noted that these drugs have potentially serious side effects with prolonged use.

Stability in their Relationship
Ideally, the couple should view the operation as a mutual commitment to an already successful marriage or relationship. Good candidates are those men who are part of a couple that considers their family complete and permanent birth control as one method of maintaining the family’s stability. Vasectomy generally is not a good idea if the couple’s relationship is under great stress, it is not a cure for emotional or sexual problems between a man and woman.

What are after–effects?
Postoperative Complications
Vasectomy is a low–risk procedure and the complications, which occur in about 10% of patients, are usually easy to control.
Immediately Postoperative Pain. All men experience some acute pain in the scrotum after the operation. Acetaminophen (tylenol) with or without codeine is the primary choice for postoperative pain. Aspirin, ibuprofen (advil, Medipren, Motrin, Nuprin) or nap oxen (aleve) or other so–called NSAIDs can cause bleeding and should be avoided. This pain generally disappears within two days, although the patient may feel sore for a few more days.

Allergic Reaction
A few men may have an allergic reaction to the local anesthesia and develop itching and hives.

Bleeding
Frequently, blood may seep under the skin, so that the scrotum and penis appear to be bruised. If there is no dangerous swelling, this painless problem usually disappears without treatment within a week or two. If the patient bleeds excessively in the days after the operation and requires more than two or three gauze changes per day, he should call his doctor.

Hematoma
In about 2% of cases, bleeding inside the scrotum can cause a painful swelling known as a hematoma. In these cases, the scrotum swells up shortly after vasectomy. The doctor should be called immediately. Risk for hematoma is less in no–scalpel vasectomy.

Infection
Infections occur in about 4% of men after standard vasectomy. The risk for infection is reduced with no–scalpel vasectomy. The incision site may become infected, causing a redness and swelling around the incision. Antibiotics, antimicrobial creams or ointments, or both, along with hot baths several times a day will usually clear the infection in a few days.

Sperm Granulomas
After vasectomy, sperm often leaks from the vasectomy site or from a rupture in the epididymis, the tightly coiled, thin tube that connects the testicle to the vas deferens. Sperm has very strong antigenic qualities, that is, the immune system views sperm as foreign agents and attacks them. Sperm leakage provokes an inflammatory reaction. The body forms pockets to trap the sperm in scar tissue and inflammatory cells. Firm balls of tissue about one–half inch in diameter then form, these are known as sperm granulomas. They occur in about 60% of vasectomy patients. In about 3% to 5% of cases, sperm granulomas obstructing the already blocked ends of the vas deferens can generate pressure build–up in the epididymis, causing a rupture from the pressure of the fluid. If the epididymis ruptures, the testicles can become enlarged and painful. A damaged epididymis can be repaired, but if the patient later wishes a reversal of the vasectomy, disruption of this tiny tube makes success much less likely.

Chronic Orchialgia
In about one percent of all vasectomies, the epididymis becomes so congested with dead sperm and fluid that the patient feels a dull ache in his testicles. This condition, called chronic orchialgia, usually disappears within six months.

Epididymitis
Epididymitis occurs when an inflammation at the site of the vasectomy causes swelling of the epididymis. This condition occurs within the first year and can be treated with heat and anti–inflammatory medications. It usually clears up within a week.

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