Vasectomy: General Information

Vasectomy

It is a procedure where the vas deferens of a man is severed under Local/sedative anaestheisa so as to block passage of the sperms in the semen for the purpose of contraception.


History:

The term vas deferens was coined by Berengarius (1470- 1530). In latin language, vas means vessel and deferre means 'to carry down'.

Vasectomy is a historical, social, philosophic, medical, demographic, and legal phenomenon. There has been constant attempts at renewing the techniques for simplicity and better outcomes.There are lot of misconceptions, false beliefs, and erroneous indications.

Early Years Then in 1830, Sir Ashley Cooper's found that when the blood vessels of a dog's testicle were tied, no issues followed coitus. This was the first step towards development of a surgical procedure for birth control in men called vasectomy. The dog however retained its ability to produce sperms even after 6 years of the surgery.
The first use of vasectomy (1899) was on a 19 year male who had complained of excessive masturbation. The surgery was carried out by a physician by name Harry Sharp. (?Logistics behind the surgery)
Between 1904 and 1907, vasectomy was used to reduce the chances of infection of the epididymis following prostate surgery.
The infamous case where a patient murdered a surgeon, for castration as birth control measure, prompted surgeons to look for another alternative for castration and very soon, vasectomy began to assume an important role.
The vasectomy became so fashionable that it was made compulsory of any confirmed idiot, rapist or a criminal. This led to the flourishment of the concept of eugenics where individuals who were considered as being nuisance to the society were vasectomised so ensure that the future generations were healthy
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Vasectomy in India:
The 1st vasectomy program on a national scale was launched in 1954 in India. In 1976, a huge government campaign for sterilization was launched and was responsible for the sterilization of millions of Indian couples. Health Ministry had then to face a lot of critisism for carrying out forced vasectomies of men and sterilization of women as a part of the initiative to control population

Indications:
• Contraception
• There are controversial indications for excessive masturbation and for social reasons as explained earlier.

RISKS :
A relationship between vasectomy and increased risk of prostate cancer was postulated (relative risk of 1.6) based on two large cohort stdies.The magnitude of the relative risk is small enough to potentially be explained by the reason those patients who undergo vasectomy are usually people with more health awareness.So these people are more like to undergo prostate cancer screening than the general public.
Myths and misconceptions:







1. Vasectomised people don’t ejaculate:wrong.
More than 95 % of the ejaculate comes from prostate and the seminal vesicles and only 3 % is contributed by the testes so the ejaculate remains the same whether the patient gets vasectomised or not.




2.Men become less masculine.Testosterone continues to be produced even after vasectomy.
Benefits:
• Apart from contraception men are found to increased sexual quality of life probably because of decreased insecurity of making the partner pregnant.
Procedure
Usually done in an outpatient setting, a traditional vasectomy involves numbing (local anesthetic) of the scrotum after which small incisions are made on the hemiscrotum , allowing a surgeon to gain access to the vas deferens. The "vas" is cut and sealed by tying, stitching, cauterization (burning), double folding onto itself or burying in the scrotal fascia.







Modifications:

1. The No-Scalpel method:Dr Shunqiang developed the Non Scalpel Vasectomy popularised as NSV in 1974.It has less complication rate: pain,early recovery,no scar etc.Over 15 million people have undergone NSV since 1974 and the number is increasing.In India this facility is made available by training the Primary Health Centre Officers so that even remotest place also people can undergo NSV.





In this method a sharp hemostat, rather than a scalpel, is used to puncture the scrotum and by rotation bring the vas out.The vas is then stripped and with any of the methods outlined above vasal severence can be carried out.
2. No Needle Non scalpel Vasectomy: Wilson in 2001 initially described this technique .The jet technique of injection obviates use of the needle and has almost 100% efficasy rate.



3. An "open-ended" vasectomy obstructs only one end of the vas deferens, which allows continued pouring of sperm into the scrotum. This method may avoid build-up of pressure in the epididymis. Testicular congestion may also be reduced using this method.
4. The "Vas-Clip" method uses a clip to squeeze shut the flow of sperm. This method may facilitate a better outlook for reversal, as well as reduced pain with probably less success rate.
5. Percuatenous chemical vas occlusion(with silastomers) technique: with reportedly 98% success rate.
Pre-operative counselling:
• This is a permanent method of contraception and reversal is technically challenging procedure.
• Regarding the procedure details and the possibility of hematoma and pain post-operatively.
• Those patients apprehensive can cryopreserve the sperms.
• The slight chance of failure(1:500 short term and 1:4500 long term )should be explained.
• Contraception is not immediate so for first few weeks he may have to use other methods for contraception(may need 6-8 weeks for azoopsermia and about 20-25 ejaculations for the same).
• Patients with unstable relationship with the partner need to give a serous thought regarding the procedure.
• Patient needs to be emphasized that the Vasectomy doesnot protect against STDs and HIV infection.
• Some men are forced by spouses to undergo the surgery in that case the men should be totally convinced and satisfied for the reason.
Why female tubal ligations are more(world wide 5 times more than the vasectomy)This is inspite the mortality rate of vasectomy is 0.1/1 lakh while that of tubal ligation is 4 /1 lakh population)
1. Fear in men regarding the surgery
2. The tubal ligation can be combined with the Cesarean section so it becomes convinient for the couple to go for it after they decide to complete the family.
3. Men forcing the female partner to undergo the procedure(India is a male dominated society)





Complications:


Hematoma,brusing, local pain are some of the uncommon complications (0.1-3%) (rather common with the conventional vasectomy not NSV)





Li S., Goldstein M., Zhu J., et al: The No-Scalpel Vasectomy. J. Urol 1991; 145; 341-4
Sperm granuloma:this can occur in 30% of the people because of the leakage of the sperms from the vasectomy end.Chance of surgical recanalisation is better in sperm granuloma because there is no back pressure blow-outs and secondary epididymal obstruction making reversal difficult.

Post-Vasectomy Pain Syndrome
Post-Vasectomy Pain Syndrome (PVPS), genital pain of varying intensity that may last for a lifetime, (5% and 35% of vasectomized men), The pain can be orchialgia, pain during intercourse, ejaculation, or physical exertion, or tender testes.The pain usually may last for upto 3 months. In cases of persisting pain ,several drugs like NSAIDS,tramadol,gabapantin have been tried with varied success.
In one study, vasectomy reversal was found to be effective for 9 out of 13 patients in reducing the symptoms of refractory chronic post-vasectomy pain. Treatment options for the 4 patients whose pain did not respond to vasectomy reversal were limited. In severe cases castration has been resorted to.
Post-operative care:

1. NSAIDS(pain killers )are given for pain relief.
2. Avoiding exertion and lying supine for 48 hrs is recommended by many doctors.
3. Ice pack application can be resorted to if the pain is refractory.
4. Sexual intercourse should be avoided for 1 week.
5. Patient should document absence of sperms atleast on two occasions to prove that the procedure is successful before he relies totally on vasectomy for contraception.
Vasectomy reversal:

In 2-6% couples vasectomy reversal is undertaken either for desire to have children(change of the partner/change of mind to have more children/unfortunate loss of previous children etc).Some resort to it for unabating post-vasectomy pain syndrome.This surgery is more successful(more than 80% results in our hands) done with microsurgical method.Earlier is the vasal recanalisation better is the chance of success.(Success rate drops after 15 years of the vasectomy)