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Vasectomy
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What is Vasectomy?

Vasectomy is a method of permanent male sterilization. Vasectomy is a surgical procedure in which the vas deferens of the man is cut to prevent transport of sperm out of the testes. Vasectomy does not affect the man's ability to achieve orgasm or ejaculate (potency). There will still be a fluid ejaculate, but without sperm. Vasectomy is an effective, inexpensive, and easy-to-perform procedure, which results in permanent sterility. Vasectomy may be recommended for adult men who are certain that they wish to prevent future pregnancies (permanent sterilization). Vasectomy is not recommended as a temporary or reversible procedure. Vasectomy does not offer protection against sexually transmitted diseases.

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Physiology of Sperm Production:

The testis is composed of coiled tubes called seminiferous tubules, in which the sperm is formed. The sperm then empty into the epididymis, another densely coiled tube. This leads to the vas deferens, which then enters the prostrate gland. (See figure). The sperm formed in the seminiferous tubules matures in the epididymis and are stored in the vas deferens. During ejaculation they travel to the ejaculatory duct. Right before ejaculation, fluid from the prostate gland and seminal vesicles mix with the sperm in the ejaculatory ducts to form semen, which is forced through the urethra during orgasm. In vasectomy the vas deferens is cut and the sperm does not travel to the ejaculatory duct. Sperm make up only a very small portion of semen. Most of the semen is made up of the fluid from seminal vesicles (60%), and fluid from the prostrate gland (30%) and only 10% is the sperm from the vas deferens. So vasectomised men will not find any difference in the amount of semen ejaculated. Testosterone continues to be produced in the testes and delivered into the blood stream.

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Psychological Implications:

Sterilisation is an emotional process. There may be negative feelings associated with the procedure Men with poor self-images about their physical health or sexual ability may have difficulty adjusting psychologically to vasectomy. Men who have the operation only for the sake of their partner's health and not for voluntary reasons may face problems. . Some women think vasectomy may encourage outside affairs. (Research (1970) indicates, that married men who have been sterilized are no more likely to indulge in extramarital sex than fertile men are)The couple should have a thorough discussion and may undergo counseling if needed, before making a decision

Majority of the men who seek a vasectomy have been married for ten years or more and have a stable relationship. The reasons for vasectomy may be

1) Having had enough children, to prevent future pregnancy,

2) Unable or unwillingness to use other methods of contraception,

3) A health problem in the woman that makes pregnancy unsafe,

4) A genetic disorder, or

5) A desire to enjoy sex without fear of unwanted pregnancy.

Vasectomies may not be right for those

1) Who are unsure of having children in the future.

2) Whose current relationships are unstable or going through a stressful phase,

3) Who are considering the operation just to please their partners,

4) Who have thoughts of reversal procedures to have children later on either by storing sperm or surgical reversal of their vasectomies.

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How is Vasectomy Performed?

 

Preoperative Considerations

The patient has to sign a consent form stating that the patient is aware of the risks involved. The patient should have no doubts regarding the operation and get his queries answered if any, before signing the consent form.

Sperm Banking. Storing frozen sperm in a sperm bank before vasectomy might enable the patient to have children later. Before vasectomy, the patient collects sperm, which are frozen and stored until he wants to have a child. However the procedure is expensive and the success rate is low.

Standard Vasectomy

Vasectomy is usually done in the surgeon's office using local anesthesia. It is a minor operation that takes about 30 minutes and is usually performed in a doctor's office or a family planning clinic. The patient's scrotum is shaved and cleaned, and a local anesthetic is injected into it. The surgeon makes a tiny incision on one side of the scrotum and locates one vas deferens. The vas deferens is isolated, drawn through the incision, and clamped at two sites close to each other. The segment between the clamps, which should be more than 15 mm, is then removed.

The surgeon then seals off (ligates) the tube with surgical clips or sutures or cauterization using an electric needle, or some combination. The surgeon may choose to close off either one (called an open-ended procedure) or two ends (closed-ended) of the vas. In the open-ended procedure, the vas section connected to the testis is left open and the one leading to the prostate is sealed; in the closed-end both are ligated. The open-ended version has lower complication and failure rates than the closed-ended, and results in fewer cases of chronic pain. After closing off the tube, the vas deferens is gently placed back into the scrotum. The skin incision is stitched and closed. The procedure is then repeated on the other side. After a short rest of an hour, the patient can leave the doctor's office or clinic.

Vasectomy Procedure

A small section of each vasdeferens (spermatic duct) is removed through small incisions on either side of the scrotum.

vasectomyprocedure.gif (9844 bytes)


A-Bladder

B-Vas deferens

C-Area to be removed

D-Penis

E-Testis

No-Scalpel Vasectomy

A method of vasectomy that does not require the use of a scalpel is now used in one-third of vasectomies. The no-scalpel vasectomy (NSV) differs from a conventional vasectomy in the method of accessing the vas deferentia. An improved method of anesthesia that allows an injection under the skin instead of into the testicle makes the procedure less painful.

In this operation, the doctor feels for the tubes under the skin and holds them in place with a small clamp. Instead of making two incisions, the doctor makes one tiny puncture with a special instrument, which is then used to gently stretch the opening until the vas deferens can be pulled through it. The vas is then blocked using the same methods as conventional vasectomy. As with standard vasectomy, the closures can be open - or close - ended. There is very little bleeding with the no-scalpel vasectomy. No stitches are needed to close the tiny opening, which heals quickly and leaves no scar. The technique takes about 10 minutes and is performed in a doctor's office or a family planning clinic.

The advantages of NSV are many. There is less injury to the tissues and no stitches and so less discomfort to the patient. The procedure offers shorter operating time, less pain, swelling and faster recovery than standard vasectomy. The risk of hematoma and infections are lower. Postoperative care is similar to that for conventional vasectomy.

Postoperative Care

General Guidelines: Oral painkillers are used to alleviate the pain. Most men return to work within 2 to 3 days. Postoperative care includes

1) Wearing a scrotal supporter,

2) Placing an ice pack over the dressings to prevent swelling, and

3) Staying in bed on his back to reduce postoperative pain.

Blood may ooze onto the gauze pads during the first day or two after the operation. Nearly all men recover completely in a few days. The patient should not perform any heavy physical labor for the next few days. Sports and heavy lifting may be resumed two to three weeks after surgery.

Temporary Risk of Pregnancy:

Sexual intercourse can be resumed as soon as the patient feels ready (usually about a week after the surgery. Initially, the patient may experience some discomfort in the groin and testicles during ejaculation due to the contraction of the vas deferens. This diminishes as the tissues heal. The couple must, however, continue to use conventional birth control methods for few months. About fifteen to twenty ejaculations are required to clear the viable sperm. The sperm count gradually decreases after vasectomy. At 4 to 6 weeks sperms are no longer present in the semen. A semen specimen must be examined and should be totally free of sperm in a month’s time. Continued use of contraception is recommended, until 2 to 3 sperm count tests are negative, indicating that the patient is sterile.

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Complications of  Vasectomy:

Most men recover quickly with no problems. Vasectomy is a low-risk procedure, the complications occur in 10% of patients.

Immediate Postoperative Pain: Men experience acute pain in the scrotum after the operation. Acetaminophen with or without codeine is the primary choice for postoperative pain. Aspirin, ibuprofen or naproxen 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. Some may be allergic 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 the patient bleeds excessively require 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 becomes infected, causing inflammation and swelling. Antibiotics, antimicrobial creams or both, along with hot baths several times a day will usually clear the infection in a few days.

Sperm Granulomas. When the body fails to absorb the sperms and they leak into the surrounding tissues, the body becomes allergic to its own sperms and starts producing its own antibodies. It views sperm as foreign agents and attacks them. The body forms pockets to trap the sperm in scar tissue and inflammatory cells. Firm balls of tissue about one-half inch in diameter form, known as sperm granulomas. They occur in about 60% of vasectomy patients. Sperm granulomas can generate pressure build-up in the epididymis, causing its rupture. The testicles then 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 one percent of all vasectomies, the epididymis becomes 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. The epididymis becomes inflamed and swollen. It occurs within the first year and can be treated with heat and anti-inflammatory medications.

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Long -Term Risks of Vasectomy:

Long-Term Testicular Pain. A third of the men experience testicular pain that lasts longer than three months. The source of the pain is not fully known. The cause may be because of the scarring from the surgery or due to obstruction of the epididymis. 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.

Prostate and Testicular 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. The relationship between vasectomy and prostate cancer is being studied and there is no conclusive result.

Immune System Changes. . Infections in the genital tract, orchitis and sexually transmitted diseases, increase the risk of anti-sperm antibodies. 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. 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. The anti-sperm response appears to be a problem only if a man wishes to reverse the 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. 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 vasectomized 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.

Psychologic 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 newfound 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. No recent comprehensive studies have been performed on long-term patient satisfaction following vasectomy.

About half of vasectomy patients keep their operations a secret is feeling emasculated, but they overcome this later on. However men with poor self-image continue to face problems

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Vasectomy 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 vas deferentia 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.

Recanalization. When the cut ends of the vas deferens reconnect through a process known as spontaneous recanalization, vasectomy fails. This is very rare but may occur if a sperm granuloma deforms. Recanalization has been known to occur as soon as a man has achieved a zero sperm count and as late as 17 months after vasectomy. The overall risk for recanalization is only .025% or one in 4,000 vasectomies. This natural vasectomy reversal occurs regardless of the type of vasectomy surgery. Men should have a follow-up examination a year after the procedure to be sure that there are no residual or new sperm.

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Can Vasectomy be Reversed?

Vasectomy can be reversed by a surgical procedure known as a vasovasostomy. This restores 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.

Vasovasostomy (reversal surgery) procedure:

In vasovasostomreversal surgery the severed ends of the vas deferens are reconnected to reestablish the flow of sperm. The reversal procedure is difficult; it involves sewing together the two ends of both tubes, each with pinhead-sized openings. If the vas deferens is blocked, the surgeon may try to connect the epididymis to an area in the vas that bypasses the blockage. Use of an experimental special glue instead of sutures may help reduce operation time and difficulty. Laser surgery is being investigated and may prove to require lesser skills, reduce operating time, and result in fewer complications.

Reversal surgery is a major operation lasting one to two hours and requiring several days in the hospital and two to three weeks for recovery at home. It is far more expensive than vasectomy itself, and it is even costlier if the procedure involves connecting the vas to the epididymis, which takes about three hours. One study reported that even when pregnancy was achieved, successful conception took an average of one year after the vasovasostomy.

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Causes of Vasovasostomy Failure

The chances for pregnancy decrease the longer the duration between vasectomy and the reversal operation.

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.

Autoantibodies. In the majority of cases, the reversal procedure reopens the epididymis, but fertility is not necessarily automatic. Autoantibodies are produced against the sperm, when they leak into the surrounding tissues. 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 Antifertility Factors. Among their other harmful effects is the production of particles called oxygen-free radicals (also called reactive oxygen metabolites), that are particularly injurious to sperm thereby impairing fertility.

Reoperations after a failed vasectomy:

A repeat operation of vasovasostomy may be performed for reverting vaasectomy. 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. Pregnancy rate is only 30%. Damage to the epididymis occurs in 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.

Fertility treatments after vasectomy or after a failed vasostomy:

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Assisted reproductive technologies (ART)
Assisted reproductive technologies (ART) or intrauterine insemination are available for men who want to conceive children after a vasectomy. Intracytoplasmic Sperm Injection (ICSI) is an effective fertilisation technique for vasectomisd men. In this procedure, as single sperm, taken from the epididymis, is injected into an egg with the aid of powerful microscopic and robotic instruments. The fertilized egg is then implanted in the woman.

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