VASECTOMY
Vasectomy is the contraceptive choice for around 15 per cent of sexually active males. Worldwide, 42 million couples rely on this method of contraception; in the UK, around 40,000 vasectomies are performed each year. Of these, it is estimated that around 2% are reversed per year.
Vasectomy can be performed under a local or general anaesthetic. A few operations have been performed using hypnosis or acupuncture for pain control.
In the traditional vasectomy, a midline incision is made in the scrotum although some surgeons make a small cut on each side. The two vas deferens, one arising from each testicle, are then identified and a small section pulled out through the incision. A small length is clamped and cut and the two cut ends securely tied. Altogether, vasectomy usually takes less than 20 minutes, and is usually completed within 10 minutes.
Several refinements of this technique are used. The cut ends of the vas deferens may be sealed by heat rather than tied. Other surgeons loop the cut end back on itself and stitch it to prevent spontaneous rejoining of the ends. Yet others slip one cut end behind an anatomical membrane (fascia) so that it cannot come into contact with the other cut end on that side.
The Li vasectomy, perfected in China, is a no-scalpel technique. The vas is gripped through the scrotal skin by a ringed instrument and the overlying scrotum punctured with a sharp pair of dissecting forceps. The vas deferens are individually fished out to be cut and sealed. The small puncture in the scrotal skin is pinched tightly for a minute and then swabbed with anaesthetic. No stitches are required and the procedure is quick, with less risk of complications than with traditional methods.
The newest technique is a non-surgical, easily reversible vasectomy. Under local anaesthetic, the vas deferens are gripped through the scrotal skin by a special clamp. The vas is then injected with a freshly prepared elastomer liquid which hardens over 1020 minutes. This forms a pliable but non-adherent plug about the size of a grain of rice which blocks the central bore of the vas deferens.
In China, over 12,000 men have had this procedure; a success rate of 98 per cent has been quoted. For easy reversal, a small slit is made over the scrotum under local anaesthetic and the elastomer plug is squeezed out.
After the Vasectomy
Immediately after the operation the man is usually advised to rest for 24 hours and to avoid strenuous activities for a few days. Paracetamol usually controls any discomfort and is better than aspirin, which may prolong bleeding. Most men are able to return to work within 24 hours and to resume an active sex life (using a temporary method of contraception such as the condom) when they feel like it. Tight-fitting underpants or an athletic jockstrap are often advised for use during the first 48 hours (or longer if necessary) to support the scrotum and minimize discomfort.
Early Complications of Vasectomy
Complications of vasectomy are rare but can include bleeding, swelling and bruising (haemotoma). The scrotum may turn blue or black, or may harden and become intensely painful usually if instructions to rest are not followed. If bleeding
continues, an exploratory operation to tie off the bleeding vessel may rarely be needed.
Occasionally, the operative site becomes infected. Swelling, redness, pain and fever depend on the severity of the infection. Any infection needs urgent antibiotics to prevent epididymo-orchitis.
Vasectomy Lag Period
A vasectomy is not immediately effective as a method of contraception. The vas deferens is a sperm storage duct and it takes at least three months (1530 ejaculations) to clear out the current 'lodgers'. Semen samples are checked monthly from three months after the operation until three ejaculates have been declared free of sperm. Alternative methods of contraception must be used until the man is told the vasectomy may be relied upon. It is then wise to have a semen analysis once per year.
Failure of Vasectomy
The cut ends of the vas deferens can spontaneously rejoin soon after the operation. This most commonly occurs 1014 weeks after the operation, although cases of recanalization (as this is known) occurring 12 years later have been reported.
The failure rate of vasectomy is usually quoted as 1 in 2,000. In skilled hands, where the surgeon separates the two cut ends of each vas by placing them either side of a sheet of tissue called the spermatic fascia, the chance of regaining spontaneous fertility (by the two ends coming together and rejoining) is an order of magnitude less, at 1 in 10,000. Nor does this technique affect the chances of successful future reversal.
One case has been cited where a vasectomized man with scanty, occasional motile sperm in his ejaculate (therefore considered infertile) managed to impregnate his wife three years after a vasectomy. DNA and other tests suggested he was 99.999 per cent likely to have been the father.
Vasectomy and Future Health
There is no evidence that having a vasectomy increases the risk of sexual problems, that it changes testosterone hormone levels or decreases sex drive.
Within the last few years, researchers have suggested that vasectomy increased the risk of prostate cancer. After much examination of the data, US health experts declared there was no biological evidence to suggest this. The risk of developing prostate cancer after vasectomy was considered too small to justify any changes in medical practice and it was recommended that doctors should continue to offer and perform vasectomies.
Sixty per cent of vasectomized males do develop antibodies that cause sperm clumping. Testicular biopsies of the testes after vasectomy show that spermatogenesis is disrupted and fibrosis (scarring) of the testes occurs in some cases. Many of these patients were subsequently proved fertile, however, so the importance of these changes is difficult to assess. Sperm granulomas (immunological swellings) below the area where the tubes were tied may cause small, painful lumps in some males, and 1 per cent of men complain of prolonged pain following the operation. This is probably due to distension of the epididymes.
Three studies have suggested a link between vasectomy and future development of testicular cancer. Other studies have found no such association and the risk is not thought to be significant. More studies are needed, however, to evaluate the long-term risks of vasectomy.
Reversal of Vasectomy
A vasectomy should always be assumed permanent when a man first decides to undergo the procedure. In practice, however, 2 per cent of vasectomies are reversed per year due to future, unforeseen changes in circumstance.
The skill of the surgeon and the length of time that has passed since the original vasectomy are the biggest factors in determining a successful outcome.
Reversal of vasectomy is a relatively long procedure, taking 90120 minutes. It is performed under either local or general anaesthesia. Men who are having a second attempt at reversal, or those with anatomical irregularities (e.g. hernia, varicocoele) usually receive a general anaesthetic.
The cut ends of each vas must be identified and the scarred, tied or burned tissues trimmed. Once the central bore (lumen) of each vas deferens is opened, the epididymis on that side is gently squeezed to check that sperm are siphoning up through. This rules out any blockages further down. The tubes are then flushed with saline to remove debris and the ends painstakingly sewn together. Chances of success are greatest where a specialist uses micro-surgical techniques and magnification (using an operating microscope). The vas channel being rejoined is only 0.25 to 0.33 mm in diameter, and 90 per cent of the thickness of the tube consists of the muscular walls. Often the testicular end of the tube has dilated due to the pressure of semen build-up, and additional skill is required to join the ends of tubes with different bores.
Tiny stitches are inserted to join the inner walls of the two trimmed ends. These must be placed skilfully to oppose the ends exactly and to minimize the formation of scar tissue. Several larger stitches then bring the thick outer walls of the vas together.
Following the original vasectomy, immunological and inflammatory processes can lead to tissue changes within the testes. The build-up and reabsorption of sperm can lead to swellings (sperm granulomas) forming in each epididymis, which may interfere with semen flow once the vasectomy is reversed.
Vasectomy also introduces the risk of a man making auto-antibodies against his own sperm, rendering them sluggish and interfering with future fertility should the vasectomy be reversed.
Different surgeons have different success rates for reversal of vasectomy. These vary from 40 per cent to 90 per cent success in restoring sperm passage through the vas deferens, and a 30 per cent to 50 per cent chance of the man fathering a child. The odds are significantly reduced if the vasectomy was performed more than 10 years previously.
Following a reversal of vasectomy, men often have a lower sperm count than achieved before the original operation. There is an improvement in sperm count, viability and motility over the first year.
If conception does not occur, sperm from the ejaculate (or aspirated from the epididymis) can be harvested and concentrated for use in assisted fertility techniques such as in vitro fertilization.
EMERGENCY CONTRACEPTION
All males should be aware of the existence of female methods of emergency (so-called 'morning after') contraception. These may prove necessary when a condom bursts or when the withdrawal method fails.
The morning after pill is more flexible than it sounds and can be started within 72 hours of unprotected sex. The female takes two tablets as soon as possible within 72 hours of the unprotected sex. Two more tablets are then taken 12 hours later. This emergency pill has a 4 per cent failure rate.
In some cases, a woman can also have a contraceptive coil inserted into her womb up to five days following unprotected sex.
