VasectomyBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1674 (Published 02 April 2013) Cite this as: BMJ 2013;346:f1674
- S Jamel, foundation year 1 doctor1,
- S Malde, specialist registrar in urology1,
- I M Ali, general practitioner with special interest in urology2,
- S Masood, consultant urological surgeon1
- 1Department of Urology, Medway NHS Foundation Trust, Gillingham ME7 5NY, UK
- 2Halfway Surgery, Chatham ME4 4QR, UK
- Correspondence to: S Malde
- Accepted 19 December 2012
A 40 year old man attends your clinic with his 37 year old wife to discuss long term contraceptive options. They inform you that they have three children and have completed their family. The wife has been taking oral contraception for the past five years but does not want to continue with this. They have both considered other contraceptive options and have decided on vasectomy.
What you should cover
Patient selection and counselling is crucial. To determine if vasectomy is suitable for them, consider the following points.
Ideally both partners should be present.
Establish the patient’s age, relationship status or stability, and number of children. Young, single men with no children are more likely to regret their decision and request a reversal later in life.
Discuss other contraceptive methods. Female sterilisation (tubal ligation) can be done hysteroscopically under local anaesthesia; or laparoscopically or through a mini-laparotomy, under general anaesthesia. Consequently, the morbidity of the procedure is higher than for vasectomy, and some studies suggest that the reported lifetime failure rate is higher, at 1 in 200.
Emphasise the need to use alternative contraception after vasectomy until semen analysis confirms the absence of sperm (usually three months).
Ask about any current systemic or sexually transmitted infection, coagulation or other blood disorders, and chronic testicular pain, as these will influence the timing of and preparation for surgery. A small number of patients will develop chronic testicular pain after this procedure, which can interfere with their quality of life. This typically occurs in 1-2% of men.
Examine the testis and both vasa deferentia for any abnormality that may interfere with the procedure, such as a large hydrocele, inguinoscrotal hernia, or testis tumour.
Emphasise the need for post-vasectomy semen analysis three months after vasectomy. Some sperm may still be present in the semen for a few months, and so the patient should continue other methods of contraception until the semen analyses show azoospermia.
Inform the patient that 100% guarantee cannot be given of permanent sterility as there is a rare chance of early failure (0.2-5.3%) and late recanalisation (0.03-1.2%).
Explain the operation and complications (box).
Provide the couple with leaflets or booklets or other printed material outlining the information covered in the counselling session.
If there is any doubt, ask the couple to return for a further consultation once they have had time to make their decision.
Vasectomy has an associated low complication rate; patients should be informed about the following complications.
Scrotal bruising, haematoma
Chronic testis pain affecting quality of life (1-2%) and sperm granuloma
Bleeding requiring further surgery
Infection of testis or epididymis requiring antibiotics
Early recanalisation resulting in persistence of motile sperm in the ejaculate for which repeat vasectomy is indicated (0.2-5.3%)
A risk of about 1 in 2000 of pregnancy resulting from late recanalisation after previous clearance
How it works
Vasectomy is an effective, reliable, and permanent form of male sterilisation with no serious long term side effects. It is usually done under local anaesthesia and very occasionally under general anaesthesia. In the conventional incisional technique one or two small incisions are made with a scalpel on the scrotum and both vasa deferentia are exposed. The no-scalpel method involves puncturing the skin with a sharp haemostat. A small segment of vas is removed from both sides and the ends are ligated with sutures. Soft tissue is interposed between the two ends of vas to prevent recanalisation.
After the procedure there is usually some discomfort and bruising for a few days, which can be improved by wearing tight fitting underwear. Patients are advised not to work on the day after the operation and that a return to normal activity is usual within a week. Three months after vasectomy a semen analysis is required. If no spermatozoa are detected in the ejaculate, give the patient clearance to stop using other methods of contraception. If motile spermatozoa persist at the six month follow-up, a repeat vasectomy is advisable. Other contraceptive methods should be continued until clearance is given.
Frequently asked questions
Q: How effective is vasectomy?
A: Vasectomy is a safe and reliable procedure. However, 1 in 2000 men can become fertile again due to rejoining of the two ends of the vas, so vasectomy is not 100% effective.
Q: Can I stop using contraception immediately after the procedure?
A: No. Sperm can still be present for a few months and so a semen analysis is done three months after vasectomy. If it is clear of sperm you can stop using contraception.
Q: Will it affect my sex drive?
A: No. The sex hormones will still be produced by the testes so libido and erectile function are unaffected.
Q: What will happen to the sperm?
A: Sperm will still be produced by the testis but will get dissolved in the body.
Q: What if I change my mind after the operation?
A: You should regard vasectomy as a permanent procedure. The success rate of vasectomy reversal is only 30-60%, with a lower success rate in men who have a later reversal.
Q: Does the operation hurt?
A: It is done under local anaesthesia. You may experience some discomfort during the injection and the procedure but not severe pain.
Q: How soon after the operation can I have sexual intercourse?
A: You can resume sexual activity as soon as it is comfortable. You have to use other methods of contraception until the semen analysis shows no sperm in the specimen.
Q: Is there any risk of prostate or testis cancer after vasectomy?
A: No. Several studies have shown no relation between vasectomy and cancer.
NHS Choices (www.nhs.uk/conditions/vasectomy/pages/introduction2.aspx)
British Association of Urological Surgeons (www.baus.org.uk/Resources/BAUS/Documents/PDF%20Documents/Patient%20information/Vasectomy.pdf)
For healthcare professionals
European Association of Urology Guidelines on Vasectomy (www.europeanurology.com/article/S0302-2838%2811%2901101-8/fulltext)
American Urological Association Guidelines on Vasectomy (www.auanet.org/content/media/vasectomy.pdf)
Cite this as: BMJ 2013;346:f1674
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.
Contributors: SJ was involved in the initial conception and drafting of the article and was involved in final approval of the version to be published. S Malde and IMA were involved in revising the article critically for important intellectual content and in final approval of the version to be published. S Masood is guarantor for the paper and was involved in initial conception, literature review, revising the article critically for important intellectual content, and in final approval of the version to be published.
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Not commissioned; externally peer reviewed.