Int J Gynaecol Obstet 15: 163-166, 1977

Vasectomy: Benefits Versus Risks Joseph E. Davis Department of Urology, New York Medical College, New York, New York, USA



Davis, J. E. (Dept. of Urology, New York Medical College, New York, New York, USA). Vasectomy: benefits versus risks. Int J Gynaecol Obstet 15: 168-166, 1977 The benefits and risks of modern vasectomy are presented, including a discussion of precautions and contraindications, the incidence of specific complications and suggestions for minimizing them, and the incidence of and reasons for procedure failures. Long-term side effects, including psychological sequelae, are also discussed.

Although vasectomy is a simple operation which can be performed almost anywhere, the more removed the setting is from medical backup, the more important it is to screen out men who are likely to develop complications. Selected studies reported between 1969 and 1974 (7) indicate the types of complications (or risks) which occur and their incidence. Surgical complications are technique-related, except where anomalous conditions or anatomic variations exist. The physician must pay particular attention to hemostasis and cannot hope for subcutaneous bleeding points to stop by themselves since the complex scrotal fascial layers do not readily tamponade bleeding. Sterile technique is required but is not as rigidly maintained perhaps as in a hospital operating room. The occurrence of epididymitis, though rare, may be related to infection or may be a result of back pressure from the occluded vas. That this does not occur very often and that gross distension or pain from the epididymis is not noted clinically are indicative of some as yet unknown homeostatic mechanism in the human male, not seen in other animals. Sperm granuloma appears to be effectively controlled by fulguration techniques. Recanalization should become rarer as surgeons utilize fascial interposition techniques and avoid catgut ligation of the vas. In general, external compression of the vas may result in necrosis of the wall, sperm extravasation, and sperm granuloma formation. Idiosyncratic reactions to local anesthetic agents do occur, and appear to be dose related. Very small amounts (3-5 cc) of anesthetic are usually sufficient. Appropriate resuscitative equipment must be available where local anesthetic agents are used.

INTRODUCTION Vasectomy has emerged in the United States as a highly effective, permanent, simple outpatient procedure requiring one-time motivation. However, in most other countries, except India, Japan and South Korea, vasectomy is far less prevalent than other temporary and permanent methods of contraception. The reasons for this are legion. The Association for Voluntary Sterilization estimates that several million vasectomies have been performed in the United States since 1968 and that currently approximately 250000 are performed annually. The benefits of a 15-minute, outpatient surgical procedure which generally causes no loss of time from work and which has an end point of azoospermia after 10 to 15 ejaculations (or less using one of several vas flushing methods now available) are evident. As a contraceptive method, it is not coitally related, appears to cause no hormonal changes, and with appropriate screening and counseling should result in no psychological problems. Refinements and improvements in technique (3, 4), including (a) fulguration of the vas lumen after cutting it to prevent sperm granulomas (which may lead to spontaneous recanalization or may be implicated in sperm antibody formation); (b) merely sectioning without resecting the vas to preserve the blood and nerve supply; and (c) emphasis on high sectioning of the vas, away from the convoluted portion, all appear to result in even less postoperative discomfort and morbidity. Furthermore, as an added benefit, these improvements in technique may offer a better chance of success should a reversal be desired.

Contraindications The major physical contraindications to vasectomy are local infections and systemic blood disorders. Local infections, which can prevent normal healing, are easily recognized and should be treated and cleared up before the operation is performed. Other local conditions which make vasectomy more difficult to perform include: inguinal hernia or previous surgery for hernia,

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orchiopexy (a fixed, undescended testis), hydrocele, varicocele, preexisting scrotal lesions, and a thick, tough scrotum. Systemic blood disorders which call for special precautions would include any disease (e.g. hemophilia) that interferes with normal blood clotting. In such cases, the technique used should minimize tissue trauma, and emergency equipment should be available. The therapeutic use of anticoagulants may require the same precautions. Other systemic diseases such as diabetes or hypertension are not contraindications to vasectomy, but hospitalization may be advisable should emergencies arise. COMPLICATIONS Pain and swelling The most frequent, and fortunately not very serious, side effects of vasectomy are skin discoloration, swelling, and pain. These postoperative reactions occur in up to 50% of the patients and are common to all surgery. They are difficult to measure quantitatively and are frequently combined in clinical reports. Postoperative swelling occurs as often as bruising. A low reported incidence may simply mean that the men were not sufficiently troubled to report it to the physician. Pain is a subjective reaction, even more difficult to quantify than bruising or swelling. Edey (2) calls it the most frequent "anticipatory anxiety" of vasectomy. Most doctors and counselors warn vasectomy candidates that some discomfort is normal. Although seldom severe, pain or discomfort may occur at several specific junctures in the procedure—when the local anesthetic is injected, when traction is put on the vas to bring it into view, and when the procedure is over. Following the operation, I instruct my patients to use ice packs every 20-30 minutes for several hours and to refrain from strenuous exercise for 1-2 days. A scrotal support and oral analgesics such as aspirin are usually sufficient to relieve postoperative discomfort. Hematoma Hematoma—the formation of a mass of clotted blood from injured blood vessels in the loose connective tissue layers of the scrotum—occurs in less than 4% of all vasectomy cases, and usually in less than 1%. Prompt diagnosis and treatment are important because, in addition to discomfort, infection may develop. The best way to prevent hematomas is by meticulous attention to hemostasis during the procedure. Bleeding from large blood vessels can be stopped by fulgurating or tying off Int J Gynaecol Obstet 15

the bleeding vessels. Bleeding from small vessels may not be noticed, however, and in fact, may not occur until the effect of the local anesthetic has worn off. Hematomas are more likely to occur if the scrotal area is strained too soon after vasectomy. Since strenuous activity interrupts the healing process, most men are advised to rest for the first few hours after the operation and to refrain from heavy labor for several days. Infection Infection may occur at any of a variety of sites—incision, vas, epididymis, and testes. Superficial skin infection usually appears 3-4 days after the operation and may be caused by tissue irritation from the skin sutures, lack of asepsis during the procedure, or the patient's lack of cleanliness after the procedure. Sometimes a more severe and painful cellulitis (often accompanied by fever and chills) will develop under the skin, but it usually responds well to antibiotics. Before treatment, it may be prudent to do a culture of any superficial discharge to determine the causative organism and the most appropriate antibiotic. If an incisional abscess develops and does not drain freely, surgical incision may be necessary. The best defenses against infection are: 1. Examining patients and treating superficial or deep infection before vasectomy 2. Sterilizing operative equipment and draping materials 3. Maintaining asepsis during preoperative preparation and the operative procedure 4. Instructing patients on the importance of keeping the scrotal incision clean 5. Providing follow-up care if there is doubt that the patient will keep the incision clean Sperm granuloma Sperm granuloma is an inflammatory response to the leakage of sperm from the vas or epididymis into surrounding tissues. It has been reported in 0.1 to 3.0% of vasectomy cases. Most granulomas are small and harmless, however, and would go unnoticed except in cases of later surgery. Thus, it is estimated that their true incidence may be as high as 20% for granulomas in the vas and 15% for those in the epididymis. Some have been discovered only a few weeks after the procedure, others as long as 25 years later. Although generally asymptomatic, sperm granulomas can be troublesome if they become infected, if they create vasocutaneous fistulae, if they cause recanalization of the vas through ducts formed within the granuloma, or if they prevent later surgical reanastomosis. In theory at least, an immune response may result from absorption of sperm from the granuloma. A diagnosis of sperm granuloma should be


considered if the man complains of pain and swelling at the site of vasectomy after 1 or 2 weeks. Specifically, if the patient has been asymptomatic for some time after the operation, a sudden onset of pain suggests a granuloma; but because their symptoms are similar, cancer, tuberculosis, and neoplasms should first be ruled out. On gross examination, granulomas begin as an inflammatory response surrounding creamy-white, thick seminal fluid. The initial lesion is usually pea-sized. As it matures, a thick, grayish-red wall forms around gray, puttylike contents. If the lesion becomes large and cystic, its contents may become tinged with blood. As the inflammation subsides, the lesion becomes yellowish-brown, and the walls become fibrous and sometimes calcified. In controlled studies, i.e., those which include both preoperative and postoperative testing, local obstruction of the vas showed no significant systemic effects. Where changes did occur, they were usually within the range of normal limits and were not harmful. About one half to two thirds of vasectomized men develop antibodies to sperm, i.e., an immune response is established that inhibits further sperm activity (5). Although similar antibodies have been found in normal fertile men, they are more common in infertile men and in men who have had their vasa ligated. Even if sperm antibodies are formed following vasectomy, no evidence has yet been presented, after millions of vasectomies have been performed over many years, that links such antibodies with disease. Except for a possible negative effect on fertility if reanastomosis is attempted, sperm antibodies pose no apparent threat to health. PROCEDURE FAILURES Although vasectomy is not completely foolproof, it is the most effective male method of fertility control now available, and it is becoming more effective as practitioners gain greater skill and experience. Studies conducted in the late 1960s reported failure rates up to 4 per 100 procedures performed. Recent studies show failure rates of less than 1 per 100 procedures. This decline probably reflects the use of more effective and less traumatizing operative techniques, as well as greater experience. Nevertheless, a vasectomy candidate should understand that a small possibility of failure exists. Failure in vasectomy may or may not result in pregnancy in the female partner. It is usually discovered when semen examinations indicate the presence of sperm more than 3 months after the operation or after 10-12 ejaculations, when there is sperm in the semen after a period of azoospermia,


or when pregnancy takes place in the female partner. Although the female partner may be impregnated by another male, pregnancy in the partner accompanied by the appearance of motile sperm in a patient's semen is reasonably conclusive. The likelihood of recanalization may be influenced by the vasectomy technique employed. For example, crushing and tying the vas, a widely used procedure, can lead to recanalization. Members of the workshop on clinical aspects of male sterilization at the 1973 Geneva conference agreed that separating the treated vas ends with a barrier of fascia is an effective means of preventing vasectomy failure. The likelihood of operative failure is reduced if the surgeon performs the procedure frequently. The importance of frequent practice was emphasized by Sobrero et al. (6) (1973) of the Margaret Sanger Research Bureau, New York. They reported six failures in 236 procedures performed during the first year of the vasectomy service at the Bureau. Four of these procedures were performed by physicians-in-training and two by general surgeons with little experience in the operation. Failure also results from inadequate occlusion of the vas ends. If ligatures or clips are applied too loosely, sperm continue to pass through the vas; if they are applied too tightly, they may cut through the vas wall and permit the sperm to exit. PSYCHOLOGICAL SEQUELAE There is no physiological basis for an adverse psychological response to vasectomy. Although there is a paucity of reliable information on the subject, available literature suggests that a normal, sexually well-adjusted male will experience no significant psychological changes following elective sterilization if he understands what he can expect during and after the procedure and if he is given an opportunity to express his fears and have his questions answered in advance. When psychological problems do occur postoperatively, they can usually be explained by preoperative attitudes and conditions. For the man with serious neuroses or sexual maladjustments, vasectomy may not be advisable. If professional counseling is available, vasectomy candidates with suspected psychological problems should be interviewed and evaluated individually. Tests measuring psychological adjustment indicate that postoperative problems can usually be traced to preoperative ones. Using the Minnesota Multiphasic Personality Inventory, Ziegler et al. (8) observed that men who experienced problems after the procedure had shown hypochondria or concern about their masculinity prior to the procedure. Int J Gynaecol Obstet 15

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REFERENCES 1. Ansbacher, R: Sperm-agglutinating and sperm-immobilizing antibodies in vasectomized men. Fértil Steril 22:629, 1971. 2. Edey, H: Voluntary sterilization. N Y State J Med 77:483, 1972. 3. Freund, M & Davis, J E: Disappearance rate of spermatozoa from the ejaculate following vasectomy. Fértil Steril 20:163, 1969. 4. Schmidt, S S: Techniques and complications of elective vasectomy. Fértil Steril 77:467, 1966. 5. Shulman, S, Zappi, E, Ahmed, U & Davis, J E: Immunologic consequences of vasectomy. Fed Proc 23:374, 1970. 6. Sobrero, A J, Kohli, K L, Edey, H, Davis, J E & Karp, R: A vasectomy service in a free-standing family planning center: one year's experience. Soc Biol 20:303, 1973.

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7. Vasectomy—what are the problems? Population Reports, Series D, No. 2, 1975. 8. Ziegler, F J, Rodgers, D A & Prentiss, R J: Psychosocial response to vasectomy. Arch Gen Psychiatry 27:46, 1969.

Address for reprints: Joseph E. Davis Department of Urology New York Medical College New York, New York 10029 USA

Vasectomy: benefits versus risks.

Int J Gynaecol Obstet 15: 163-166, 1977 Vasectomy: Benefits Versus Risks Joseph E. Davis Department of Urology, New York Medical College, New York, N...
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