Vasectomy: pros and cons

Vasectomy: pros and cons – includes related information

Choosing a suitable form of birth control is a major decision for sexually active people who want to avoid pregnancy’ Since there is no perfect contraceptive, people must choose from a selection of “second bests,” according to their age, stage of life and sexual relationships. For those who already have a family, sterilization – tubal ligation for women and vasectomy for men – is today’s most effective and popular form of birth control. Sterilization blocks the tubes that carry eggs or sperm by cutting, tying or coagulating (“burning”) them. It is a safe, convenient and reliable method that does not affect the reproductive hormones, male potency or sexual enjoyment. However, the procedure does not protect against sexually transmitted diseases (STDs), including HIV infection (AIDS) – only proper use of latex condoms does that!

Sterilization should be considered permanent

Once a couple decides on sterilization the question arises as to which partner should have it. Since the operation is simpler and safer for men, and as women may already have borne the brunt of childbearing, it is often the male partners who decide to go for it. In North America almost one in five men over age 40 has been sterilized. In Ontario alone, more than 20,000 men choose vasectomy as their preferred method of birth control each year. Although it is sometimes possible to reverse vasectomy (rarely tubal ligation), reversal is major surgery with uncertain success rates. Therefore those considering vasectomy are urged to view it as irreversible The vasectomized man (and his partner) must be as sure as possible that he does not want to sire any more offspring.

Counselling beforehand is a good idea

Since rumours and misconceptions abound, anyone undertaking sterilization should find out about the procedure and what it offers. Urologists, gynecologists, family physicians, nurses, and family planning or birth control experts can explain what can and cannot be expected from it. Although for most it’s a choice they never regret, the decision to be sterilized requires a thorough evaluation of the benefits, risks and the possible psychological or emotional costs. Counselling and expert advice beforehand can help diminish anxieties about vasectomy by allowing men to express and discuss their fears and find out precisely what the operation involves. Counsellors explain that although the operation itself is quick and simple, sterility is not immediate – it takes a few weeks for infertility to be established – and vasectomy is not foolproof. There are occasional failures. Although partner or spousal consent isn’t required, including partners in the decision-making is advised. Usually, in well-adjusted men, there are no adverse psychological consequences or “hang-ups” after successful sterilization. In fact, many couples report an improved sex life.

Although there are no hard and fast rules, the “best” candidates for vasectomy are healthy, sexually well-adjusted males over age 35 with more than one child, who are in stable relationships and satisfied not to have any more children. Vasectomy is not advised for men who have STDs or undiagnosed bleeding disorders, or for those who are emotionally unstable or in a poor sexual relationship.

Understanding the vasectomy operation

The surgical procedure is a simple one that blocks the sperm-carrying tubes. In order for sperm to get from the testicles, where they are produced, to the end of the male penis, where they are ejaculated, they must travel through a pair of long, thin tubes called the vas deferens or vas for short. In a vasectomy, these tubes are surgically cut and the ends closed, or the tubes are tied or clipped. The procedure prevents sperm from completing their journey so that they are excluded from the male ejaculate. The amount of ejaculate stays the same, but as it no longer contains sperm, conception is prevented. After vasectomy, the sperm – which continue to be produced even though they aren’t included in the ejaculate – are broken down and destroyed by normal bodily processes.

The operation, which takes just 10-20 minutes, requires only a small cut in the scrotum (often with no need for stitches). It is performed under local anesthetic in a physician’s office, hospital or clinic. Generally, the man can leave directly after the vasectomy and be back at work within a few days to a week. There may be some post-operative pain and bruising at the surgical site, reduced by applying ice packs and wearing tight, supportive underwear or an athletic support (jock-strap) for a week or two. Heavy lifting must be avoided for 10 days or so. Sexual activity can be resumed once the discomfort fades, with the clear understanding that sterility takes several weeks to achieve and alternate birth control must be used in the interim.

An elegant vasectomy procedure called the “no-scalpel technique,” pioneered in China in 1974, uses a tiny puncture hole through which forceps are used to clip the vas, with far fewer complications, bleeding and pain than standard vasectomy. The Chinese have done over 15 million vasectomies this way. But although many Western physicians are learning the technique, so far fewer than 20 doctors in Canada perform this no-scalpel procedure.

Possible post-operative complications

Following vasectomy, complications are usually minor and last only a few days to a couple of weeks – perhaps a little swelling, pain and bruising – treated with painkillers, ice packs and scrotal supports. Complication rates vary according to the skill of the surgeon and the type of vasectomy performed, less than one per cent requiring hospital treatment.

A hematoma or painful swelling can develop, which usually vanishes in a week or so. In one to three per cent of cases hematomas become quite large, even as big as an orange, requiring drainage.

Sperm granulomas, or small, hard, inflamed nodules, can develop at the cut end of the vas (in 10-20 per cent of cases), sometimes quite painful. Most resolve on their own, but in some cases further surgery may be necessary.

Epididymitis – an ache in the scrotal region – can occur, but rarely lasts more than a week or two, easily relieved by painkillers. If it persists, surgical repair may be necessary.

Not instantly effective: takes a few weeks to work

Many vasectomized men believe that the operation is 100 per cent guaranteed to render them instantly sterile and unable to impregnate a woman. However, since there are millions of sperm downstream, below the point of blockage, it takes a few weeks (usually 4 to 16 weeks) until sperm are fully eliminated from the ejaculate and the man becomes infertile. How long it takes to become sterile depends largely on the number of post-vasectomy ejaculations. In practice, sperm are usually cleared from the reproductive tract after about 20 ejaculations, sometimes sooner. During the interval, men remain fertile and must use some other form of birth control.

Experts usually advise men to use alternate contraception for at least three months after the operation, and until semen tests show the ejaculate to be sperm-free. Semen samples (produced by masturbation) are tested to check whether all sperm have been eliminated, usually about 12 weeks after the operation. As one physician notes, “only when two specimens one week apart show the ejaculate is sperm-free can infertility be assured.” If sperm persist in the ejaculate, an exploratory procedure may be advised to find out why, and a repeat operation may be needed.

Vasectomy failures can occur

Occasionally vasectomy fails to achieve sterility and the operation may need to be redone. One urologist explains that “failures can occur because the cut ends of the vas deferens spontaneously rejoin or recanalise while healing, so that fertility isn’t halted. The likelihood of recanalization depends partly on the surgical technique and is least likely after occlusion (coagulation), although this method is also least likely to offer the chance of later reversal. Rarely, vasectomy fails because there is an extra vas that hasn’t been cut.” Failure rates among well-practiced surgeons average 2 to 4 per thousand vasectomies, higher with inexperienced operators. In one British study, vasectomies performed by 19 highly experienced surgeons – who had performed more than 1,000 vasectomies – failed at a rate of 0. 14 per cent to 0.41 per cent, compared to less experienced surgeons, who had performed fewer than 200 vasectomies, failing 1.40 per cent of the time.

Pregnancies occur in the partners of vasectomized men at an average rate of one in 400 – usually because of unprotected intercourse too soon after the operation. Sperm may linger for weeks in the “nozzle” end of the vas deferens and lead to pregnancy from unprotected sex during the immediate post-surgical weeks. Rarely, even years later, one of the severed tubes spontaneously re-connects and pregnancy occurs. For example, in one case in England, a woman whose husband was vasectomized five years earlier stopped having periods. Thinking the halted periods were due to early menopause, by the time she realized she was pregnant she was already into the fifth month of gestation. Late failures are extremely rare, occurring in about 0.1 per cent of cases. However, pregnancy as a cause of missed periods in the partner of a vasectomized man must not be entirely ruled out.

Any possible long-term health effects?

While vasectomy is highly effective, safe and reliable, no surgical procedure is entirely risk-free and there remains slight uncertainty about its long-term health effects. Unsettling reports have surfaced suggesting that, over the long haul, vasectomy might contribute to atherosclerosis, heart disease and, most recently, prostate cancer. After thorough investigation, earlier concerns that vasectomy might contribute to atherosclerosis and cardiovascular disease are now considered unfounded. Research at Oxford University and at Harvard Medical School found that coronary artery disease was in fact slightly below average in vasectomized men. Similarly, suggestions that vasectomy might be related to testicular cancer have been overturned. The formation of anti-sperm antibodies after the surgery has so far shown no ill effects.

The remaining concern is a possible link between vasectomy and prostate cancer. Some studies find a correlation, most do not. One 1993 Harvard study published in the Journal of the American Medical Association reported a slight increase in prostate cancer among vasectomized men. Experts who have examined these and other studies conclude that, although it is possible that vasectomy contributes to prostate cancer, the relationship may arise from bias in the studies. For example, vasectomized men tend to visit urologists more frequently for check-ups and are therefore more likely to have prostate cancer detected early than non-vasectomized men who consult urologists less often. It will be many years before the issue is entirely settled. Meanwhile, the World Health Organization and other authorities maintain that there is no cause for concern, and no reason why vasectomized men should worry about prostate cancer any more than non-sterilized males.

Vasectomy reversal – tricky, but sometimes works

Occasionally, owing to unanticipated circumstances – such as divorce, remarriage, the death of a child or other changes – men wish to have their vasectomy reversed. As vasectomy is increasingly popular, so too are demands for reversal. However, vasectomy reversal or vavovasectomy is major surgery – a complicated, difficult microsurgical procedure requiring experience and expertise. It means rejoining the severed ends of the vas so that sperm once more travel through them. Even if well done, return of fertility is not guaranteed. For example, sperm antibodies may kill or damage sperm and prevent conception, even if sperm again enter the vas.) Success depends on the surgeon’s skill and the original vasectomy technique. Success rates for reversal average 50 per cent in skilled hands. After vasectomy reversal, sperm counts take a long time to reach normal. Men can wait up to five years to become fertile. The operation may need to be performed several times.

The best candidates for vasectomy reversal are men who had the operation relatively recently. It is rarely successful 10 years or more after vasectomy. In one 1991 U.S. study, the more recent the vasectomy the better the chances of reversal. Those with three years between vasectomy and reversal had a 76 per cent success rate; with 3-14 years from vasectomy to reversal, 44 per cent were successfully returned to fertility; and 15 or more years after vasectomy only 30 per cent of those reversed produced a pregnancy.

Comparing tubal ligation and

vasectomy

For a couple who opts for sterilization as their method of birth control, the best way to put vasectomy into perspective is to compare it with tubal ligation in women.

Morbidity (illness): Vasectomy, which is done under local anesthetic, is easier and cheaper to perform, and has fewer complications than tubal ligation, which is done under general anesthesia. Tubal ligation is more painful, carries greater risks of infection and other complications, and requires a longer convalescence.

Mortality: While both vasectomy and tubal ligation are considered safe, vasectomy is definitely safer for a man than tubal ligation is for a woman. Deaths due to the general anesthetic given for tubal ligation are 4 per 100,000; for men undergoing vasectomy deaths average less than 0.1 per 100,00.) In the U.S., there are about 14 deaths per year from tubal ligation – mostly blamed on the anesthesia – virtually zero attributed to vasectomy. (Deaths in childbirth average 7.9 per 100,000.)

Effectiveness: Both tubal ligation and vasectomy are 99.8 per cent effective. Suspected vasectomy failures can be detected by a semen analysis for sperm, but there is no similar method to check the success of tubal ligation. A failed tubal ligation, while rare, can result in a life-endangering ectopic pregnancy.

No effect on potency or

sexual pleasure

Vasectomy is not – as some men think – castration, nor does it alter the ability to have an erection or enjoy sex. Physiologically, the only difference is that before vasectomy a man’s ejaculate contains sperm, and after a successful operation it does not. The procedure has no effect on hormones (testosterone levels stay the same) and it does not alter arousal, pleasure or the amount of fluid ejaculated. Despite the many myths and misconceptions surrounding it, vasectomy does not halt sperm production, reduce a man’s potency or diminish sexual satisfaction.

Weighin risks versus benefits

Vasectomy: Advantages * Highly effective (late failure rate 0.1 per cent) * Minor surgical procedure * Virtually permanent * Few complications * Covered by medical insurance schemes * Frees female partner from contraceptive hassle.

Vasectomy: Disadvantages * Surgical procedure with a few potential complications * Takes several weeks to months to become fully effective * Irreversible – on the whole – although new techniques sometimes make reversal possible * Long-term health effects not entirely certain.

Who might later regret the operation?

Studies looking into the after-effects of vasectomy find that most men are pleased with the results and enjoy relief from the worry of undesired pregnancy. Nonetheless, they must continue safe-sex practices to avoid catching or transmitting sexually transmitted diseases. The men most likely to regret the decision to undergo sterilization are those who make the choice when still young, for emotional reasons or during times of crisis in a relationship – perhaps just after the birth of a child or during financial hardship. A few men have regrets years later when they switch partners and wish to start a new family, or perhaps after the death of a child. As one vasectomized father of four notes, “in the unlikely eventuality that all our children perish through some disaster, I might regret the decision, but one cannot run one’s life on such dismal odds.” Men younger than 25, those with sex problems and men who have no children are relatively poor candidates for vasectomy and are apt to feel sorry later on. Some estimate that five per cent of vasectomized men eventually regret the decision.

COPYRIGHT 1996 Strategic Inc. Communications Ltd.

COPYRIGHT 2004 Gale Group