Vasectomy: a guidelines-based approach to male surgical contraception

Key points

• Apart from condoms, vasectomy is the only approved form of male contraception; it is as effective as tubal ligation but simpler, safer, faster and less expensive, and more than 80% are performed in the office.
• Vasectomy is underused: in 2015-2017, 21.5% of women aged 15-49 relied on female sterilization versus 14.7% on male sterilization, and only 0.78% of men aged 18-64 received vasectomy counselling in 2007-2015 claims data.
• Vasectomy does not cause immediate sterility: another contraceptive is needed until a postvasectomy semen analysis shows azoospermia or fewer than 100,000 nonmotile sperm per millilitre, yet only 50-55% of men complete this test.
• Even after confirmed sterility, there is a 1 in 2,000 risk of pregnancy due to delayed recanalization.
• Prophylactic antimicrobials are not indicated unless the patient is at high risk of infection, and NSAIDs are preferred to routine opioid prescriptions for postvasectomy pain.

Overview

This review summarises the 2012 American Urological Association (AUA) vasectomy guideline on counselling, occlusion techniques and postprocedural care, and discusses areas for improvement: low awareness, routine opioid prescribing and poor completion of postvasectomy semen analysis.

Counselling and technique

Vasectomy is intended as permanent; reversal or testicular sperm extraction are not 100% effective. The European guidelines list young age and absence of a relationship as relative contraindications. The authors favour in-person counselling, which allows a physical examination, and Medicaid patients must sign consent 30 to 180 days before the procedure. The target site is the straight portion of the vas deferens, and the guideline describes several acceptable occlusion methods, including mucosal cautery with or without fascial interposition. Routine histology of the vas segment and a routine postvasectomy examination are not required.

Semen analysis and recovery

Patients should avoid ejaculation for at least 1 week; the semen analysis is done on average 3 months after vasectomy, and the European guidelines add that 20 ejaculations should have occurred by then. If more than 100,000 sperm per millilitre persist, serial analyses may continue until 6 months, when repeat vasectomy should be offered. Several home kits have lowest detectable concentrations above 100,000 per millilitre, and home testing did not clearly improve completion (59.6% vs 58.8%). Including the female partner in counselling and reminders may help.

Pain, complications and regret

A survey found that 51.5% of urologists routinely prescribed opioids, but 28% of patients did not fill the prescription and 42% of those who did took none; in another study 7.8% of opioid-naive patients had persistent use 90 days later. Complications occur in 1-2% of men and include haematoma, infection and chronic pain lasting at least 3 months. Regret was reported in about 7% of patients and was similar after tubal ligation and vasectomy (7% vs 6.1%).

FAQ

When can other contraception be stopped after vasectomy?

Only after a postvasectomy semen analysis shows azoospermia or fewer than 100,000 nonmotile sperm per millilitre.

Is vasectomy reversible?

It is intended to be permanent; vasectomy reversal or testicular sperm extraction are possible but neither is 100% effective.

Are opioids needed after vasectomy?

Usually not; NSAIDs are a better strategy, and an NSAID was as effective as acetaminophen with codeine in one comparison.

Source

Velez D, Pagani R, Mima M, Ohlander S. Vasectomy: a guidelines-based approach to male surgical contraception. Fertil Steril 2021;115(6):1365-1368. DOI: 10.1016/j.fertnstert.2021.03.045. Copyright ©2021 American Society for Reproductive Medicine, Published by Elsevier Inc. Summary prepared by Medpresso from the original publication; it is not a substitute for the full text or for medical advice.