A minimally invasive technique, the No-Scalpel Vasectomy (NSV) has decreased the incidence of local complications and enhanced the popularity of vasectomy as a means of birth control.
Vasectomy is a simple and effective method for providing permanent contraception. Vasectomy is the surgical interruption of the two tubes (vas deferens) that carry a man's sperm from his testicles to his ejaculatory ducts, where the sperm are stored before departure from his body during orgasm. A vasectomy prevents sperm from being added to the man's ejaculation fluid (semen); therefore, he can no longer make a woman pregnant. The sperm containing fluid that is blocked by vasectomy constitutes only 2-3% of a man's semen volume, therefore, a man and his partner will not notice any changes in the amount or appearance of his semen.
A minimally invasive technique, the No-Scalpel Vasectomy (NSV) has decreased the incidence of local complications and enhanced the popularity of vasectomy as a means of birth control. Since Dr. Marc Goldstein introduced the No-Scalpel Vasectomy into the United States in 1985, the Center for Male Reproductive Medicine and Microsurgery at Weill Cornell Medicine has played a leading role in the development of research protocols, manuals, videos, books and training programs for standardizing NSV technique. The NSV starts with a more effective technique to anesthetize the scrotum and vas using a high pressure jet injector instead of a needle. Two special instruments are used for the NSV procedure instead of using a scalpel. It is an elegant technique for delivering the vas deferens through a tiny puncture hole, which is dilated, pushing the potential blood vessels and nerves aside instead of cutting across them. Once the vas is delivered, its ends are sealed several ways to prevent failure. The puncture wound contracts and is virtually invisible at the end of the procedure. No sutures are necessary to close the puncture hole.
A vasectomy, no matter the technique, is a simple, effective, inexpensive, easy-to-perform method of contraception. Over 500,000 men in North America choose vasectomy each year. It is important for the patient to understand how the procedure is done, and all potential complications that might arise, both short-term and long-term.
Candidates for Vasectomy
Vasectomy should be considered permanent. Men considering vasectomy should be certain they do not want to father a child under any circumstances. It is important to talk to one's partner to make the decision together. Other forms of birth control should be considered. Talking to a friend or relative who has had a vasectomy may be helpful. A vasectomy may not be right for you if you are very young, if your current relationship is not stable, if you are having the vasectomy just to please your partner, if you are under a lot of stress or if you are counting on being able to reverse the procedure later. That said, sperm banking prior to vasectomy should be discussed. Since sperm loses half of its vitality after freezing and thawing, 2–3 specimens should be banked.
A vasectomy will interrupt the vas deferens, the tubular structure that carries sperm from the testes to the semen. The penis and testes are not altered in any way. A vasectomy will not alter a man's sensation of orgasm and pleasure. The operation has no noticeable impact on the man's ability to perform sexually, nor does it affect the balance of male hormones, male sex characteristics or sex drive. The body still produces semen, and erections and ejaculation occur normally. There is no noticeable change in the amount of fluid that comes out during ejaculation. Most of the semen is from the prostate and seminal vesicles; only 2–3% is vasal fluid.
A vasectomy is simply a sterilization procedure; once it has been performed, a man's semen will no longer contain sperm and he can no longer father a child. A vasectomy will not prevent a male from getting or passing on a sexually transmitted infection.
After vasectomy, contraception is required until sperm are cleared, which typically takes 15 ejaculations or 6 weeks, whichever comes first.
Post-Vasectomy Considerations
After surgery, the patient may be sore for a few days. He should limit physical activity and lie down as much as possible during the first 24 hours. Intermittent application of an ice pack during the first 24-48 hours helps to decrease pain and swelling. Patients may return to deskwork the next day, but heavy lifting, vigorous activity and sexual intercourse should be avoided for one week.
Most patients require only over-the-counter medications (Tylenol) for pain control. Aspirin and Ibuprofen type medicines should be avoided for 7 days pre- and post-vasectomy to prevent potential bleeding problems.
Minor pain and bruising are to be expected and do not require medical attention. The patient should seek medical attention if he has fever, excessive pain, swelling or bleeding from the puncture site (wound).
Vasectomy does not change semen volume or appearance; only 2-3% of ejaculate volume is from epididymal and testicular fluid. There is a slight risk of failure (recanalization - 1/1000), hematoma and infection (less than 1%). Sperm granuloma, a hard, sometimes painful lump, about the size of a pea, may form as a result of sperm leaking from the cut vas deferens. The lump is not dangerous and is almost always resolved by the body in time. Congestion, a sense of fullness or pressure caused by sperm in the testes, epididymis and lower vas deferens may cause discomfort some 2 to 12 weeks after vasectomy. Like granuloma, congestion is not serious and usually resolves itself in time. Lastly, undergoing a vasectomy does not increase a man's risk for developing cancer, heart disease or other health problems.
Most importantly, patients must understand that other forms of contraception must be continued until two separate semen analyses document azoospermia (absent sperm). The disappearance of sperm from the ejaculate correlates more with the number of ejaculates than with the time interval after vasectomy. Approximately 90% of men will be azoospermic after 15 ejaculations. About 80% of men will be azoospermic 6 weeks after vasectomy, regardless of ejaculatory frequency.
Symptoms & Evalution
Prior to a vasectomy, the patient should be counseled to consider vasectomy as a permanent form of surgical contraception. It must be emphasized that although vasectomy reversal is often successful, it is not 100% effective in restoring fertility to the man who has undergone a vasectomy. Although not required, involvement of the spouse or partner in the decision-making and in witnessing the consent is highly recommended. In New York, a minimum 30-day period is required between the time initial consent for the vasectomy is signed and the operative procedure is performed.
A medical history and physical examination should be performed. The patient should be questioned regarding medications, drug allergies and any history of bleeding disorders. Prior scrotal surgery, such as orchiopexy or hydrocelectomy, should be noted because this may make the procedure more difficult. Any history of testicular or scrotal pain should also be clearly documented.
Physical examination of the genitalia should be performed in a warm room to allow for relaxation of the scrotum and detection of any anatomic abnormalities or unusual tenderness. Since men who request vasectomy usually have no specific complaints, it is tempting to perform a cursory exam to simply document the presence of two vasa. This temptation must be resisted. Many men requesting vasectomy are in the age group for which the incidence of testicular cancer is the highest. Furthermore, hernias, hydroceles or symptomatic varicoceles that need repair should be diagnosed so that treatment can be offered concurrently with the vasectomy.
Any abnormalities on scrotal examination or unexplained testicular symptoms should be evaluated with a scrotal ultrasound. If one of the vasa is congenitally absent, an abdominal ultrasound should be obtained because these patients have a high incidence of renal agenesis (absent kidney on the same side). A vas that is difficult to palpate may require performance of the vasectomy in the operating room. Penile or scrotal infections should be diagnosed and treated prior to the vasectomy. Routine laboratory testing is unnecessary in most cases and should only be obtained for specific indications. A semen analysis could be considered prior to vasectomy in men who have not had children or a documented pregnancy, or who have undergone chemotherapy, radiation therapy or hernia repairs.
Treatment Options
A standard vasectomy is performed through one or two small scrotal incisions. Once the procedure starts, the patient may experience mild discomfort when local anesthesia is administered. However, once the anesthesia takes effect, the patient should feel no pain. Some men feel a slight "tugging" sensation as the vasa are manipulated. Following local anesthesia, the vas deferens are isolated on each side and skeletonized of their surrounding tissue, vessels, and nerves. Multiple redundant steps are routinely taken in order to ensure discontinuity of the vas deferens and prevent recanalization. These steps can include transection of the vas with removal of an intervening segment, cauterization of the lumen of the vas deferens, ligation of the vas with a clip or suture and transposition of a tissue layer between the cut ends of the vas.
Most vasectomies are done right in the doctor's office or in a clinic. The ideal vasectomy results in minimal bleeding and almost no intra-operative pain. A vasectomy is facilitated by a warm antiseptic solution for the skin preparation and a warm procedure room (20C to 25C), which allows relaxation of the scrotal dartos muscle, facilitating easy isolation and fixation of the vas deferens.
The patient is placed in a supine position (lying on his back). Surgical preparation includes shaving of the skin of the upper scrotum and retraction of the penis, keeping it out of the way. On average the procedure takes roughly 20-30 minutes.
No-Scalpel Vasectomy (NSV)
The No-Scalpel Vasectomy uses an advanced technique to access the vas deferens. Two special instruments are used for this procedure. A scalpel is not needed. These two instruments are (1) ring fixation forceps and (2) dissecting forceps.
The benefits of NSV are:
- Fewer complications, resulting in almost 10 times fewer hematomas, infections and other complications—a rate of 0.4% for NSV versus 3.1% for conventional vasectomy
- Less bleeding and pain
- Faster and no sutures needed. With hands-on training and practice, NSV can be performed up to 50% faster than the conventional technique
- Enhanced popularity. Increased patient satisfaction with NSV results in good word of mouth and the enhanced popularity of vasectomy for permanent contraception
The chance of failure after No-Scalpel Vasectomy at Cornell is about 0.1%. The most frequent complaints after vasectomy are swelling of the scrotal tissue, bruising and minor pain. While these symptoms generally disappear without treatment, ice packs and scrotal support provide relief. More serious complications of the No-Scalpel Vasectomy, such as hematomas and infection, are uncommon, less than 0.1% at Cornell.
Vasectomy Reversal
An estimated 2% to 6% of men undergoing vasectomy may request a reversal at a later date. In many cases, the cut ends of the vas deferens can be surgically reattached. However, this operation, a microsurgical vasovasostomy, is expensive and for a variety of reasons, does not guarantee a return to fertility. Vasectomy reversal appears to be more successful if performed within 10 years of the vasectomy, but again, there is no guarantee that fertility will be restored. Vasectomy should therefore be considered a permanent procedure. Before you choose to have a vasectomy, make quite sure that you and your partner do not want any more children. If you are thinking about a reversal now, perhaps you should take more time to decide whether vasectomy is right for you.
Conclusion
Vasectomy is a simple and effective method for providing permanent contraception. A minimally invasive technique, the No-Scalpel Vasectomy, decreases the incidence of complications and has enhanced the popularity of vasectomy as a means of birth control.
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