Vasectomy Summary

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AUA Update SeriesLesson 22 Volume 27 2008

VasectomyLearning Objective: At the conclusion of this continuing medical education activity, theparticipant will be familiar with the different aspects of vasectomy from its history to itsfuture, surgical technique, outcomes and complications.

Howard H. Kim, M.D.Disclosures: Nothing to disclose

and

Peter N. Schlegel, M.D., F.A.C.S.Disclosures: Intarcia Therapeutics, Inc.: Consultant/Advisor; Theralogix, Inc.: Board member/Officer/Trustee

Department of Urology and Cornell Institute for Reproductive MedicineThe New York Weill Cornell Medical Center

andThe Population Council

Rockefeller UniversityNew York, New York

Supported by the Frederick J. and Theresa Dow Wallace Fund of the New York Community Trust.

This self-study continuing medical education activity is Credit Designation Statement: The American Urological of the audience with information on which they can

designed to provide urologists, Board candidates Association designates this educational activity for a make their own judgments. The program planners

and/or residents affordable and convenient access to maximum of 1.0 AMA PRA Category 1 Credit. Each must resolve any conflicts of interest prior to the

the most recent developments and techniques in physician should only claim credit commensurate with commencement of the educational activity. It remains

urology. The American Urological Association (AUA) is the extent of their participation in the activity. for the audience to determine if the facultys

accredited by the Accreditation Council for Continuing relationships may influence the educational contentAUA Disclosure Policy: As a provider accredited by theMedical Education (ACCME) to provide continuing with regard to exposition or conclusion. WhenACCME, the AUA must insure balance, independence,medical education for physicians. The AUA takes unlabeled or unapproved uses of drugs or devices areobjectivity and scientific rigor in all its activities. Allresponsibility for the content, quality and scientific discussed, these are also indicated.faculty participating in an educational activity provided

integrity of this CME activity. Unlabled/Unapproved Uses: It is the policy of the AUAby the AUA are required to disclose to the audienceto require the disclosure of all references toany relevant financial relationships with anyunlabeled or unapproved uses of drugs or devicescommercial interest to the provider. The intent of thisprior to the presentation of educational content.disclosure is not to prevent faculty with relevantPlease consult the prescribing information for fullfinancial relationships from serving as faculty, butdisclosure of approved uses.rather to provide members

Publication date: August 2008

Expiration date: August 2011

2008 American Urological Association, Education and Research Inc., Linthicum, MD


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contraceptive method in only 6 Western countries (Australia,

Canada, Great Britain, the Netherlands, New Zealand and

United States) and 3 Eastern countries (China, India and

South Korea).17, 18 More than 55,000 vasectomies are per-

formed in Canada yearly.15 The average annual incidence of

vasectomy from 1992 to 1999 for men 20 to 64 years old in

the United Kingdom was 4.48 per 1000 person years.19 The

prevalence of sterilization in UK men was 17% in 1990,19

and in New Zealand the overall prevalence of vasectomy is

44%, adjusted to the age distribution of all New Zealand

men 40 to 74 years old.18 About 42 million couples worldwide

use vasectomy as the method of contraception, of whom

32 million reside in China and India.17, 20 In contrast, few

vasectomies are performed in France as a result of the 19th

century Napoleonic Code which prohibits vasectomy as a

form of self-mutilation.21

SURGICAL TECHNIQUE

Several vasectomy techniques are performed today, includ-

ing those using the standard anesthetic cord blocks. Many

of these methods yield good results but we favor a no-scalpel,

no-needle approach modified from the Chinese technique

initially developed by Li et al in 1974.22

Preparation. Perioperative anti-inflammatory treatment

with 200 mg celecoxib orally twice a day started the night

before the procedure may help to prevent postoperative pain.

This medication can be given for an additional 4 to 7 days

postoperatively since it does not increase bleeding risk. The

patient may also be given 10 mg diazepam orally or sublin-

gually about 15 minutes before the start of the procedure. In

the procedure room he reclines in the supine position andthe scrotum is shaved. The penis is kept out of the surgical

field using gentle cephalad traction with a rubber band

wrapped around the corona and clipped to the patients gown

at the level of the umbilicus. Before scrubbing and gloving,

a finger cot may be placed on the left middle finger to

protect it during the delivery of anesthesia using a needle-

less delivery device. Once gloved, the surgeon preps the

anesthetic delivery site with an alcohol pad.

Anesthesia. The median raphe is identified, and the non-

dominant hand is used to palpate the vas deferens. The index

finger and thumb form a C configuration and the vas deferens

is pressed between this C and the middle finger. When stand-ing on the patients right side, the right-handed surgeon faces

the patients head when grasping the right vas deferens and

the patients feet when grasping the left vas deferens. Each

vas is brought up against the skin to the same spot at the

median raphe, about 2 cm below the base of the penis. The

MadaJet XL Medical, Urology (Mada, Inc., Carlstadt, New

Jersey) is used to deliver the anesthetic cocktail, which is a

1-to-1 mix of 2% plain lidocaine and 0.5% plain bupivacaine.

Each high pressure spray delivers about 0.1 cc of the anesthe-

tic solution.23 About 3 sprays are delivered to each vas defer-

ens, being careful to deliver the anesthetic against the finger

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cot to avoid inadvertent injection into the surgeons finger

The surgeon removes the gloves and finger cot, and then

puts on a gown and fresh gloves for the procedure. The

surgical field is prepped with betadine solution and draped

in the usual fashion. Alternatively, local infiltration of 1%

xylocaine to the skin may be performed with a 1.5-inch 25

gauge or longer needle advanced along the vas deferens to

provide a cord block. Other surgeons have used a blindcord block at the level of the upper scrotum that appears to

have a slightly higher risk of cord hematoma.

Vasal access. Once the vas deferens is brought up to the

skin of the median raphe using the 3 finger grasp, a ring-

tipped clamp is used to secure the vas through the skin. One

blade of the fine curved mosquito hemostat is used to punc-

ture the skin and the vas deferens until the lumen is reached

The puncture hole is enlarged to about 4 mm by placing both

blades of the mosquito hemostat into the hole and gently

stretching the skin by opening the blades transversely acros

the vas deferens. The vas deferens is again speared with 1

blade of the mosquito hemostat and the tip of the instrumenis rotated up toward the ceiling. This motion delivers the vas

deferens out of the scrotum and into the operative field. The

ring-tipped clamp is reapplied for better purchase around the

vas deferens. Tissue adherent to the vasal sheath is cleared

away with the mosquito hemostat using the same spreading

motion of its blades, and the vasal sheath is further cleared

of adventitia. It is important to achieve a segment of vasa

sheath completely free from adherent tissue. Blunt dissection

can be used to push away associated blood vessels.

Alternatively, in a modification of the no-scalpel vasectomy

a percutaneous vasectomy omits the initial grasping of the

vas deferens through the scrotal skin with the ring-tipped

clamp.24 Instead, the mosquito hemostat is used to first punc-

ture the scrotal skin and to spread tissue overlaying the vas

deferens. Once the vas deferens is exposed, it is grasped with

the ring-tipped clamp and pulled out of thescrotum for furthe

dissection.

Vasal occlusion. A reusable Hi Temp Cautery device (Ad-

vanced Meditech International, Inc., Flushing, New York) is

used for the occlusion. The vas deferens is hemi-transected

with the cautery, exposing the lumen. The tip of the device

is inserted into each end of the vas deferens and both opening

are cauterized. Care should be taken to avoid full-thicknesscautery of the vas deferens to prevent necrosis. Cautery is

done just to obliterate the luminal lining. A small segment

of vas deferens is excised for pathological evaluation. The

distal cut end of the vas deferens (toward the testis) is closed

with a small surgical clip. The proximal end is pushed (tele-

scoped) down into the vasal sheath and a small surgical clip

can be placed on the sheath overlying the vasal end. This

move separates the 2 ends of the vas deferens into different

planes or compartments, reducing the risk of recanalization

Care must be taken to avoid including any spermatic cord

nerves in the clip during this process of fascial interposition


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a potential cause of post-vasectomy pain. For this reason,

some surgeons avoid fascial interposition despite its benefit

of marginally improving the effectiveness of vasectomy.

After careful inspection for hemostasis, the vas deferens is

returned to its native position in the scrotum. The same

process is repeated for the contralateral vas deferens through

the same opening.

Once the procedure is completed, the opening is pinchedfor a few minutes for hemostasis while the betadine is wiped

away from the skin. A scrotal supporter with fluff type dress-

ing is applied along with an ice pack. No antibiotics are

required, and acetaminophen or celecoxib is sufficient for

postoperative pain management.

COMPLICATIONS

Early. Vasectomies are often performed in the office setting

using local anesthesia and in general have low acute compli-

cation rates. Early complications of vasectomy include hema-

toma and infection, with an average reported incidence of

about 2% and 3.4%, respectively.25

Long term. Chronic testicular pain or the post-vasectomy

pain syndrome is one of the most vexing postoperative

complications of vasectomy. Patients can present with or-

chalgia, pain with intercourse and/or ejaculation, pain with

physical exertion and tender or full epididymides.26 In a

retrospective survey of 396 patients 27.2% complained of

postoperative testicular pain.27 Fortunately, 82% of the pa-

tients experienced only transient pain, while 19% had pain

for more than 3 months, or a 5% overall incidence of chronic

testicular pain in this study group. Troublesome pain resulting

in a request for vasectomy reversal appears to occur afterfewer than 1 in 1000 vasectomy procedures but some com-

plaints are more common. Leslie et al reported a much higher

incidence of chronic pain, 14.7% at 7 months after vasec-

tomy.28 Finally, Manikandan et al reported the incidence of

chronic scrotal pain at 1 and 10 years after vasectomy to be

16.8% and 13.8%, respectively.29

The pathophysiology of PVPS is incompletely understood.

Because reversal surgery can successfully treat this symptom

in some patients and pain can be associated with ejaculation,

congestion of the obstructed vas deferens and epididymis

has been hypothesized as the etiology.30 In their review of

PVPS Christiansen and Sandlow indicated that anatomicalderangement following vasectomy results in opposing forces

with intercourse and ejaculation. Smooth muscle cells of the

efferent ducts and initial segment of the epididymis push

fluid into the epididymal tail while contraction of the vas

deferens results in retrograde flow of fluid into the caudal

epididymis.31 Myers et al reported pain relief after vasectomy

reversal in 24 of 32 patients (75%) and in 3 of 32 (9.4%)

after a second reversal procedure.32 Denervation of the

spermatic cord is another therapeutic strategy, with 1 group

reporting 13 of 17 (76.5%) complete and 4 of 17 (23.5%)

partial responses.27

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Sperm granulomas have been implicated in exacerbation

and amelioration of PVPS. Sperm granulomas form in 4%

to 60% of closed ended vasectomies.26, 31-36 Shapiro and

Silber theorized that the presence of a sperm granuloma at

the vasectomy site would prevent epididymal pressure build-

up, perforation and the formation of an epididymal sperm

granuloma, reducing the likelihood for pain.34 However,

Schmidt reported that the sperm granuloma itself was a pain-ful lesion in 40% of cases.33

OUTCOMES

Level I evidence indicates that the no-scalpel method is

generally preferred over the conventional technique for

fewer complications but it appears more difficult for phy-

sicians to learn. In a Cochrane database review Cook et al

evaluated 2 randomized controlled trials comparing the scal-

pel and no-scalpel incisions for vasectomy.37 Although no

difference in effectiveness was found between the 2 tech-

niques, the authors noted that the no-scalpel approach resulted

in less bleeding, hematoma, infection and pain, as well as

shorter operative times. The same group compared vasectomy

occlusion techniques.38 Of the 6 randomized controlled trials

conclusions could not be drawn about trials using vas occlu-

sion clips or vas irrigation. Fascial interposition was noted

to reduce surgical failure.

Failure rate. In a survey of 586 U.S. urologists about 1

pregnancy was reported per 1000 vasectomies, with 51% of

pregnancies occurring during the immediate post-vasectomy

period.39 In another review of 5331 vasectomies performed

by 1 physician during 24 years with at least 2 postoperative

semen tests there were 97 failures of all types, with 32(0.60%) early overt failures, 4 (0.08%) late overt failures (at

least 4 years after the second semen test) and 61 (1.14%)

technical failures involving the persistence of small numbers

of spermatozoa.40 Of the 97 failures 4 were attributed to

missed vasa deferentia and the remaining to recanalization.

The U.S. Collaborative Review of Sterilization prospective

cohort study reported a 9.4 (95% CI 1.2-17.5) cumulative

probability of failure per 1000 procedures 1 year after vasec-

tomy and an 11.3 (95% CI 2.3-20.3) cumulative probability

at years 2, 3 and 5.41

Post-vasectomy semen analysis. Follow-up after vasectomy

typically involves semen analyses to document azoospermia,although routines vary according to individual practices.

There is considerable discord as to how many semen analyses

are necessary and at what intervals they should be performed.

Studies have demonstrated variable time and number of ejac-

ulations required to achieve azoospermia.42 In a review of

56 studies Griffin et al reported a median achievement of

azoospermia of greater than 80% after 3 months and 20

ejaculations, with 1.4% of patients demonstrating persistent

nonmotile sperm.43 They recommend a protocol involving 1

semen analysis after 3 months and 20 ejaculations, and pa-

tients with positive samples can be followed with periodic


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testing until azoospermia is achieved. Men with a persistently

low number of nonmotile sperm can be given cautious assur-

ance of success. The British Andrology Society guidelines

put forth the following recommendations for assessment

of post-vasectomy semen analysis: Initial assessment

should take place at 16 weeks post vasectomy and after

the patient has produced at least 24 ejaculates; if no

sperm are seen on direct microscopy of freshly producedspecimen, a centrifuged specimen examination for the

presence of motile and nonmotile spermatozoa should

follow; clearance should be given after 2 sperm free ejacu-

lates; and in cases of persistent identification of nonmotile

spermatozoa, the patient should be advised regarding the

cessation of other contraceptive precautions.44

The finding of motile sperm on the first PVSA is not uncom-

mon and should be followed with additional PVSA before

considering a repeat vasectomy. In a descriptive study of

5460 patients Labrecque et al reported that 347 (6.4%) had

motile sperm in the initial PVSA.45 Of 309 of these men

with motile sperm selected for additional analyses 174(56.3%, 95% CI 59.7-61.7) had delayed vasectomy success.

Many practitioners will accept a semen sample with rare non-

motile sperm as evidence of initial success after vasectomy,

allowing couples to stop contraception, with the proviso that

a repeat semen analysis is required. In practice most men do

not follow full guidelines that are recommended for follow-

up semen analyses after vasectomy. An AUA consensus panel

is expected to produce recommendations for post-vasectomy

follow-up in the next year.

Compliance: Proponents for fewer post-vasectomy sperm

analyses point to poor overall patient compliance rates after

vasectomy. Badrakumar et al assessed compliance rates for

1 and 2 PVSA regimens, and not surprisingly compliance

was better for the first requested sample (82% to 84% vs

72%).46 A review of 1892 consecutive patient records re-

vealed that 644 (34%) never returned for follow-up after

vasectomy, 1619 (33%) returned for a single PVSA, 1629

(33%) returned for a second PVSA and only 60 (3%) com-

pleted instructions for a yearly PVSA.47 Chawla et al reported

that 45.6% of 690 patients failed to submit even 1 sample.48

Persistent Nonmotile Sperm: Persistence or reappearance of

nonmotile sperm after vasectomy is a management dilemma

familiar to many urologists. In 1 study nonmotile sperm wasfound in 33% of patients 12 weeks after surgery and the mean

time to azoospermia was 6.36 months, while reappearance of

nonmotile sperm after initial azoospermia was reported in 5

of 65 patients.49 Philp et al reported no pregnancies in 310

men with persistent nonmotile sperm who were given special

clearance.50 Two other studies also indicated no pregnancies

by 15151 and 20052 men with persistent nonmotile sperm.

Lest these reports lull urologists into complacency, there are

reports of DNA confirmed paternity in vasectomized men

with 2 consecutive azoospermic samples,53, 54 including 1

man whose spun sample demonstrated only a few nonmotile

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spermatozoa.55 In a medicolegal review of vasectomy Gingel

et al recommended that the patient, not the physician, should

make the decision to discontinue contraception in cases of

persistent nonmotile sperm.56 Fresh semen samples should

be examined to ensure that the sperm are truly nonmotile,

as the presence of even 1 motile sperm more than 3 to 6

months after the procedure is an indication for repeat

vasectomy. Furthermore, as a procedure vulnerable to litiga-tion, the authors stress the importance of sound surgica

technique, clear communication with the patient, and docu

mentation of all aspects of the procedure and encounters

including counseling and consent. Laboratory results should

be communicated directly to the patient by the surgeon.

OTHER CONSIDERATIONS

Despite extensive discussion in the lay press, there are no

data to link performance of a vasectomy as a cause for anothe

significant medical disorder.

Prostate and testicular cancers. The popularity of vasec-

tomy has been shadowed by studies reporting an association

between this procedure and prostate cancer.57, 58 Several

physiological alterations after vasectomy are proposed to

explain this potential link, including an increase in circulating

androgen levels, formation of anti-sperm antibodies, produc

tion of local growth factors such as epidermal growth factor

and transforming growth factor-alpha, and changes in semina

fluid.59 None of these biological factors has been conclusively

demonstrated to support the relationship of vasectomy and

prostate cancer.

Many studies including several meta-analyses have disputed

the link to prostate cancer.59, 60

In 1998 Bernal-Delgado etal performed a meta-analysis of 14 original studies (5 cohor

and 9 case control) evaluating the association of vasectomy

and prostate cancer.59 Although the overall relative risk was

1.23 (95% CI 1.01-1.49), indicating a slight but statistically

significant excess risk of prostate cancer among individuals

who had undergone vasectomy, the systematic review dem-

onstrated numerous methodological problems of the constit

uent studies. Sensitivity analysis indicated the detected effec

was influenced strongly by studies more vulnerable to bias

(case control and hospital based) and internal validity prob-

lems (detection bias and inadequate selection of controls)

As a result, the authors concluded no causal associationbetween vasectomy and prostate cancer. Similarly, in their

2002 meta-analysis of 22 studies (5 cohort and 17 case con

trol) Dennis et al noted that men with a prior vasectomy may

be at an increased risk of prostate cancer but concluded that

the increase may not be causal because of potential bias.60

Several population based studies also revealed no causal

relationship between vasectomy and prostate cancer. In a

national population based, case control study 923 new cases

of prostate cancer from the New Zealand Cancer Registry

were compared to 1224 randomly selected controls.61 The

relative risk of prostate cancer for men who had a vasectomy


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versus those who had not was 0.92 (95% CI 0.75-1.14). The

time since vasectomy was also not significant (RR 0.92, 95%

CI 0.68-1.23 for greater than or equal to 25 years since

vasectomy). In a population based registry data study from

Denmark a total of 46 cohort patients were diagnosed with

prostate cancer while 46.93 were expected (standardized inci-

dence ratio 0.98, 95% CI 0.7-1.3); time since or age at vasec-

tomy also showed no trend.62

In a study from England Golda-cre et al found no elevation of prostate cancer risk after

vasectomy (rate ratio 0.74, 95% CI 0.45-1.14).63

The literature is replete with studies looking into the rela-

tionship between vasectomy and prostate cancer. The overall

trend of these reports points to the general consensus that

there is no definitive evidence for causal association be-

tween vasectomy and prostate cancer despite a few posi-

tive associations. The positive findings are weakened by

methodological issues such as detection bias and lack of

statistical power among other factors. For example, as vasec-

tomies are often performed by urologists in the United States,

undergoing this procedure may increase the likelihood forprostate cancer screening and detection by said provider.64

Some small studies have proposed a link between vasec-

tomy and testicular cancer. Although this potential associa-

tion has received less media attention than the alleged rela-

tionship between vasectomy and prostate cancer, Moller et

al performed a large cohort study of more than 73,000 men

to explore the possible risk of testicular cancer after vasec-

tomy.65 They found no increased incidence of testicular can-

cer in vasectomized men compared to the whole Danish

population (standardized morbidity ratio 1.01, 95% CI 0.79-

1.28). They also reported that vasectomy does not accelerate

the growth or diagnosis of preexisting testicular neoplasms.

Autoimmunity. The production of anti-sperm antibodies in

men undergoing vasectomy is attributed to granuloma forma-

tion, increased permeability of epithelial barriers in the rete

testis and epididymis, and transport of phagocytic cells to

regional lymph nodes.66 Do the autoimmune effects of vasec-

tomy have an impact on immunological disorders in vasecto-

mized men? To answer this question, Goldacre et al compared

a population of men who underwent vasectomy with a refer-

ence population to determine the rate ratios for selected im-

mune related diseases before and after vasectomy.67 After a

mean follow-up of 13 years, the authors reported no long-term elevation of risk following vasectomy of several im-

mune related diseases including asthma, diabetes mellitus,

ankylosing spondylitis, thyrotoxicosis, multiple sclerosis,

myasthenia gravis, inflammatory bowel disease, rheumatoid

arthritis and testicular atrophy.

Cardiovascular disease. As a corollary to autoimmune con-

cerns of vasectomy, another potential sequela of circulating

immune complexes derived from anti-sperm antibodies is

endothelial injury and inflammation leading to cardiovascular

disease. In 1980 Clarkson and Alexander reported more se-

vere and extensive atherosclerosis in rhesus monkeys vasec-

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tomized for 9 to 14 years and fed a non-atherogenic diet

compared to controls.68 However, this finding has been dis-

puted by several human and animal studies. One such study

was performed by Manson et al in 1999 as part of the U.S.

Physicians Health Study.69 Of 22,071 participating U.S.

male physicians 4546 reported having undergone vasectomy

including 1159 who had undergone the procedure at least 15

years before study entry. With 258,892 person years of fol-low-up, the reported multivariate relative risk of total myo-

cardial infarction was 0.94 (95% CI 0.77-1.14) for men with

compared to men without vasectomy. Risk estimates for fatal

and nonfatal events were not significantly different for the

2 groups. A study of men participating in the Atherosclerosis

Risk in Communities Study also revealed no evident associa-

tion between vasectomy and atherosclerosis.70

Urolithiasis. To explore the reported increase in renal stone

frequency and disturbance of mineral and hormone homeo-

stasis after vasectomy, Schreiber and Schwille compared 14

vasectomized rats to 12 sham surgery controls.71 At 7 months

after surgery serum magnesium was decreased (p=0.014)and phosphaturia was increased (p=0.025) in the vasectomy

group. Vasectomy resulted in significant accumulation of

phosphorus, calcium and magnesium in renal papillae. Fur-

thermore, calcium phosphate stones were found in 2 of the

vasectomized rats. The authors theorized that vasectomy may

result in disturbance of magnesium, calcium and phosphorus

homeostasis at the level of the kidney, and induce mild

hypomagnesemia and marked hyperphosphaturia in the pres-

ence of normal parathyroid function. Some human data are

also available, although they do not adequately consider so-

cioeconomic variables that predispose men to choose vasec-

tomy and the risk of urolithiasis. As an offshoot of the U.S.

Coronary Artery Surgery Study, data on urological disease

in 11,205 men were collected, and the age adjusted relative

risk for calculi in vasectomized men was 1.67 (p


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mental. In a questionnaire analysis of psychological corre-

lates of vasectomy Sandlow et al reported that anxiety about

vasectomy was driven mainly by fear of pain and of the

unknown and, although concerns about the finality of the

procedure was not a major concern, there was confusion

about the reversibility of the procedure.76 The authors recom-

mended adequate pre-vasectomy counseling to counter these

fears and misconceptions.Another group used a biographical questionnaire to deter-

mine whether vasectomy had effects on marriage such as

sexual and marital satisfaction, communication and fre-

quency of sexual intercourse.77 The authors did not detect a

significant difference in these parameters before and after

vasectomy. In contrast, Maschhoff et al reported that certain

indices of marital stability improved after vasectomy, notably

sexual frequency and the initiation of intercourse by the

female.78

Sexual effects. Although an anatomical etiology of erectile

dysfunction following vasectomy does not exist, Buchholz

et al scrutinized the psychosexual aspects of post-vasectomyerectile dysfunction.79 Of the patients who attributed erectile

dysfunction to a previous vasectomy a significant 22% had

been urged into the decision to undergo a vasectomy by their

female partners, and many of these patients believed there

was a relationship between the erectile dysfunction and va-

sectomy. Although erectile dysfunction is not a widespread

problem following vasectomy, psychological studies provide

insight into potential non-organic consequences of the pro-

cedure.

Reversal surgery. Since up to 6% of men undergoing vasec-

tomy eventually seek reversal surgery, Potts et al evaluated

patient characteristics that may predict this change of heart.80

Among age at time of vasectomy, religion, occupation,

wife employment status, number of marriages, number

of children, reason for reversal and number of years

between vasectomy and reversal, younger age at time of

surgery and a wife who worked outside the home were

associated with increased vasectomy reversal. In a related

study of vasectomy regret from the partners perspective

Jamieson et al found the cumulative probability of a woman

expressing regret within 5 years after her husbands vasec-

tomy was 6.1% (95% CI 3.6-8.6), which is comparable to

the 7.0% (95% CI 5.8-8.1) 5-year cumulative probability of

regret among women after tubal sterilization.81 Women who

had substantial conflict with their husbands before the surgery

were more likely to request vasectomy reversal compared to

women who did not report conflict (rate ratio 25.3, 95% CI

2.9-217.2).81

FUTURE

Surgical contraception. Variations of the Standard Vasec-

tomy: Numerous variations on a theme have emerged on

the vasectomy procedure, ranging from slight alterations of

occlusion techniques to implementation of new devices and

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technology. An example of occlusion technique modification

is use of an implantable ligation device called the Vasclip.82

The overall procedure is similar to the standard vasectomy

but instead of sectioning and cauterizing the vas deferens, a

small biocompatible polymer lock is placed.

Percutaneous injection of polyurethane elastomer plugs is

another alternative occlusion method used in China.83 With

this no-incision method, the vas deferens is secured andanesthetized, and a 6 gauge needle is used to deliver the

polymer into the lumen. In a series of 12,000 men Zhao

reported an azoospermia rate of 98% at 1, 2 and 3 years

and a complication rate of 0.47% (84% local infection, 16%

local hematoma).83 Furthermore, of 86 men who had the

plugs removed 51 achieved pregnancy.

Another novel application of technology for vasal occlusion

is the use of high intensity focused ultrasound ablation. Rob

erts et al applied this technique in a canine model using

a high intensity focused ultrasound transducer which was

incorporated into a handheld clip.84 The authors aim is to

use current technology for benign prostatic hyperplasia andrenal tumor ablation for a rapid non-invasive alternative to

vasectomy.

Laparoscopy: As with many areas of urological surgery

laparoscopy may play a significant albeit limited role as a

vasectomy technique, and several cases have been reported

in the literature.85-89 Specifically, men undergoing a laparo-

scopic hernia repair who desire vasectomy may benefit from

a concurrent laparoscopic vasectomy and avoid a separate

scrotal incision. One group hypothesized that another poten

tial benefit to the laparoscopic approach is fewer symptomatic

post-vasectomy sperm granulomas.85 Schmidt postulated that

pain associated with a sperm granuloma may be secondary

to entrapment of nerves within the granuloma.33 As the vas

deferens diverges from the cord structures at the internal

ring, Kakitelashvili et al note that granuloma pain may be

less likely with the laparoscopic approach.85 However, diffi-

culty of future reversal surgery is a major disadvantage to

this approach. Obviously, laparoscopy is a far more invasive

procedure, requiring general anesthesia, than the standard

scrotal procedure.

Medical contraception. Reversibility is a key benefit of

medical and pharmacological contraception. To date, male

non-barrier contraceptive options have been limited to vasec-tomy and inadequate non-surgical methods such as with

drawal and periodic abstinence.90 Potential developments in

male contraception include hormonal suppression of testos-

terone and vaccines to immobilize sperm.91

Vaccines: Many sperm proteins are being considered as

potential targets for anti-sperm vaccines,91 including a human

sperm antigen called SP-10, which has been called a primary

vaccine candidate by the WHOs Taskforce on Contraceptive

Vaccines.92 Vaccines against sperm acrosome, midpiece and

tail cause sperm clumping and also prevent penetration of the

zona pellucida.91 Animal trials have demonstrated persistent


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immunity for about 1 year.91, 93-95 Immunization against an-

other spermatozoal antigen, PH-20, resulted in reversible

infertility in male guinea pigs lasting about 1 year.96 Immuni-

zation can be directed against other targets along the endo-

crine axis such as FSH, LH and GnRH. However, potential

problems with immunotherapy such as induction of autoim-

munity and variable responses in individual patients make it

a less attractive male contraceptive option.97

Hormonal Contraception: In the reproductive endocrine axis

pulsatile GnRH secretion from the hypothalamus triggers the

release of LH and FSH from the anterior pituitary. Leydig

and Sertoli cells in the testis are dependent on LH and FSH

for testosterone production and spermatogenesis. Hormonal

contraception inhibits spermatogenesis by the negative feed-

back effect of exogenous testosterone. Different regimens

have been tested, including various formulations of testoster-

one and GnRH analogues, and combination therapy with

progestins and antiandrogens.90

In a Cochrane database review Grimes et al evaluated 30

randomized trials of male hormonal contraception withazoospermia as the primary outcome measure.98 Various regi-

mens were included and results varied widely. Although the

data were insufficient to evaluate pregnancy rates and side

effects, the authors concluded that several trials of male

hormonal contraception demonstrated promising efficacy for

inducing azoospermia. Potential adverse effects of exogenous

testosterone such as acne and weight gain depend on the

formulation and dose. More significant and long-term conse-

quences to the cardiovascular system, bone and prostate are

difficult to determine with available short-term studies.97

Non-endocrine Contraception: Several non-endocrine male

contraceptives are being investigated, including Eppin (epi-

didymal protease inhibitor), calcium channel blockers, lon-

damine derivates, triptolide and N-butyldeoxynojirimycin.90

Non-hormonal agents have the potential advantages of rapid

action and sparing of non-reproductive androgen dependent

function.97

Eppin, a protein specific to the testis and epididymis, is an

illustrative example of a non-hormonal post-testicular male

contraceptive target. Eppin originates from Sertoli cells and

epididymal epithelial cells, and coats the surface of ejaculated

human spermatozoa.99 Eppin interacts with semenogelin and

forms a part of the ejaculate coagulum,100

and also has strongantibacterial activity.101 In 2004 ORand et al immunized 9

male Macaca monkeys with Eppin, of which 7 (78%) devel-

oped high titers and infertility.102 In addition, 5 of the 7

monkeys (71%) recovered fertility with cessation of immuni-

zation therapy. The authors speculated that infertility resulted

from the interference of Eppin interaction with semenogelin

and the sperm surface by antibodies.

Potential targets for male medical contraception abound

but are limited not only by conventional criteria such as

efficacy, safety and cost, but by personal and sociopolitical

attitudes. With the exception of vasectomy and barrier meth-

204

ods such as condoms, contraception traditionally has focused

on women, perhaps because contraceptive failure has greater

consequences for women.97 Would women trust men not

to forget a dose? And would men willingly take on this

responsibility? In surveys 44% to 83% of men103 and 71%

to 90% of women104 indicated their willingness to use male

medical contraception.

Implementation of male medical contraception representsa paradigm shift that faces many challenges. Even with in-

creasing interest and research in male medical contraception,

years will pass before its clinical fruition. In the meantime

vasectomy remains one of the safest and most cost-effective

contraceptive options.

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Study Questions Volume 27 Lesson 22

1. Which of the following interventions during vasectomy havebeen shown to decrease failure (recanalization) rates?a. Vas occlusion clipsb. Polyurethane elastomer plugsc. Fascial interpositiond. Vas irrigatione. High intensity focused ultrasound ablation

2. In the British Andrology Society guidelines for post-vasec-tomy semen analysis the initial assessment should take placehow many weeks after surgery?

a. 8b. 10c. 12d. 14

e. 163. In an animal study vasectomized rats demonstrated

a. Hyperphosphaturiab. Hypocitraturiac. Hypercalciuriad. Hypermagnesemiae. Hypercalcemia

T k hi li h // / f / /

4. What percent of vasectomized patients eventually seek rever-sal surgery?a. 0-2b. 3-6c. 7-10d. 11-14e. 15-20

5. Which of the following is not a potential male medical contra-ceptive?

a. Testosteroneb. Progestinc. Triptolided. Pyrazolidine derivatese. Londamine derivatest

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