Vasectomy is a safe and effective procedure for permanent contraception. Vasectomy is 30 times less likely to fail and 20 times less likely to have postoperative complications than its gynecologic counterpart. Complications from vasectomy are rare and minor in nature. Immediate risks include infection, hematoma, and pain. Complications seldom lead to hospitalization or aggressive medical management. Technique is surgeon dependent; however, certain techniques, such as fascial interposition, seem to decrease rates of vasectomy failure. Despite myriad vasectomy techniques, failure rates are less than those seen with tubal ligation. Available data suggest that vasectomized men do not seem at increased risk for immune-complex diseases.
Vasectomy remains an important tool in the armamentarium of contraception. A large historical cohort study revealed that approximately 12% of men aged 12 to 39 have undergone vasectomy. There are approximately 500,000 vasectomies done in the United States yearly, making vasectomy the most common urologic procedure done in this country. Worldwide, 42 to 60 million men use vasectomy as their primary method of contraception. The number of vasectomies performed in the United States and globally, however, pales in comparison to tubal ligation. In 2002, female sterilization done in the United States outnumbered vasectomy by a margin of 3 to 1 (27% versus 9%); this margin also approximately holds true globally.
According to a 2004 study, vasectomy costs seem lower than those associated with tubal ligation in the United States. The same study also found that vasectomy was 30 times less likely to fail and 20 times less likely to have postoperative complications.
Vasectomy is considered a safe and effective way to deliver permanent sterilization. Additionally, 72% of the vasectomies in the United States are performed by urologists. Nevertheless, vasectomy is still a surgical procedure and, as such, has appreciable complications and long-term morbidity. Complications of the procedure include hematoma formation, infection, failed sterilization, sperm granuloma, short-term incisional pain, and chronic pain syndromes. Another possible consequence of vasectomy is the development of antisperm antibodies. This article discusses in detail the prevalence of these risks, how variations in surgical technique affect complications, and how current pathophysiology explains some of the complications.
Hematoma formation
The most common immediate complication of vasectomy is hematoma formation. Scrotal hematoma is aesthetically displeasing and painful during the postoperative course. The incidence of scrotal hematoma after vasectomy is low. The accepted overall incidence for hematoma formation is 2% (range, 0.09%–29%). According to a national survey of vasectomy providers, the incidence of scrotal hematoma is directly related to the number of vasectomies completed by a physician annually and was reported to be 4.6% for physicians performing 1 to 10 vasectomies annually, 2.4% for those performing 11 to 50 annually, and 1.6% for those performing more than 50 annually. Physician experience also correlates with hospitalization with incidences of 0.8%, 0.3%, and 0.2%, respectively.
One of the factors that influences hematoma occurrence involves the chosen surgical technique, more specifically, no-scalpel vasectomy versus traditional incisional vasectomy. The no-scalpel vasectomy technique has been reported associated with a lower incidence of bleeding and hematoma formation compared with the standard incisional technique. Two randomized controlled studies have demonstrated this advantage. A pivotal study done by Sokal and colleagues showed an 85% reduction in the frequency of hematoma formation (1.8% versus 12%). In this study, two of the three hospitalizations required after vasectomy were related to hematoma formation. Christensen and colleagues had a much smaller patient population but showed a reduction of hematoma formation with no-scalpel (9.5%) versus standard incision (15.9%). Sokal and colleagues also showed a decrease in perioperative bleeding with no-scalpel (2.1%) versus standard incision (4.29%). As the scrotum is expandable and has poor tamponading characteristics, strict hemostasis at the end of the procedure, regardless of technique, is essential to prevent hematoma. Postoperative care, including elevation of the scrotum and compressive dressings, also plays an important role in reducing postoperative bleeding. Some studies recommend suturing the scrotum to the abdominal wall or use of scrotal hitches to prevent subcutaneous tracking of blood, but this is not common practice.
Vasectomy failure
The failure to achieve or maintain sterilization is one of the most devastating risks of vasectomy. In general, vasectomy failure is defined by the presence of sperm in the ejaculate after the procedure, but the actual definitions vary in terms of sperm numbersand time after vasectomy. For example, although some investigators define vasectomy failure as more than 10 million sperm/L at 12 weeks or later, others define it as more than 5 million motile sperm/mL at 14 weeks or later or more than 100 000 sperm/mL with any motility at 26 weeks or later. It is recommended, however, that if any motile sperm are found in the ejaculate 3 months after vasectomy, the procedure should be repeated. Unwanted pregnancy can place major strains on couples and be a source of litigation against the practicing physician. Pregnancy rates associated with failure are reported to range from 0% to 2%. There is no absolute standard of care for the confirmation of postvasectomy sterility. Follow-up semen analysis is recommended 2 to 3 months after vasectomy, with the goal of obtaining at least one and preferably two absolutely azoospermic specimens 4 to 6 weeks apart. Vasectomy failure can be a result of a surgical error, such as disrupting or occluding a structure other than the vas deferens, incomplete disruption of the vas, failure to recognize duplications of the vas deferens, or repeating a vasectomy on the same vas. Practicing unprotected sexual intercourse too soon after a vasectomy also represents a potential cause of failed sterilization.
When appropriate disruption of both vasa deferentia is accomplished and sufficient time before resuming unprotected sexual intercourse is allowed, however, recanalization of the vas deferens may be the cause of vasectomy failure. Knowledge of the recanalization process is based on histopathologic studies. Tissue samples obtained from men undergoing vasectomy reversal have shown epithelialized microtubules on both abdominal and testicular vasal ends; sperm has been observed within the microtubules themselves or extravasating from them. A novel experiment by Stahl and coworkers showed statistically significant up-regulation of selected growth factors at vasectomy sites, although a direct mechanism of microrecanalization could not be elicited. Further studies are needed to delineate the exact mechanism of postvasectomy microrecanalization.
The most heavily debated source of failed sterilization stems from the surgical technique used for vasectomy. Disruption of the vas represents the most important step to achieve permanent sterilization. Many techniques have been described in the literature with associated failure rates. Worldwide, the most commonly used technique is simple suture ligation with excision. Although vasectomy traditionally has been believed to have overall failure rates of 1% to 3% or lower, recent studies indicate higher failure rates for the ligation and excision technique. A large, multinational, randomized trial showed that ligation and excision plus fascial interposition ( Fig. 1 ) is significantly more effective than ligation and excision alone. Addition of fascial interposition to suture ligation with vasal excision lowered the failure rate (defined in that study as more than 5 million motile sperm/mL at 14 weeks or later or more than 100 000 sperm/mL with any motility at 26 weeks or later) from 12.7% to 5.9%. A common explanation for this failure rate involves tip necrosis and sloughing secondary to ligation; this is turn leads to recanalization of the cut vas segments.
Failure rates seem to decrease dramatically with use of fascial interposition and use of electrocautery. A retrospective Canadian study reported an 8.7% failure rate with clip ligation and excision without fascial interposition; however, the same study found that cautery with fascial interposition had approximately a 0.3% failure rate. Dassow and Bennett compiled a variety of vasectomy techniques with corresponding failure rates based on comparative literature review ( Table 1 ).
| Surgical Technique | Reported Failure Rates |
|---|---|
| Cautery and excision | ≤4.8% |
| Cautery and fascial interpostion | ≤1.2% |
| Ligation and fascial interposition | ≤16.7 |
| Intraluminal cautery | <1% |
| Ligation and excision | 1.5%–29% |
| Cautery (open testicular end) and fascial interposition | 0.02–2.4% |
Vasectomy failure
The failure to achieve or maintain sterilization is one of the most devastating risks of vasectomy. In general, vasectomy failure is defined by the presence of sperm in the ejaculate after the procedure, but the actual definitions vary in terms of sperm numbersand time after vasectomy. For example, although some investigators define vasectomy failure as more than 10 million sperm/L at 12 weeks or later, others define it as more than 5 million motile sperm/mL at 14 weeks or later or more than 100 000 sperm/mL with any motility at 26 weeks or later. It is recommended, however, that if any motile sperm are found in the ejaculate 3 months after vasectomy, the procedure should be repeated. Unwanted pregnancy can place major strains on couples and be a source of litigation against the practicing physician. Pregnancy rates associated with failure are reported to range from 0% to 2%. There is no absolute standard of care for the confirmation of postvasectomy sterility. Follow-up semen analysis is recommended 2 to 3 months after vasectomy, with the goal of obtaining at least one and preferably two absolutely azoospermic specimens 4 to 6 weeks apart. Vasectomy failure can be a result of a surgical error, such as disrupting or occluding a structure other than the vas deferens, incomplete disruption of the vas, failure to recognize duplications of the vas deferens, or repeating a vasectomy on the same vas. Practicing unprotected sexual intercourse too soon after a vasectomy also represents a potential cause of failed sterilization.
When appropriate disruption of both vasa deferentia is accomplished and sufficient time before resuming unprotected sexual intercourse is allowed, however, recanalization of the vas deferens may be the cause of vasectomy failure. Knowledge of the recanalization process is based on histopathologic studies. Tissue samples obtained from men undergoing vasectomy reversal have shown epithelialized microtubules on both abdominal and testicular vasal ends; sperm has been observed within the microtubules themselves or extravasating from them. A novel experiment by Stahl and coworkers showed statistically significant up-regulation of selected growth factors at vasectomy sites, although a direct mechanism of microrecanalization could not be elicited. Further studies are needed to delineate the exact mechanism of postvasectomy microrecanalization.
The most heavily debated source of failed sterilization stems from the surgical technique used for vasectomy. Disruption of the vas represents the most important step to achieve permanent sterilization. Many techniques have been described in the literature with associated failure rates. Worldwide, the most commonly used technique is simple suture ligation with excision. Although vasectomy traditionally has been believed to have overall failure rates of 1% to 3% or lower, recent studies indicate higher failure rates for the ligation and excision technique. A large, multinational, randomized trial showed that ligation and excision plus fascial interposition ( Fig. 1 ) is significantly more effective than ligation and excision alone. Addition of fascial interposition to suture ligation with vasal excision lowered the failure rate (defined in that study as more than 5 million motile sperm/mL at 14 weeks or later or more than 100 000 sperm/mL with any motility at 26 weeks or later) from 12.7% to 5.9%. A common explanation for this failure rate involves tip necrosis and sloughing secondary to ligation; this is turn leads to recanalization of the cut vas segments.
