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===Fascial Interposition to prevent recanalization===
===Fascial Interposition to prevent recanalization===
[http://www.wisegeek.com/what-is-recanalization.htm Recanalization] of the vas deferens is a known cause of vasectomy failure(s). Fascial Interposition ("FI") helps to prevent this type of failure, increasing the overall success rate of vasectomy. FI is the positioning of the prostatic "receiving" end of the vas deferens to the outside of the fascial sheath<ref>http://www.ncbi.nlm.nih.gov/pmc/articles/PMC406425/figure/F1/ of</ref> while leaving the testicular end within the confines of the fascia. The [[Fascia]] is a fibrous protective sheath that surrounds the vas deferens. <br />
[http://www.wisegeek.com/what-is-recanalization.htm Recanalization] of the vas deferens is a known cause of vasectomy failure(s). Fascial Interposition ("FI") helps to prevent this type of failure, increasing the overall success rate of vasectomy. FI is the positioning of the prostatic "receiving" end of the vas deferens to the outside of the fascial sheath<ref name="pmid=15056388">{{cite journal | pmc=406425 }}</ref> while leaving the testicular end within the confines of the fascia. The [[Fascia]] is a fibrous protective sheath that surrounds the vas deferens. <br />
The "No-Scalpel" method, along with vas occlusion by cauterization with fascial interposition, currently provides the safest, most reliable procedure outcome. <ref>http://www.ncbi.nlm.nih.gov/pubmed/15157272?dopt=Abstract</ref> <ref>http://www.ncbi.nlm.nih.gov/pmc/articles/PMC406425/</ref>
The "No-Scalpel" method, along with vas occlusion by cauterization with fascial interposition, currently provides the safest, most reliable procedure outcome. <ref>{{cite journal | pmid = 15157272 }}</ref> <ref name="pmid=15056388" />


==Outlook==
==Outlook==

Revision as of 18:24, 1 April 2011

Vasectomy
Background
TypeSterilization
First use1899 (experiments from 1785)[1]
Failure rates (first year)
Perfect use<0.1%
Typical use0.15%, "Vas-Clip" nearly 1%
Usage
Duration effectPermanent
ReversibilityPossible, but expensive and low success rate.
User reminders2 consecutive negative semen specimens required to verify successful procedure.
Clinic reviewAll
Advantages and disadvantages
STI protectionNo
BenefitsNo need for general anesthesia. Lower cost/less invasive than tubal ligation for women.
RisksTemporary local inflammation or swelling of the testes. Long-term genital pain (PVPS).

Vasectomy is a minor surgical procedure wherein the vasa deferentia of a man are severed, and then tied/sealed in a manner which prevents sperm from entering into the seminal stream (ejaculate).
Vasectomy should not be confused with castration (male), which is the surgical removal of the testicle(s).

Procedure

Vasectomy causes sterilization by preventing sperm from entering into a man's ejaculate. A traditional vasectomy involves numbing of the scrotum with local anesthetic. Once the anesthetic has taken effect, small incision(s) are made, allowing a surgeon to gain access to the vas deferens of each testicle. The vasa deferentia are cut (sometimes a piece removed), separated and then sealed by ligating, cauterizing, or clamping. Vasectomy procedures are usually performed in an "out-patient" setting.

Techniques

Vasectomy techniques/methods have evolved to achieve higher success rates, reduce healing times, and lower chances of infection. Some of these variations may also decrease the risk of post-vasectomy pain syndrome (PVPS).

  • No-Scalpel vasectomy, also known as a "key-hole" vasectomy,[2] in which a sharp hemostat (as opposed to a scalpel), is used to puncture the scrotum (scrotal sac). The resulting smaller "incision" or puncture wound typically has less chance of infection, resulting in faster healing times compared to the larger/longer incisions made with a scalpel. The surgical wound created by the No-Scalpel method usually does not require stitch(es).
  • "Open-Ended" vasectomy. The testicular end of the vas deferens is not sealed, which allows continued streaming of sperm into the scrotum. This method may avoid testicular pain as a result of increased back-pressure in the epididymis[3].
  • "VasClip" vasectomy does not require cutting the vas deferens, but rather uses a clip to squeeze shut the flow of sperm. This method, reportedly, has resulted in lower success rates. Also, because vas deferens is not cut and/or tied with this method, it may not technically be considered vasectomy. Vasectomy reversal (and the success thereof) may be higher by virtue of simply removing the Vas-Clip. This method currently, appears to be in limited or no use, and therefore no reversal data is currently available. [4]


Fascial Interposition to prevent recanalization

Recanalization of the vas deferens is a known cause of vasectomy failure(s). Fascial Interposition ("FI") helps to prevent this type of failure, increasing the overall success rate of vasectomy. FI is the positioning of the prostatic "receiving" end of the vas deferens to the outside of the fascial sheath[5] while leaving the testicular end within the confines of the fascia. The Fascia is a fibrous protective sheath that surrounds the vas deferens.
The "No-Scalpel" method, along with vas occlusion by cauterization with fascial interposition, currently provides the safest, most reliable procedure outcome. [6] [5]

Outlook

Sexual intercourse can usually be resumed in about a week (depending on recovery), however, pregnancy is still possible as long as the sperm count is above zero. Another method of birth control must be used until a follow-up sperm count test two months after the vasectomy, or after 10 to 20 ejaculations over a shorter period of time, can be performed.

Biological implications

A post-vasectomy scrotum, showing typical post-operative bruising, incision stitches and a shaved scrotum.

Vasectomy essentially ensures that the patient will be sterile after surgery. The procedure is regarded by the medical profession as permanent because vasectomy reversal is costly and often does not restore the sperm count/flow to pre-vasectomy levels.

Men with vasectomies have a very small (nearly zero) chance of making a woman pregnant, but they will still have exactly the same risk of contracting and spreading sexually transmitted infections. For vasectomized men who are not in monogamous relationships, the rate of acquired STD's may be higher (compared to a similar cross-section of non-vasectomized men), due to the elimination of pregnancy risk, and therefore lack of using barrier protection (condoms). In short, a man who is active with new partners would be more likely to use barrier protection if he has not had a vasectomy.

After vasectomy, the testes remain in the scrotum where Leydig cells continue to produce testosterone and other male hormones that continue to be secreted into the blood stream. One study found that sexual desire after vasectomy was diminished in 6% of vasectomized men,[7] whereas other studies find higher rates of diminished sexual desire, for example nearly 20%.[8]

When the vasectomy is complete, sperm cannot exit the body through the penis. Sperm are still produced by the testicles, but they are broken down and absorbed by the body. Much fluid content is absorbed by membranes in the epididymis, and much solid content is broken down by the responding macrophages and re-absorbed via the blood stream. Sperm is matured in the epididymis for about a month before leaving the testicles. After vasectomy, the membranes must increase in size to absorb and store more fluid; this triggering of the immune system causes more macrophages to be recruited to break down and re-absorb more solid content. Within one year after vasectomy, sixty to seventy percent of vasectomized men develop antisperm antibodies.[9] In some cases, vasitis nodosa, a benign proliferation of the ductular epithelium, can also result.[10][11] The buildup of sperm increases pressure in the vas deferens and epididymis. The entry of the sperm into the scrotum causes sperm granulomas to be formed by the body to contain and absorb the sperm which the body treats as a foreign substance.[3]

Effectiveness as birth control

The Royal College of Obstetricians and Gynaecologists state there is a generally agreed upon rate of failure of about 1 in 2000 vasectomies which is considerably better than tubal ligations for which there is one failure in every 200 to 300 cases.[12] Early failure rates, i.e. pregnancy within a few months after vasectomy typically result from having unprotected intercourse too soon after the procedure. Late failure, i.e. pregnancy after recanalization of the vasa deferentia, has been documented.[13] A 2005 systematic review of 28 studies described a total of 183 failures or recanalizations from approximately 43,642 vasectomy patients (0.4%), and 20 studies in the same review described 60 pregnancies after 92,184 vasectomies (0.07%).[14]

Most physicians and surgeons who perform vasectomies recommend one (sometimes two) post-procedural semen specimens to verify a successful vasectomy, however many men fail to return for verification tests citing inconvenience, embarrassment, death, or change in partner.[15] In January 2008 the FDA cleared a home test called SpermCheck Vasectomy[16] that allows patients to perform postvasectomy confirmation tests themselves, however compliance for postvasectomy semen analysis in general remains low.

Complications of vasectomy

Short-term complications include temporary bruising and bleeding, known as hematoma. The primary long-term complication is/are chronic pain condition(s)/syndromes that can effect any of the scrotal, pelvic and/or lower-abdominal regions, known as post-vasectomy pain syndrome. Animal and human data indicate that vasectomy does not increase atherosclerosis and that increases in circulating immune complexes after vasectomy are transient. Furthermore, the weight of the evidence regarding prostate and testicular cancer suggests that men with vasectomy are not at increased risk of these cancers.[17]

Post-vasectomy pain syndrome

Main article: post-vasectomy pain syndrome

Post-vasectomy pain syndrome (PVPS) is a chronic and sometimes debilitating condition that may develop immediately or several years after vasectomy.[18] One survey cites studies that estimate incidence at one case every ten to thirty vasectomies.[19] The pain can be constant orchialgia or epididymal pain, or it can be pain that occurs only at particular times such as with intercourse, ejaculation, or physical exertion.[3]

Vasectomy reversal

Main article: Vasectomy reversal

Although men considering vasectomies should not think of them as reversible, and most men and their partners are satisfied with the operation,[20] [21] there is a surgical procedure to reverse vasectomies using vasovasostomy (a form of microsurgery first performed by Earl Owen in 1971[22][23]). Vasovasostomy is effective at achieving pregnancy in only 50%-70% of cases, and it is costly, with total out-of-pocket costs in the United States often upwards of $10,000[24] The rate of pregnancy depends on such factors as the method used for the vasectomy and the length of time that has passed since the vasectomy was performed. The reversal procedures are frequently impermanent, with occlusion of the vas recurring two or more years after the operation. After reversal, sperm counts are usually much lower than pre-vasectomy levels. There is evidence that men who have had a vasectomy may produce more abnormal sperm, which would explain why even a mechanically successful reversal does not always restore fertility.[25][26] The higher rates of aneuploidy and diploidy in the sperm cells of men who have undergone vasectomy reversal may lead to a higher rate of birth defects.[25]

Conceiving after vasectomy

In order to allow the possibility of reproduction via artificial insemination after vasectomy, some men opt for cryostorage of sperm before sterilization.

The cost of Cryo-preservation (Sperm Banking) itself may also be substantially less (approximately $500.00 every 5 years) than alternative Vaso-vasectomy procedure(s), (est surgery cost of $10,000.00) however the costs of In-vitro fertilization which are rarely below $10,000.00 US, and usually run between $12-15,000.00 US, must be considered. Those interested may want to research and consider the statistical cost/risk/success factors when choosing either of these methods.

Intracytoplasmic sperm injection: Sperm can be aspirated from the testicles or the epididymis, and while there is not enough for successful artificial insemination, there is enough to fertilize an ovum by ICSI. This avoids the problem of anti-sperm antibodies and may result in a faster pregnancy. IVF (In-vitro fertilization) may be less costly (see aforementioned text) per cycle than reversal in some healthcare systems, but a single IVF cycle is often insufficient for conception. Disadvantages include the need for procedures on the woman, and the standard potential side-effects of IVF for both the mother and the child.[27]

As in all cases of sterilization (vasectomy) or male infertility, conception can take place with donor sperm.

Psychological impact

A review of the the psychological impact of vasectomy was done on vasectomized men.[28] Informal postoperative surveys indicated that sexual behavior, happiness and the satisfaction of having the procedure done was generally high. In studies that employed psychological tests, and/or interviews from a clinical standpoint, a different overall conclusion emerged. Men were willing to verbally express satisfaction with the procedure, but when questions relating to their perceptions of themselves after the procedure were asked, it became clear that a large number of men had some concern about the long-term consequences of having had the procedure. Furthermore, the psychological impact of being rendered sterile weighed heavy on the majority of participants. In short, a high percentage of men struggle emotionally at some level, and at some point, with the idea of being permanently sterile, but, they remain satisfied with the decision, from the standpoint of having had a successful vasectomy.

History

The first recorded vasectomy was performed on a dog in 1823.[29] A short time after that, R. Harrison of London performed the first human vasectomy, however the surgery was not done for sterilization purposes, but to bring about atrophy of the prostate. Vasectomy began to be regarded as a method of birth control during the Second World War. The first vasectomy program on a national scale was launched in 1954 in India.

Availability and Legality

Vasectomy costs is/are (or may be) covered in different countries, as a method of both birth control or population control, with some offering it as a part of a national health insurance.

The legality of (and the availability of) Vasectomy may be different from country to country.

See also

References

  1. ^ Popenoe P (1934). "The progress of eugenic sterilization". Journal of Heredity. 25 (1): 19.
  2. ^ Cook LA, Pun A, van Vliet H, Gallo MF, Lopez LM (2007). "Scalpel versus no-scalpel incision for vasectomy". Cochrane Database Syst Rev. 18 (2): CD004112. doi:10.1002/14651858.CD004112.pub3. PMID 17443540.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  3. ^ a b c Christiansen C, Sandlow J (2003). "Testicular Pain Following Vasectomy: A Review of Post vasectomy Pain Syndrome". Journal of Andrology. 24 (3): 293–8. PMID 12721203.
  4. ^ http://www.vasweb.com/vasclip.htm.
  5. ^ a b . PMC 406425 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC406425. {{cite journal}}: Cite journal requires |journal= (help); Missing or empty |title= (help)
  6. ^ . PMID 15157272. {{cite journal}}: Cite journal requires |journal= (help); Missing or empty |title= (help)
  7. ^ Nielsen CM, Genster HG (1980). "Male sterilization with vasectomy. The effect of the operation on sex life". Ugeskr Laeger. 142 (10): 641–643. PMID 7368333.
  8. ^ Dias PL (1983). "The long-term effects of vasectomy on sexual behavior". Acta Psychiatrica Scandinavica. 67 (5): 333–338. doi:10.1111/j.1600-0447.1983.tb00350.x. PMID 6869041.
  9. ^ Hattikudur NS, Shanta SR, Shahani SK, Shastri PR, Thakker PV, Bordekar AD (1982). "Immunological and clinical consequences of vasectomy". Andrologia. 14 (1): 15–22. doi:10.1111/j.1439-0272.1982.tb03089.x. PMID 7039414.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  10. ^ Deshpande RB, Deshpande J, Mali BN, Kinare SG (1985). "Vasitis nodosa (a report of 7 cases)". J Postgrad Med. 31 (2): 105–8. PMID 4057111.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  11. ^ Hirschowitz L, Rode J, Guillebaud J, Bounds W, Moss E (1988). "Vasitis nodosa and associated clinical findings". J. Clin. Pathol. 41 (4): 419–23. doi:10.1136/jcp.41.4.419. PMC 1141468. PMID 3366928.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  12. ^ Royal College of Obstetricians and Gynaecologists. "Sterilisation for women and men: what you need to know".
  13. ^ Philp T, Guillebaud J, Budd D (1984). "Late failure of vasectomy after two documented analyses showing azoospermic semen". British Medical Journal (Clinical Research Ed.). 289 (6437): 77–79. doi:10.1136/bmj.289.6437.77. PMC 1441962. PMID 6428685.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  14. ^ Griffin T, Tooher R, Nowakowski K, Lloyd M, Maddern G (2005). "How Little is Enough? The Evidence for Post-Vasectomy Testing". The Journal of Urology. 174 (1): 29–36. doi:10.1097/01.ju.0000161595.82642.fc. PMID 15947571.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  15. ^ Christensen R, Maples Jr DC (2005). "Postvasectomy Semen Analysis: Are Men Following Up?". The Journal of the American Board of Family Practice. 18 (1): 44–47. doi:10.3122/jabfm.18.1.44. PMID 15709063.
  16. ^ Klotz K, Coppola MA, Labrecque M, Brugh III VM, Ramsey K, Kim KA, Conaway MR, Howards SS, Flickinger CJ (2008). "Clinical and Consumer Trial Performance of a Sensitive Immunodiagnostic Home Test That Qualitatively Detects Low Concentrations of Sperm Following Vasectomy". The Journal of Urology. 180 (6): 2569–2576. doi:10.1016/j.juro.2008.08.045. PMC 2657845. PMID 18930494.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  17. ^ Schwingl PJ, Guess HA (2000). "Safety and effectiveness of vasectomy" (PDF). Fertility and Sterility. 73 (5): 923–936. doi:10.1016/S0015-0282(00)00482-9. PMID 10785217.
  18. ^ Nangia AK, Myles JL, Thomas Jr AJ (2000). "Vasectomy reversal for the post-vasectomy pain syndrome: a clinical and histological evaluation". J. Urol. 164 (6): 1939–42. doi:10.1016/S0022-5347(05)66923-6. PMID 11061886.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  19. ^ Potts JM (2008). "Post-vasectomy Pain Syndrome In Genitourinary Pain And Inflammation". Humana Press: 201. doi:10.1007/978-1-60327-126-4_13. ISBN 978-1-58829-816-4. {{cite journal}}: Cite journal requires |journal= (help)
  20. ^ Landry E, Ward V (1997). "Perspectives from Couples on the Vasectomy Decision: A Six-Country Study" (PDF). Reproductive Health Matters. (special issue): 58–67.
  21. ^ Jamieson DJ, Kaufman SC, Costello C, Hillis SD, Marchbanks PA, Peterson HB, US Collaborative Review of Sterilization Working Group (2002). "A Comparison of Women's Regret After Vasectomy Versus Tubal Sterilization". Obstetrics & Gynecology. 99 (6): 1073–1079. doi:10.1016/S0029-7844(02)01981-6. PMID 12052602.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  22. ^ "About Vasectomy Reversal". Professor Earl Owen's homepage. Retrieved 2007-11-29.
  23. ^ Owen ER (1977). "Microsurgical vasovasostomy: a reliable vasectomy reversal". Urology. 167 (2 Pt 2): 1205. PMID 11905902.
  24. ^ Vasectomy Reversal http://www.epigee.org/guide/vasectomy_reversal.html
  25. ^ a b Sukcharoen N, Ngeamvijawat J, Sithipravej T, Promviengchai S (2003). "High Sex Chromosome Aneuploidy and Diploidy Rate of Epididymal Spermatozoa in Obstructive Azoospermic Men". Journal of Assisted Reproduction and Genetics. 20 (5): 196–203. doi:10.1023/A:1023674110940. PMID 12812463. {{cite journal}}: |access-date= requires |url= (help)CS1 maint: multiple names: authors list (link)
  26. ^ Abdelmassih V, Balmaceda JP, Tesarik J, Abdelmassih R, Nagy ZP (2002). "Relationship between time period after vasectomy and the reproductive capacity of sperm obtained by epididymal aspiration". Human Reproduction. 17 (3): 736–740. doi:10.1093/humrep/17.3.736. PMID 11870128.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  27. ^ Shridharani A, Sandlow JI (2010). "Vasectomy reversal versus IVF with sperm retrieval: which is better?". Curr Opin Urol. 20 (6): 503–509. doi:10.1097/MOU.0b013e32833f1b35. PMID 20852426.
  28. ^ http://www.ncbi.nlm.nih.gov/pubmed/932701
  29. ^ Leavesley, JH (1980). "Brief history of vasectomy". Family planning information service. 1 (5): 2–3. PMID 12336890.
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