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Vasectomy

Surgical ligation of both vas deferens for sterilisation.

Safest, simplest, and cheapest form of permanent contraception.

 

Pre-operative assessment and consent

All patients must be reviewed and counselled prior to procedure.

Examine all patients prior:

  • Hydrocele, epididymal cysts, difficult to palpate vas, absent vas, sensitivity

Involve partners in discussions.

Consider some time to think about it or cooling off period.

Consent points:

  • Intended to be permanent – whilst reversal and IVF are options in future, these are expensive with success rates of 50 % or less
  • Does not produce immediate sterility
  • Other contraceptive options available – IUD, tubal ligation, OCP, barriers
  • Small chance of unwanted pregnancy despite azoospermia initially (1 in 2000).
  • 1 % chance of needing repeat procedure due to failure to achieve azoospermia

Risks:

  • Bleeding / haematoma 1 – 2 %
  • Infection 1 – 2 %
  • Sperm granuloma
  • Testicular atrophy / damage to arterial supply
  • Failure
    • 1 % failure to achieve azoospermia
    • 1 in 2000 late recanalization
  • Pain
    • 1 – 2 % risk of chronic scrotal pain negatively impacting life

 

AUA guidelines – clinicians do not need to discuss prostate cancer, coronary heart disease, stroke, hypertension, dementia, testicular cancer, Fournier’s or death during pre-operative counselling.

Risk factors for regret or dissatisfaction:

Single, no children, younger couples, lower SES, emotionality behind decision, male ambivalence

 

Technique

  • Local vs GA – surgeon and patient preference
  • Incision and delivery of vas
    • 1 vs 2 incision – 2 incision less likely to divide same vas twice
    • Minimally invasive / ‘no incision’ – reported less haematoma or infection vs conventional incision
    • I use sharpened artery and ring forceps
    • Strip away peri-vasal fascia to skeletonise vas, watching for vessels
  • Divide and occlude the vas
    • Complete transection and excision of 1 cm portion of vas between artery forceps (+/- send for histology)
    • Occlusion methods
      • Suture ligation with vicryl
      • Ligaclip
      • Folding back on itself
    • Mucosal cauterisation (pinpoint diathermy)
    • Fascial interposition
    • Open ended testicular end (reportedly reduces back pressure and pain, may make reversal easier)

 

Post vasectomy semen analysis

Must use alternate contraception until clearance provided.

First semen analysis at 3 months, after a minimum of 20 ejaculations.

If azoospermia at 3 months = consider patient sterile and can be discharged.

If motile sperm at 3 months = likely failure, re-check in a month. May need repeat procedure.

If non-motile sperm present = monthly tests until azoospermia, or special clearance.

Special clearance – two samples containing < 100 000 non motile sperm / mL, at least 7 months post vasectomy

 

Vasectomy reversal

Vasectomy reversal is an option for men who are wishing to have children after a previous vasectomy.

  • The alternative is IVF or ICSI

Outcomes can be reported as:

  • Tubal patency (positive sperm count): 80 – 90 %
  • Pregnancy: 40 – 50 %

 

Predictors of success or failure:

  • Obstructive interval (time since vasectomy)
    • This is most important factor
    • More than 15 years = significantly reduced success
  • Female age
  • Sperm granuloma (positive predictor)
  • Technique of previous vasectomy – mucosal cautery, clips etc
  • Previous reversal attempt
    • Less likely to be successful, more likely to need epididymovasostomy
  • Intra-operative:
    • Thin watery fluid from testicular end is a good sign
    • Microsurgical technique suggested to improve success
  • Absence of post-operative complication and return to normal semen parameters

 

Technique:

  • Jackson table – allows sitting with legs under table. Drapes tightly under scrotum (don’t want to lose an 8-0 needle under drapes).
  • Incision over palpable defect
  • Isolation of the vas ends, with transection until clearly visible lumen. Passer suture down abdominal side. Look for fluid coming from testis side.
  • Leave adventitia on vas as much as possible (blood supply)
  • Vasectomy reversal clamp
  • One or two layer, tension free anastomosis
  • Microscope
  • 8/0 nylon sutures
  • If testicular end is obstructed / can’t get enough length -> epididymovasostomy

 

Epididymovasostomy:

  • Incision of tunica overlying epididymis
  • Dissection of dilated tubule thought to contain sperm
  • Opening in side of tubule about the size of the lumen of the vas
  • 9/0 nylon dual layer anastomosis