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Surgical Procedures

Vasectomy

Vasectomy is a surgical procedure for male sterilization and/or permanent birth control. During the procedure, the vasa deferentia of a man are severed, and then tied/sealed in a manner such to prevent sperm from entering into the seminal stream (ejaculate). Vasectomies are usually performed in a doctor's office or medical clinic.

There are several methods by which a surgeon might complete a vasectomy procedure, all of which occlude (seal) at least one side of each vas deferens. To help reduce anxiety and increase patient comfort, men who have an aversion to needles might opt for the "no-needle" application of anesthesia while the "no-scalpel" or "open-ended" techniques help to speed-up recovery times and increase the chance of healthy recovery. Due to the simplicity of the surgery, a vasectomy usually takes less than 30 minutes to complete. After a short recovery at the doctor's office (usually less than an hour), the patient is sent home to rest. Because the procedure is minimally invasive, many vasectomy patients find that they can resume their typical lifestyle routines within a week, and do so with minimal discomfort.

Because the procedure is considered a permanent method of birth control (not easily reversed), men are usually counseled/advised to consider how the long-term outcome of a vasectomy might affect them both emotionally and physically.

Vasectomy Surgery Information

The traditional incision approach of vasectomy involves numbing of the scrotum with local anesthetic after which a scalpel is used to make two small incisions on each side of the scrotum at a location that allows the surgeon to bring each vas deferens to the surface for excision. The vasa deferentia are cut (sometimes a piece removed), separated and then at least one side is sealed by ligating (suturing), cauterizing (electrocauterization), or clamping. Currently, there are several variations to this method that improve healing, effectiveness and help mitigate long-term pain such as Post-vasectomy pain syndrome (PVPS)

No-Scalpel vasectomy, also known as a "key-hole" vasectomy, in which a sharp hemostat (as opposed to a scalpel), is used to puncture the scrotum (scrotal sac). This method has come in to widespread use as the resulting smaller "incision" or puncture wound typically limits bleeding and hematomas. Also the smaller wound 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. Studies suggest that this method may reduce long-term complications such as Post-vasectomy pain syndrome.

"No-Needle" anesthesia. Fear of needles for injection of local anesthesia is well known. In 2005, a method of local anesthesia was introduced for vasectomy which allows the surgeon to apply it painlessly with a special jet-injection tool, as opposed to traditional needle application. The numbing agent is forced/pushed onto and deep enough into the scrotal tissue to allow for a virtually pain-free surgery. Initial surveys[5] show a very high satisfaction rate amongst vasectomy patients. Once the effects of no-needle anesthesia take effect, all other aspects of the vasectomy surgery remain the same.

"Fascial Interposition". 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 while leaving the testicular end within the confines of the fascia. The Fascia is a fibrous protective sheath that surrounds the vas deferens. This method, when combined with intraluminal cautery (one or both sides of the vas deferens), has been shown to increase the success rate of vasectomy procedures.

"Vas Irrigation" Injections of sterile water or euflavine (which kills sperm) in to the distal portion of the vas at the time of surgery brings about a near-immediate sterile (azoospermatic) condition. The use of euflavine did however, decrease time (or, number of ejaculations) to azoospermia vs. the water irrigation by itself. This additional step in the vasectomy procedure (and similarly, fascial interposition), has shown positive results but is not as prominent in use, given the fact that few surgeons offer it as part of their vasectomy procedure.

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

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 and/or motility 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[citation needed].

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, whereas other studies find higher rates of diminished sexual desire, for example nearly 20%.

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.

In some cases, vasitis nodosa, a benign proliferation of the ductular epithelium, can also result. 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.

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. 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. 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%). 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. In January 2008 the FDA cleared a home test called SpermCheck Vasectomy 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 complications are chronic pain conditions or syndromes that can affect 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

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