Vasectomy - No Scalpel Vasectomy Procedure

Vasectomy is a male sterilization procedure. It is a minor surgical procedure performed under local anesthesia in a doctor's office. The procedure takes approximately 10-20 minutes to perform. The goal of the procedure is to render the ejaculate free of sperm. This prevents the sperm from entering the semen (ejaculate) so that the female egg cannot be fertilized after intercourse. Remarkably, sperm continue to be produced within the testis but disintegrate and are reabsorbed by the body. In clinical use for over 100 years, a vasectomy can be performed by making small surgical incisions or through the No Scalpel technique that uses no incisions. Dr Turek much prefers the latter and offers it whenever possible to his patients.

There are 2 muscular tubes (the vas deferens), one from each testicle, that travel from the testicles in the scrotum up into the abdomen and end behind the prostate. During ejaculation, live sperm is conducted through these tubes to fill the ejaculate with sperm. The goal of vasectomy is to interrupt this flow of sperm. The procedure is performed in the scrotum. Before the procedure starts, men are offered (and encouraged to take) a sedative pill to help them relax. This is especially helpful if this is the first procedure that they have ever had.

With the patient lying down, the scrotum is cleaned with soap and water. Dr. Turek will then begin the procedure by gently finding the vas deferens on one side and bringing it to a position immediately under the scrotal skin (figure).

Then, a small amount of local anesthesia is placed into the scrotal skin (by fine needle or needleless injector) above and around the vas deferens (figure). A remarkably small amount of anesthesia is needed if it is placed precisely.

A small puncture is then made in the numbed area of scrotal skin directly over the vas deferens. The bare vas deferens is then secured and delivered cleanly away from its cover of nerves and blood vessels and into view with the help of 2 special instruments developed for the technique (figure).

The bare vas deferens is then treated in a variety of ways. Dr. Turek uses 3 methods to insure complete occlusion: he cuts the vas deferens in half, treats the hole in the tube on each with cautery to scar it, and places small titanium clips (or a permanent suture) across each face of the opened vas deferens (figure). The vas deferens is then placed back into the scrotum in its normal anatomic position within its cover ("in-line" vasectomy). He prefers not to leave the testicular end open ("open-ended" vasectomy), nor does he remove a long segment of vas deferens, or send a segment for review by a pathologist.

A similar procedure is performed on the opposite vas deferens through the same puncture hole to complete the vasectomy. A single absorbable suture may or may not be placed across the puncture site to close it. A scrotal support is applied and the patient can then leave the office. The local anesthesia will keep the area numb from 2-4 hours after the procedure.

How is Dr. Turek's procedure different from, or better than, any another doctor's?

Dr. Turek has an international reputation as a fellowship-trained microsurgeon and performs vasectomies on a regular basis. He has performed 1000 No Scalpel vasectomies since the technique was introduced in the U.S in the early 1990's, has published his experience with the technique and his modifications to it and has trained over 50 urology residents, fellows, practicing urologists and family physicians in the No Scalpel approach. In addition, many vasectomy patients he sees have failed the procedure elsewhere or are referred because of complications from vasectomies performed elsewhere. Because of this experience, his complication rates are extremely low. An example of how Dr. Turek's procedure benefits from his experience concerns the issue discussed below of pain after vasectomy.

One example of Dr. Turek's level of detail regarding the care of his vasectomy patients involves the issue of scrotal pain. Dr. Turek realizes that what men worry most about when considering a vasectomy is pain - both during and after the procedure. The literature suggests that approximately 20% of men will have "chronic pain" (pain 3 months or more after the procedure) following vasectomy. This surprised Dr. Turek and led him to undertake an extensive survey of hundreds of his patients to examine the issue of chronic pain in his practice. Overall, 7% of respondents said they had pain, much lower than the well-recognized and commonly published rate. In addition, no man in the survey was self-medicating for pain. But the survey investigated the pain even further. From this, Dr. Turek learned that the pain his patients were having was not only found in the scrotum, but was also occurring elsewhere in the body. To further examine this issue, Dr. Turek also surveyed healthy medical students who had not had a vasectomy and found almost identical findings: 5% had chronic pain, sometimes in the scrotum, but often elsewhere - and without a vasectomy! The lesson learned from this research was that: 1) normal, healthy men occasionally have scrotal and other kinds of pain, making the scrotum a "hot spot" for men, 2) the prevalence of this pain in Dr. Turek's vasectomy patients is no different from that found in healthy men without vasectomies, and 3) the men at highest risk for having pain after vasectomy are men with pain in the scrotum or even elsewhere before the vasectomy. Overall, this has been reassuring information for Dr. Turek's patients to know.

Besides pain, what are the other risks, complications and benefits of a vasectomy?

One must remember that there is no form of fertility control, except abstinence, which is completely free of potential complications. In all, vasectomy remains one of the safest and best forms of permanent contraception, provided that the patient is aware of and understands the potential risks associated with the procedure. The side effects and complications of vasectomy are divided into "early" and "late" categories, depending on when they occur. After discussing the risks of the procedure, below, we'll examine the benefits in greater detail.

Shortly after the procedure there may be mild discomfort, and most men are able to return to work in 1-2 days. Dr. Turek's patients take an average of 3 pain pills after the procedure. The issue of pain after this point is discussed above. A small amount of oozing (light bleeding, enough to stain the dressing) and swelling in the area of the incision are not unusual. This should subside within 72 hours. Occasionally, the skin of the scrotum and base of the penis turn black and blue. This is not painful, lasts only a few days, and goes away without treatment. For a period of 7 days following the vasectomy, sex should be avoided. Strenuous exercise (for example climbing, riding motorcycles or bicycles, playing tennis or racquetball) should also be avoided for 4 days, and nothing heavier than 8-10 pounds should be lifted during this time. The reason for these restrictions is that these activities are sometimes associated with complications.

Rarely (less than 1%), a small blood vessel may bleed into the scrotum and continue to bleed and form a clot of blood (hematoma). A small clot will be reabsorbed by the body with time, but a large one usually requires drainage through a surgical procedure. Hospitalization and a general anesthetic may be required to drain the blood clot.

Importantly, the vasectomy procedure is not always 100% effective in preventing pregnancy because, on rare occasions, the cut ends of the vas may rejoin. This occurs very infrequently; the published rate is about 1 in every 600 vasectomies. Dr. Turek's vasectomy failure rate, defined as either persistent motile sperm in the ejaculate or a pregnancy after the procedure, is less than 1/750 cases. He has never seen a pregnancy occur after one of his vasectomies.

Since sperm can survive for several months in the vas deferens above the point where they were interrupted, it is very important that another form of contraceptive is used until sterility is assured. To determine whether the ejaculate is devoid of sperm, an ejaculate must be brought in for formal microscopic examination after the procedure. Since "clearing the tubes" through ejaculation is a relatively inefficient process, it make take 20- 25 ejaculations to empty the system entirely of sperm. In terms of time after the procedure, roughly 90% of men will have no sperm in the ejaculate 3 months later. This is the reason we ask men to provide us with a semen sample 3 months after the vasectomy. Occasionally, it may take 6 months or longer after the procedure to flush out all the sperm. The semen specimen must demonstrate no sperm before unprotected intercourse is advised by Dr. Turek.

There are three main concerns regarding the long-term consequences or general health hazards of vasectomy. These concerns have arisen mainly from isolated studies over the past 50 years. Remember that it is important to show that several things be true when trying to link two medical conditions: a) that the link makes physiological sense and that this is shown in either animal models or in humans, and b) there should be excellent evidence of this link in populations of humans.

In 1979 a study was published that suggested that atherosclerosis or coronary artery disease might occur prematurely after vasectomy in monkeys. In this small study, monkeys fed high cholesterol diets were found to have what appeared to be increased amounts of atherosclerosis following vasectomy. Subsequent animal studies did not agree with these initial findings, and large epidemiological studies, including an extensive study of U.S physicians followed for 259,000 person-years have concluded that neither early atherosclerosis nor heart attacks or strokes occur more frequently in men who have had vasectomies compared to men who have not.

It is true is that after vasectomy, approximately 60-70% of men develop a form of allergy to their sperm in the form of antisperm antibodies. The body, either during the vasectomy or after, is exposed to sperm proteins that it commonly does not see and antibodies against these proteins can be observed in some patients. However, it has not been shown conclusively that the presence of these antibodies has any significant effect on other organs.

There has been much discussion over the past 15 years about whether vasectomy is associated with the development of prostate cancer later in life. The Journal of the American Medical Association published 2 reports suggesting that men who have had a vasectomy may be at risk for developing prostate cancer. Both studies were coauthored by Dr. Edward Giovannucci. One study evaluated men married to female nurses: men with vasectomies were compared to men without. The second study evaluated men in the health professions (veterinarians, pharmacists etc) who had had a vasectomy, and, again compared them with other male health professionals who had not had vasectomies. In both studies, there appeared to be an increased risk of developing prostate cancer in men who had a vasectomy more than 20-22 years before. On the contrary, several other studies, including several in the U.S showed no statistically significant increase in the risk of prostate cancer following vasectomy. Indeed, it was suggested in the same JAMA issues that a true cause-and-effect relationship could occur by chance alone, or because of biases (selectivity) or other unaccounted variables in these two studies.

Concerns raised from these studies include the fact that the men in the study might not represent the larger population of all men who get vasectomies. This means that the study cannot be used with certainty to predict a similar occurrence in the general population. It is also possible that the men who had had vasectomies in these studies would be more likely to see a urologist rather than an internist or family practice physician for later evaluation of a urologic problem than the men who had not had vasectomies. Urologists are better at finding prostate abnormalities than other kinds of physicians and therefore cancer might have been detected earlier than it would have otherwise. This is called "detection bias." It has also been suggested this study design makes it impossible to identify all of the factors that might contribute to this end result with two events (vasectomy and cancer) occurring several decades apart. A prospective study is really necessary here to answer the question. A prospective study evaluates groups of patients at the time they have the vasectomy and follows them regularly for years to see, if indeed, cancers do occur. This is the most powerful way to study this relationship, but was not used in the Giovannucci papers. In addition, no study has ever established that there is an increased risk of death after prostate cancer following vasectomy.

Because the question of a relationship between vasectomy and prostate cancer was raised, the American Urological Association first recommended that men who had a vasectomy more than 20 years ago or who were > 40 years of age at the time of vasectomy have an annual examination of their prostates as well as a blood test for prostate cancer (serum Prostate Specific Antigen or PSA). However, given the recent lack of support for this relationship between vasectomy and prostate cancer, this recommendation has been revoked. Finally, no mechanism is known, nor is there any animal model proof of the plausibility of the link between these conditions.

There is a recent, single, small paper that has linked vasectomy to the later development of a rare form of Alzheimer's disease. The issue is that a researcher found that, among a group of patients suffering a form of dementia called primary progressive aphasia (PPA) that is often confused for Alzheimer's disease, the men had a higher percentage of vasectomy than was thought normal. The study found that 40% of 47 men with PPA had had a vasectomy, while among another 57 men from the community without PPA there was a vasectomy rate of 16%. What this means is simply that the rate of vasectomy among PPA patients is a little over 2 fold higher than in otherwise healthy patients. This study did not find an increased rate of vasectomy in patients with Alzheimer's.

The most common form of dementia caused by brain deterioration in individuals over age 65 is Alzheimer's disease. A very unusual form of Alzheimer's disease is called primary progressive aphasia. This condition robs people of their ability to speak and understand language, but they are still able to maintain their hobbies and perform other complicated tasks for a long time. By contrast, Alzheimer's patients lose their memory, interest in hobbies, family life and become idle.

A "mechanism" for the association between PPA and vasectomy was also proposed in the study. It involves the fact that men can have antibodies form to sperm after having a vasectomy (see above risks) and these antibodies may somehow cross-react with the brain and cause PPA. There is no animal model data to support this theory, however.

Problems with this study are similar to that described for prostate cancer risk and vasectomy. How unique were these patients that they gathered from all over the US twice annually to participate in a support group with such rare disease? We really need a prospective study to show this relationship as retrospective studies have too much "bias" or too many uncontrolled issues that could produce the same result. In addition, the study groups were very small: fewer than 20 PPA patients had a vasectomy and fewer than 10 healthy patients had a vasectomy. It is hard to generalize at all from so few patients in a study. Also, the study methods were faulty in that the vasectomy condition should have been confirmed by reviewing the medical charts on the PPA patients, since their disease alters their ability to understand, hear and remember what has happened to them! Indeed, like the issue of prostate cancer and vasectomy, this issue will take at least a decade or two to confirm or disprove.

Vasectomy is a relatively simple, quick and safe method to prevent unwanted pregnancy. The recovery period is short, and patients can return to work and their regular lifestyle fairly quickly. Sexual activity, penile sensitivity and male hormone production are not affected by vasectomy, and there is no appreciable decrease (less than 5%) in how much ejaculate is made. After a vasectomy, the testicles continue to produce sperm, which then disintegrate and, like other dead cells within the body, are reabsorbed. Male hormone levels (also produced by the testicle) remain the same. One strong argument for choosing vasectomy in many couples is the simple fact that once the procedure is done, there is no need to constantly think about contraception, as is true with most other contraceptives. Examples of methods that require constant attention ("user compliance") are: taking a birth control pill daily, using a diaphragm or condom, and timing the sex during non-fertile time of month. In other words, after vasectomy, couples can stop thinking, worrying or reminding themselves about this issue. Some patients find that freedom from the fear of producing an unwanted child improves the mutual enjoyment of sexual relations, sometimes making it more spontaneous and frequent.

There is no currently available contraceptive that has a higher success rate than vasectomy. There is a progesterone-coated intrauterine device (IUD) that has recently become available for women that approaches the 1/600 published failure rate of vasectomy. A list of other potential contraceptive choices is given below. All of these have a higher failure rate than vasectomy. Currently, condoms, rhythm method, withdrawal and abstinence are the only other options for men.

It may very well be that the risks associated with female contraceptive measures, like oral hormone contraceptives or tubal ligation, are at least or more significant than that associated with vasectomy. That said, a vasectomy may not be the best contraceptive choice for couples who want to increase the time between pregnancies, or who have even the slightest reason to believe that they may might want to have children in the future.

Another reason to choose an alternative to vasectomy is if the male partner is anxious or concerned about what a vasectomy will do to his sexual performance. Concern about this issue may lead to stress, and stress is likely to impair a man's ability to have an erection or ejaculate, even though the production of sperm and the male hormone levels are unchanged.

Finally, a vasectomy is not the answer to a problem of failing erectile function. If a man is interested in getting a vasectomy in hopes of improving the female partner's attitude toward sex or to increase his own sexual powers, then disappointment is likely. On the other hand, the freedom from the fear of producing unwanted children might significantly increase the couple's mutual enjoyment of sex.

Male contraceptive pills have been the subject of ongoing research for years, but to date none are commercially available. Approaches to male contraception that seek to manipulate male hormone (testosterone) levels to lower sperm production: 1) do not work consistently among individuals, and among different ethnic groups, 2) have the potential for long term side effects, and 3) demand regular compliance among men who use them.

It has been debated for years whether men are ready to accept the male as the responsible partner for birth control. However, a recent marketing study indicates that the developed world may be ready for this. A study of 9,342 men aged 18-50, from Argentina, Brazil, France, Germany, Indonesia, Mexico, Spain, Sweden, and the United States found that over 55% of men were willing to try a new male contraceptive method. This study also described 3 market clusters of potential male contraceptive users: 1) informed men interested in a safe and easy-to-use contraception, but also concerned about potential risks and side effects; 2) the sex-oriented individual mainly interested in a positive effect on sexual life (enhancement of libido, sexual performance, and satisfaction); and 3) religious men who have a negative attitude toward any male fertility control method. Thus, there may in fact be substantial numbers of men worldwide who would be interested in trying new contraceptives.

How reversible is a vasectomy?
Are there other ways to be fertile after a vasectomy?

Practically speaking, vasectomy should be considered a permanent birth control procedure. Having said this, however, vasectomy can be reversed if absolutely necessary. In addition, the success rates of vasectomy reversal can be extremely high. The best (most convenience and cheapest) method to "preserve" fertility in the setting of vasectomy is to bank ejaculated sperm before the actual vasectomy procedure. Sperm cryopreservation or banking relies on the fact that sperm survive and recover remarkably well after freezing and thawing. Semen samples can be given at intervals of every 2-3 days for banking in Dr. Turek's clinic for this purpose. As a rough guide, fertile men with normal semen quality will need 2-3 semen samples to provide enough sperm for 6 monthly tries to conceive after thawing with the use of low technology procedures such as low technology assisted reproductive procedures such as intrauterine insemination (IUI). To complete this process, patients will need to:

1) Choose whether they want to bank for 1 year or 5 years.

2) Sign a sperm banking consent form and make a payment to open the account.

3) Undergo a blood test (by California law) for 5 sexually transmitted diseases (HIV; HTLV I, II; RPR; Hepatitis B surface antigen; Hepatitis C antibody).

4) Drop off the semen samples for freezing.

Importantly, The Turek Clinic will ask the patient to consider how he wants the banked sperm handled in the rare event that he cannot decide for himself (due to illness or death) on the fate of the frozen samples. Although not suitable for all couples, sperm banking may be appropriate for some couples, including those with children harboring a serious illness. Men considering vasectomy should feel free to further discuss the issue of sperm banking with Dr. Turek or his staff at their consultation visit to have all their questions answered.

A third option for fertility after vasectomy is to have a sperm retrieval procedure performed behind the vasectomy site under local anesthesia with sedation. Since a vasectomy generally does not alter sperm production, usable sperm from the testicle or epididymis can be obtained by several methods, many of which have been pioneered by Dr. Turek. Things to consider with this option are: a) another procedure will need to be performed on the vasectomized man to obtain sperm, b) retrieved sperm is generally "immature" and requires high levels of assisted reproduction for success, which can be costly. Again, this option is not for everyone but has become very popular among men who desire more children after vasectomy, but want to preserve their vasectomy.

What should I think about before and after the procedure,
in terms of planning and recovery?

To have a vasectomy in California, you are required to meet with the doctor to discuss the procedure. After that, a prescribed waiting period of 3 days must pass before you can actually have the procedure done. The following is an outline of what to expect and do before and after the procedure:

This visit is important for you to meet and feel comfortable with Dr. Turek, to figure out whether you are a good candidate for a vasectomy, and to assess if the procedure is right for you. At this visit:

• Dr. Turek will ask you questions about the kinds of contraception you are using and considering and will also ask questions about your medical history.

• Dr. Turek will perform a limited and very brief physical examination to ensure that you are a good candidate for the procedure.

• Dr. Turek will then discuss the No Scalpel vasectomy procedure, its benefits and risks, so that you have a good idea of what it involves, the recovery afterward, when you can resume your normal activities, and when you can discontinue other contraceptives.

• At the end of the visit, Dr. Turek will provide you with an information packet that provides additional detailed information and 2 consent forms for you to review. You can either sign the consents electronically immediately after that visit or take them home, review and sign them, and bring them back to the Clinic the day of the procedure. The procedure will not be performed without your signature on all consent forms.

• The vasectomy procedure is not performed at the time of the consultation visit. If, after meeting with Dr. Turek, you would like to have him do the procedure, you can either schedule your appointment at the front desk before you leave that day or contact us at 415-392-3200 at some future time when you decide to have the procedure.

• If you desire to freeze sperm prior to having a vasectomy, please notify us on the day of the consultation visit or at another time before the vasectomy. We will ask you to sign a sperm banking consent form, and you will need to have blood tests for 5 communicable diseases (by State Law: HIV, HTLV I,II, RPR, Hepatitis B surface antigen, & Hepatitis C antibody) and make a payment before you can begin to freeze sperm.

• We would like you to ask questions at this visit or afterwards to ensure that you are completely comfortable with the vasectomy procedure.

1. You may eat a light breakfast or lunch on the day of the vasectomy.

2. Bring an athletic supporter with you to wear home after the procedure.

3. Do not take aspirin, Advil, Motrin or any medications containing ibuprofen at least 10 days prior to the procedure. These medications have a side effect that can reduce platelet function and therefore lower blood-clotting ability (i.e., they are mild blood thinners).

4. If you plan to take Valium 1 hour before the procedure, make sure you have someone available to drive you to and from the procedure. Driving while under the influence of Valium is dangerous.

5. MAKE SURE THAT YOU HAVE ELECTRONICALLY SIGNED THE CONSENT FORMS OR BRING THEM WITH YOU TO THE CLINIC ON THE DAY OF THE PROCEDURE. If you have taken Valium or if you return the consent forms without signing them first, then the procedure will be cancelled.

1. Remove all dressings from inside the athletic supporter within 24 hours. You may shower the day after the procedure. Continue the scrotal support for 2 days or so, until it becomes uncomfortable.

2. Apply ice packs to the scrotum the night of the surgery and, if possible, the morning after. This can help reduce the swelling. Warm tub baths may be taken after 5 days.

3. Exercise can be restarted in 4 days. Intercourse can be resumed in 7 days.

4. Sperm can remain in your semen for 3-6 months or longer after vasectomy. Therefore, it is very important for you to continue some form of contraception until your semen is analyzed again and no sperm is found in it.

5. At 3 to 3½ months after the procedure, a semen specimen should be brought to our office for analysis. Please abstain from ejaculation for 3-4 days prior to collection of the specimen. The specimen should be collected in our office rooms or brought from home within 2 hours. Please call 415-392-3200 to arrange an appointment for semen collection and analysis.

6. Contact the office at 415-392-3200 (evenings) if any problems develop, day or night.