Vasectomy: What's worth knowing?

64 000 per yr in UK

Irreversible
Consider alternatives

Complications

EARLY
-Bleeding 3.6% (Philp)
-Bruising
-Wound D/C 1% (Philp)
-Wound infection 4%(Randall)
-Haematoma 1%
-Failure 0.36 (Philp) - 0.6% (early recanalisation, duplication, wrong structure)

LATE

-Chronic scrotal pain 13-16%
16% 1 yr, 13% 10 yrs
severe in 5%
(Stepping Hill: 460 pts in each group)
NB. Some evidence less if testicular end left open: (6% vs 2%, Moss, 1992, Contraception)

-Sperm granuloma 15-40%

-Non motile sperm (2-30%) 'special clearance' after 7mths/25 ejaculates <10000 NMS/ml
2% in Philp series from Oxford. 150 pts given special clearance, but only 51 followed up. 50/51 azoospermic, but no pregnancies attributable to vasectomy failure

-Failure 1/2500 Philp (recanalisation)

-CaP, testicular ca, IHD...no evidence in large trials

Need 2 clear SA before using as sole form of contraception at 12 &14 weeks OR 1 at 16 weeks
45% do not submit any samples (Chwala Urology 2004)
20 ejaculations probably needed (this is recommended in third world)
93% azoospermic by 20 weeks


SA Technique
Masturbation into a non-toxic container after 48hr abstinence; maintained at body temperature
Examine within 4hr
Assess within 1hr for persistent non-motile sperms
Germ cells, epithelial cells & leucocytes often seen in semen up to 16 weeks after vasectomy
Store between 20 & 40 °C and await liquefaction (within 4 hours)
Count 10 µl in a 20 µm chamber to allow sperm movement
Phase-contrast microscopy
If no sperms seen, centrifuge @ 3000g for 15 min and re-suspend in 100 µl autologous seminal plasma


Sivardeen, Annals RCS Eng 2001
75% of UK urologists send vas for histology.
95% request at least 2 semen samples.

Philp BJU 1984, from Oxford
16000 pts
1970-1983
Most diathermy, no fascial interposition
Vas not routinely sent
Semen analysis 4 and 41/2 months
Special clearance given if 2 consecutive semen analyses of under 10000 semen/ml, non motile, and >7 months post vasectomy. 2.2% in series
800 men sent questionnaire: 67% response rate
7.7% sought post op advice for pain
3.6% for bleeding
1% scrotal haematoma
Early failure 0.43%
12/69: vas not tied
57/69: early recanalisations (0.36%), 0.51% following ligation, and 0.28% after diathermy
6 late recanalisations (1 in 2000)
Failures lower in more experienced surgeons

Davies, Cranston et al, BJUI 1990, Oxford

6000pts
1980-85
2.5% men given special clearance (151)
Criteria as above
Follow up semen analysis after 3 yrs in 50
49/50 azoospermic, no attributable pregnancies

Vasectomy Reversal
1-3 per 1000 vasectomised men will request reversal (Swingl and Guess)
Testic biopsies show normal spermatogenesis up to 10yrs post vasectomy

NB Rx post vasectomy epididymal pain
Good prognostic indicators
· <8yrs since vasectomy
· Partner <40yo
· Fluid from epididymal end at time of reversal
Vasovasostomy/epididymovasostomy
2 layers
Use magnification - microscope a little better
Alternatives - ICSI, DI, Adoption