VASECTOMY METHODS
ORIGINAL RESEARCH INTO VASECTOMY FAILURE
Early Failure is defined as failure to achieve sterility at the post-vasectomy sample at 3 months (including any required confirmatory tests).
On the other hand, Late Failure describes pregnancy anytime after a clear sample
The goal of vasectomy research is to prove that one method of vasectomy is more effective (fewer failures) than another.
An interesting study published in 2005 indicates that cautery without cutting the vas deferens was linked to a failure rate of 15%. These days, everyone knows that a ‘snip’ (cut) of the vas deferens is required – but this wasn’t known at the time. The study was a reasonable attempt to see whether cautery-alone was enough. That a ‘no-snip’ vasectomy did work in as many as 85% of patients is interesting.
Effectiveness (rate of failure) was studied with two vasectomy occlusion techniques: clipping and excision of a small vas segment, or thermal cautery with fascial interposition of an open testicular end. The results showed ‘The risk of vas occlusion failure in men with at least one semen analysis was much greater in the clipping and excision group (8.7%) than in the cautery, interposition and open testicular end group (0.3%). In other words, don’t just cut and remove a segment of vas.
Another randomised trial of 826 men compared looked at rates of failure (‘early recanalization’), comparing ‘ligation and excision with versus without Fascial Interposition (FI).
The proportion of men with presumed early recanalization was 25% with simple excision and tying, and 0% with thermal cautery and FI. Other techniques were reported as 10% (tying, excision and FI) and 9% (electrocautery without FI).
Effectiveness of vasectomy using cautery was published in 2004. This study researched the effectiveness of ‘usual cautery vasectomy technique.’ A total of 365 participants in 4 study centres (US, Canada, UK & Brazil) completed 6 months follow-up.
The occlusion techniques used varied among the sites in terms of ‘type of cautery (thermal or electrocautery), open vs. closed ended, whether or not a portion of the vas was excised, and use of fascial interposition.’
There were 3 failures out of 365 participants.
The investigators concluded conclude that ‘our study was not designed to analyze the efficacy of the various occlusion procedures used at the study sites, but rather to estimate effectiveness of occlusion techniques that include use of cautery.’
However, they state that 2 out of the 3 failures ‘occurred due to apparent recanalization were at the site using electrocautery without fascial interposition or excision of a segment of the vas.’
A high quality trial of 841 men, published in the same year (2004), compared occluding (blocking) the vas with occlusion and fascial interposition. Each tube was occluded with 2 x sutures and 1cm of vas removed. Fascial interposition was additionally performed in the half of men who were randomised to this group. Note that cautery was not included in either group.
Overall, 12.7% of the non-fascial interposition group failed, compared with 5.9% in the fascial interposition group.
A 3rd paper by the same investigators was published in the same year and brought the above two studies together:
Cautery of the Tubes (Intraluminal Cautery) – without or without fascial interposition (the data was drawn from the first study above).
Cut & remove the tubes (no cautery) – with or without fascial interposition. Each vas was occluded with 2 x sutures and 1cm of vas removed (data from the second study above).
They concluded that ‘we found significantly fewer early failures in the cautery study than in the fascial interposition group from the randomized controlled trial: 1.0% versus 4.9%,’ with nearly a five-fold higher risk of early failure in the fascial interposition study than in the cautery study.
Note that the fascial interposition study did not include cautery. Many leading vasectomists perform fascial interposition with cautery – arguably the best of both worlds.
A huge UK audit of 105,393 vasectomy procedures was published in 2024. The method most commonly used in The UK is intraluminal electrocautery without fascial interposition.
Data was collected by 99 different UK clinics over a 15 year period, between 2007 and 2022. Of the total 105,393 procedures, the early (or initial – based on the initial test) failure rates was 0.93%, or 1 in 107 vasectomy results received.
COMMENT
Randomised trials are the gold standard of medical research. However, an overall conclusion from trials of vasectomy methods is challenging for these reasons:
- Randomised trials are very time-consuming to perform – there are limited number of trials.
- Limited number of participants in each trial – patients usually in their hundreds, not thousands.
- A tiny number of vasectomists (between 1 and 5) participate in each trial. The trials compare methods performed by a very small number of doctors.
- The description of methods used in the trials are loosely described, not least because multiple doctors are required to provide enough patients.
Randomised trials are interesting but do not completely settle the answer as to which vasectomy method has the lowest rate of failure.
The ‘next best’ level of evidence is audit, providing ‘real world evidence.’
Consider that each vasectomy surgeon performs one specific method for each vasectomy. Furthermore, each doctor will audit their results, and therefore know their rate of failure.
Is something missing in the data?
VASECTOMY FAILURE: GUIDELINES & COCHRANE
Guidelines bring together opinion from a panel of doctors, and give the following rates of failure:
- The British Urological Association patient information suggests a rate of failure of 1 in 250 vasectomies.
- FSRH (UK) Vasectomy serviced standards 2024 do not include a rate of failure.
- The American Urological Association guideline (2015) states ‘Repeat vasectomy is necessary in ≤1% of vasectomies, provided that a technique for vas occlusion known to have a low occlusive failure rate has been used.’
- The European Association of Urology Vasectomy guideline (2012) states that ‘Counselling of patients before vasectomy should include alternative methods of contraception, complication and failure rates.’
- The Canadian best practice report, updated 2022, states ‘The early failure rate of vasectomy is in the range of 0.2–5%.’
Guidelines reflect a lack of clear evidence from studies, and are therefore unclear as to the ‘best’ method of occluding the vas deferens – other than cautery, fascial interposition, or a combination of these two.
The highly regarded Cochrane group ‘research the research,’ and aimed to ‘compare the effectiveness, safety, acceptability and costs of vasectomy techniques for male sterilization.‘ Let’s translate the question as simply ‘which is the best way to perform vasectomy?’
They conclude that ‘Fascial interposition reduced vasectomy failure.’
COMMENTS
Major guidelines have not been updated for many years.
However, leading vasectomists in The US, Canada and Australia practice Fascial Interposition (FI) in the belief that failure rates kept to the minimum.
Is Open-Ended Vasectomy Truly Open?
Does the tube remain open after an Open-Ended Vasectomy?
Open-Ended Vasectomy is considered by many vasectomy experts to be superior to closed vasectomy. Open-Ended Vasectomy involves cutting the tube & leaving the lower end alone (no cautery or closure to the lower end). The open tube allows for drainage of sperm away from the testicle which is thought to reduce the risk of back-pressure that might cause swelling or pain.
But does the tube actually stay open after an Open-Ended Vasectomy?
You can’t randomly biopsy men a few weeks after their vasectomy. Rats, however, have a very similar Tube (Vas Deferens) to humans.
A study was performed in rats that underwent either an open or a closed vasectomy. The tubes were examined microscopically some weeks later.
Surprisingly, 2 out of 5 rats that had an Open-Ended Vasectomy revealed obstruction of the tube by a ‘fibromuscular cap.’
The study concluded that ‘by 8 weeks after surgery both vasectomy procedures are equally effective in preventing further damage in the epididymis caused by elevated intraluminal pressures.’
COMMENT
Open-Ended Vasectomy is considered to reduce back-pressure caused by sudden blockage of the tube that drains the testicle of sperm. In all likelihood, the tubes will close over several weeks.
Closed Vasectomy will immediately close the tube draining the testicle, whereas any closure after Open-Ended Vasectomy is expected to be gradual.
SAFETY & SIDE EFFECTS
INFECTION
The UK audit of 105,393 vasectomy procedures over 15 years, published in 2024, collected outcomes via patient questionnaires that were completed immediately after the procedure (focussed on patient experience), and 4 months later (for complications).
The criteria for infection was defined as any case where an antibiotic has been prescribed. Antibiotic prescribing data was obtained by the 4 month post-vasectomy patient questionnaire.
Rates of infection were 1.22%
COMMENT
Diagnosis of infection may be considered as possible, probable, and definite.
Infection rates rely on the decision to prescribe an antibiotic. This decision relies on the judgment by a doctor that an infection has developed. However, the symptoms and signs of a normal post-vasectomy recovery do overlap with those of a possible, and even probable, infection. Furthermore, a doctor may be concerned that the symptoms might reflect an infection that will progress – and prescribe antibiotics as a precaution. One may therefore argue that actual postoperative infection is significantly less common than the rate of antibiotic prescribing.
HAEMATOMA
A haematoma is a pool of blood that is caused by a broken blood vessel. Blood that pools enough to be the size of a golfball (>4cm) is considered to be a significant haematoma, whilst that of a cricket ball (>7.5cm) a large haematoma.
The same UK audit also measured rate of haematoma via the same four month post-vasectomy patient questionnaire. Clinical diagnosis was more common than ultrasound diagnosis.
Haematoma rate was 1.56%, of which 13% were larger than a cricket ball (>7.5cm).
A US reviews of vasectomies concluded in 1987 that ‘Physicians who performed between one and ten vasectomies in 1982 had higher rates of hematoma and hospitalization for treatment of a complication than physicians who performed more vasectomies.’
COMMENT
A large haematoma is an unpleasant complication that can take months to resolve. The UK audit shows a large haematoma to develop in 1 in 493 vasectomies.
The rate of Haematoma after vasectomy may be considered to be loosely associated with technical aspects of the procedure, with a rate of <1% is considered acceptable.
POST VASECTOMY PAIN
Pain is normal for a few days after vasectomy.
A 2020 paper entitle ‘Incidence of Post-Vasectomy Pain: Systematic Review and Meta-Analysis’ aimed to establish the rate of post-vasectomy pain occurring 2 weeks after the procedure. This ‘study of studies’ identified 18 separate studies for analysis.
‘The overall incidence of post-vasectomy pain across all studies was 15% with a higher incidence of 24% for traditional scalpel vasectomy compared to 7% for NSV.’
In other words, the study found that 7% of men reported pain at the 2-week mark after a no-scalpel vasectomy.
Post-Vasectomy Pain Syndrome (PVPS) is defined as pain occurring for at least 3 months after a vasectomy. The definition of PVPS requires that the pain is at a high enough level to interfere with quality of life, and that non-vasectomy causes for discomfort or pain have been excluded.
The same UK audit that measured the rates of haematoma and infection also assessed the rate of post-vasectomy pain syndrome. The rate was 1 in 715 patients.
Another much smaller (625 men) UK study from 2007 reported ‘at 7 months after vasectomy about 15% of previous asymptomatic men have some degree of scrotal discomfort.’
COMMENT
Around 7% of men were reported to discomfort 2 weeks after a no-scalpel vasectomy.
Pain after 3 months is much less clear, but the largest audit ever published found a rate of just 1 in 715 after 4 months.
LONG TERM SAFETY OF VASECTOMY
Long-term safety, health and mental status in men with vasectomy was published in October 2018.
No-Scalpel vasectomy was pioneered in China where this study was performed. 485 men with the vasectomy were recruited into the study along with 1940 men who did not undergo vasectomy. The 2 groups were compared for men’s health symptoms, hormone levels, and psychological symptoms.
Of note:
- Vasectomy had no long-term effect on the level of sex hormones, namely testosterone & free testosterone.
- Vasectomy did not increase The PSA (Prostate cancer screening blood test).
COMMENTS
The authors of the study state that ‘results showed that middle-aged and older people are mainly infuenced at the psychological level rather than the physiological level afer vasectomy.’
The study confirms what we already know – that there are no hormonal or biochemical effects following Vasectomy.
VASECTOMY & PROSTATE CANCER
This vasectomy research review blog concentrates on studies published recently. Numerous older studies attest to the safety of vasectomy and prostate cancer. Remember that recent studies does not necessarily equate to better studies.
2021 metaanalysis:
A 2021 analysis by Chinese researchers in the journal ‘prostate cancer and prostatic diseases’ concluded that ‘vasectomy was associated with the risk of any, localized, low-grade and intermediate-grade prostate cancer. Meanwhile, vasectomy was not associated with prostate cancer-specific mortality.’
The study was not an original study, but rather a ‘study of studies’ called a meta analysis. 58 out of 103 studies were deemed suitable for inclusion. The analysis reported that prostate cancer was increased by 18% in those who have had a vasectomy, but that the risk of dying from prostate cancer was not increased.
COMMENTS
The statistical tools used in this analysis are complex: the Higgins I statistic, Mantel-Haenszel method, DerSimonian and Laird methods, with use of Egers’s test and followed by the Seta SE meta-analysis, tools which were used to identify 56% of studies as suitable for the actual analysis. You need to be a statistician to make sense of all this.
The original studies were population studies are designed to look for association – in other words, condition A is more common with risk factor B.
A reasonable hypothesis is that men who have had a vasectomy are more likely to go to a doctor for a men’s health check than men who have not had a vasectomy. Prostate cancer is very commonly diagnosed following a blood test performed as part of a general health check. Recent studies have tended to show an association with prostate cancer whilst older studies have not.
Most of the studies analysed in this study were published prior to the last revision of The AUA vasectomy guidelines that indicated that vasectomy is not a cause of prostate cancer.
An individual study that did suggest a link is now discussed, but many studies in the past have found no link.
A 2020 Danish population study:
Vasectomy and prostate cancer risk: a 38-year nationwide cohort study.
A Danish study looked at a group of Danish men ‘from The National Health Insurance Service Registry.’ The database of over 2 million men included 26,238 cases of Prostate cancer.
- Men who had a Vasectomy ‘had an increased risk of prostate cancer compared with non-vasectomized men.’
- Men who had a Vasectomy had a ‘diminished relative risk of all other cancers.’
COMMENTS
All studies that are ‘observational’ need to be treated with caution. The researchers did take account of ‘potential known confounding factors’ but it’s almost impossible to truly take account of all confounding factors.
Numerous other studies have found no increased risk of Prostate cancer following a vasectomy.
The American Urology Association vasectomy guideline is made up of a panel of over 50 experts. The guideline is updated every few years, and the most recent 2015 guideline does not find that vasectomy and prostate cancer are associated.
FAINTING AFTER BLOOD DONATION
How common is fainting during or shortly after vasectomy?
There is no published data on the incidence of fainting during or after Vasectomy. However, there is research that looked at fainting after blood donation.
Overall, 1.23% of people donating blood had a faint. Women were 2.9 times more likely to faint than men during their donation.
COMMENT
Loss of consciousness during vasectomy performed in our clinic is very rare. Surprisingly, 1 in 70 individuals donating blood are reported to faint.
MORTALITY AFTER VASECTOMY
There has been one recorded death caused by Vasectomy.
A 32 year old male without any significant medical history had an uneventful vasectomy performed in The Netherlands. He presented 2 days after the vasectomy with a fever and was admitted to hospital. Blood tests showed a high white cell count. Surgery was performed to remove blood and infective tissue from the scrotum. He died of an overwhelming infection 5 days after the vasectomy.
COMMENTS
Hundreds of millions of vasectomies and one recorded death confirms that vasectomy is an exceptionally safe surgical procedure. The man sadly died of Fournier’s gangrene which is a very rare complication of Vasectomy.
Fourier’s gangrene is a very rare serious infection of the scrotum that may be triggered by any surgical procedure of the scrotum – including vasectomy. The most common risk factors are poorly controlled Diabetes, and Immunosupression. The condition is extremely uncommon.
OTHER
MEN’S ATTITUDES TO VASECTOMY
397 men age 25-70 living in The Southern USA were recruited via facebook advertisement to complete an online survey in a study published in 2020.
The authors concluded that ‘Participants who had not had a vasectomy had less positive attitudes about the procedure across all six attitude subscales compared to participants with vasectomies.’
The authors discuss possible reasons why men who have had a vasectomy are more positive about vasectomy than men who have not had a vasectomy:
- ‘Men might believe that vasectomy causes them to lose their libido; however, research has identified that vasectomy can have positive effects on sexual satisfact.
- ‘Attitudes about the procedure and recovery may be driven by beliefs that vasectomy is invasive, painful, or debilitating. Yet, the majority of vasectomies are minimally invasive outpatient procedures requiring only local anesthesia that take approximately 15 min.’
- ‘Research has demonstrated that men who had a vasectomy found it significantly less painful than they anticipated.’
COMMENTS
Humans are all prone to ‘confirmation bias’ – we tend to justify our beliefs and preconceptions.
The study was a simple ‘one point in time’ (cross sectional) study and not designed to determine association .v. causation. Association simply implies that men who have a positive attitude about vasectomy are more likely to have one. On the other hand, causation would imply that men who have a vasectomy are more positive because of the experience. Either way, guys who have had a vasectomy are usually positive about it, and men who have not had a vasectomy are less positive about it!
NO NEEDLE VASECTOMY
Introduction to The Madajet
The Madajet is used in North America and Canada for No Needle Vasectomy. The device is not approved by The TGA for use in Australia.
The No Needle device is a specialised instrument that sprays rather than injects local anaesthetic through the skin.
The instrument has a specific fitting that is designed to be used only for No-Scalpel Vasectomy. The fitting is a curved shape that is designed to gently sit on top of the tube before releasing the anaesthetic.
The high tech mechanical device works by spraying local anaesthetic through the skin to the underlying tube. The objective is to numb both the skin and the underlying tube. This is performed with meticulous attention to detail.
Guys report the following with the no needle anaesthesia device:
- ‘That’s different’ (laugh)
- ‘like a a flick’
- like an elastic band snap
The jury is really out as to whether the experience of a no needle anaesthesia is superior to that of invisible needle anaesthesia.
What does the research say?
Their conclusion is that ‘for local anesthesia in patients undergoing surgical sperm retrieval, MadaJet produces less pain and discomfort with quicker time to onset and offset of anesthesia compared with conventional needle injection.’
OFFSPRING SEX RATIO AND VASECTOMY!
The study looked at a large health database from the USA.
30,927 men underwent Vasectomy. They reported that ‘For men with at least 2 children, each additional son increased the likelihood of vasectomy by 4%, whereas each additional daughter led to a 2% decrease in vasectomy utilization.’
In other words, fathers undergoing vasectomy have a higher proportion of sons compared with fathers who have not had a vasectomy.
COMMENT
A quirky & somewhat controversial study! Men with sons are more likely to say ‘enough is enough’ – and to get a Vasectomy – than men with daughters!
ROUTINE USE OF STRONG PAINKILLERS AFTER VASECTOMY
Routine use of opioids after vasectomy was published in The Journal of Urology in 2019.
This paper attempted to answer the question as to whether strong painkillers need to be described regularly after vasectomy. Vasectomists have in the past prescribed strong painkillers routinely after vasectomy – for example panadeine forte, Endone or tramadol.
102 patients received a prescription for strong painkillers for use after their vasectomy and 126 received no prescription. The results were:
- There was no difference between the two groups in the experience of scrotal pain following the vasectomy
- Men who received a prescription for strong painkillers were more likely to get addicted to them afterwards.
A further American study published in 2020 concludes that ‘Patients that are not prescribed opioids after vasectomy do not generate additional phone calls, clinic or
ED visits compared to those that were routinely prescribed prior to our institutional change. We have permanently discontinued the routine use of opioids for post-vasectomy analgesia. Other physicians performing vasectomy should consider making this change as well.’
COMMENTS
Prescriptions for strong painkillers are simply not required after vasectomy. There is an epidemic of people who are addicted to prescribed opiates in The US where these studies were performed. There is no place for routine prescribing of strong painkillers after a vasectomy because single script has the potential to convert a ‘patient’ into a long term addict.
USE OF CONTRACEPTION BEFORE THE ‘ALL CLEAR’
Vasectomy should not be considered a reliable form of contraception until the post-vasectomy sample confirms that the vasectomy has worked.
Use of secondary contraception following vasectomy: insights from the Pregnancy Risk Assessment Monitoring System, was an American study that investigated the use of contraception in the period between the Vasectomy and the post-vasectomy test.
1004 couples were investigated who:
- Had recently had a baby, and
- The male partner had a vasectomy after the baby was born
An astonishing 57.8% of couples reported NOT using additional contraception after the vasectomy (before the post vasectomy sample). The 43% of couples who DID use additional contraception mainly used condoms (50%).
COMMENTS
This study looked at couples who had a vasectomy after having a baby. Mothers who breastfeed and have no periods are unlikely to conceive. The couples may not have used contraception because they believed that breast feeding is a good form of contraception. Nevertheless, there is concern that over half of couples in this study did not use contraception in between the vasectomy and the post vasectomy test.
Vasectomy providers emphasise that Vasectomy is only reliable after the confirmatory post vasectomy test.
CONTRACEPTION USE IN COUPLES BEFORE UNINTENDED PREGNANCY
The goal of contraception is to effectively prevent pregnancy. However, all forms of contraception can fail, particularly condoms and the pill. Vasectomy is least likely to fail.
Which type of contraception, if any, is used before an unintended pregnancy?
326 Australian women were interviewed about unexpected pregnancy in a 2018 study.
Just 41% were using contraception at the time of the pregnancy, and of these:
- 64% were using the contraceptive pill
- 27% of couples were using condoms
- 9% were using ‘the rod’ (hormonal device that is inserted in the upper arm)
POSTAL .V. FRESH POST VASECTOMY SAMPLE
The 12-14 week Post vasectomy testing requires a ‘fresh sample’ in most countries, but also available as a postal sample in The USA and The UK. The fresh sample requires taking the sample to the local laboratory for analysis of sperm concentration and motility (movement) within 2 hrs, whereas the postal sample simply requires dropping the sample into your local post box to test for zero sperm a few days later.
How does the postal sample perform against the gold standard fresh semen analysis?
This study analysed data from 58,800 vasectomies performed in The UK over 11 years. The postal method was used in 59% of vasectomies, and the fresh sample in 44% of vasectomies.
They found that ‘Compliance with postal (79.5%) was significantly greater than with non-postal strategy (59.1%), the difference being 20.4%.’
There was no significant difference in the rate of failure between postal and fresh samples.
COMMENTS
This research informs us that 20% more men offered the postal test, compared with men required to do a fresh sample, will do a post vasectomy test. The postal test is more than convenient – it can make the difference between doing the test and not doing the test.
It’s worth noting, however, that postal samples are more likely to require a further test than an initial fresh sample, and that a further test would require a fresh sample – somewhat offsetting the convenience of an initial postal sample. The reason is that the postal sample needs to be entirely clear of sperm, whereas a few non-motile sperm in the fresh sample allows for clearance from the one sample.
Perhaps the most interesting observation is the relatively high failure rate in this UK study where closed vasectomy is standard. Whilst the failure rates of 0.94% and 0.73% did not differ significantly between the two groups, these failure rates are high compared with < 0.3% failure rate of open-ended vasectomy. Many vasectomists practicing open-ended vasectomy will achieve a failure rate of < 0.2% (1 in 500).