VASECTOMY OCCLUSION: WHICH IS THE BEST TECHNIQUE?
The highly esteemed Cochrane group 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?’
The Cochrane group ‘research the research’ and conclude ‘For vas occlusion with clips or vasectomy with vas irrigation, no conclusions can be made as those studies were of low quality and underpowered. Fascial interposition reduced vasectomy failure.’
Many leading vasectomists in The US, Canada and Australia practice Fascial Interposition (FI). The research tenatively points to a lower failure rate of vasectomy after FI.
Is Open Vasectomy Truly Open?
Does the tube remain open after an open vasectomy?
Open vasectomy is considered by many vasectomy experts to be superior to closed vasectomy. Open Vasectomy involves cutting the tube & leaving the lower end alone (no cautery, no closure). 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 remain open after an open vasectomy?
Rats 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 looked at afterwards through the microscope.
Surprisingly, 2 out of 5 rats that had an open vasectomy revealed obstruction of the tube by a ‘fibromuscular cap.’The conclusion was ‘by 8 weeks after surgery both vasectomy procedures are equally effective in preventing further damage in the epididymis caused by elevated intraluminal pressures.’
We don’t know for a fact that the tube remains open after an open vasectomy. Obstruction to The Vas after an open vasectomy would expect to take some weeks. Eventually, however, the tubes are expected to eventually close. This outcome is seen at the time of Vasectomy Reversals.
Closed Vasectomy will immediately close the tube draining the testicle, whereas any closure after open vasectomy is expected to be gradual.
A COMPARISON OF METHODS OF PERFORMING VASECTOMY – WITH OR WITHOUT CAUTERY?
Men in the study had one of two methods of Vasectomy Occlusion:
- Cautery of the Tubes (Intraluminal Cautery), or
- Without Cautery (the tubes were cut & tied) – with or without fascial interposition.
Vasectomy with Cautery had fewer failures (1% versus 5%).
Results: Vasectomy with cautery was associated with a significantly more rapid progression to
severe oligozoospermia and with significantly fewer early failures (1% versus 5%).
This study suggests that methods of blocking the tube that do not involve Cautery may be risky. Cautery used ‘on its own’ is common in The UK. Cautery used alongside Fascial Interposition is common The US & Australia.
As always with research like this, the devil is in the detail & there may well be successful vasectomists who do not utilise cautery.
EFFECTIVENESS OF VASECTOMY USING CAUTERY
Effectiveness of vasectomy using cautery was published in 2004. This study researched the effectiveness of vasectomy following different methods of occlusion. All 4 methods of occlusion included Cautery of the lumen of the tube.
378 men were included in the study. The overall failure rate was 0.8%.
However, it was not possible to conclude which method is ‘best,’ with the investigators stating that 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.’
We don’t know from this study which method of occlusion is ‘best’ but simply that the overall failure rate is around 1 failure in 120 Vasectomies, and emphasizes the need for the post-vasectomy sample.
SAFETY & SIDE EFFECTS
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.
- 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).
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.
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.
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.
VASECTOMY & PROSTATE CANCER
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.’
All studies that are ‘observational’ need to be treated with a pinch of salt. 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.
Vasectomists do not routinely counsel that Vasectomies might increase the risk of Prostate cancer any more than counselling that vasectomy protects against other types of cancer. This study adds nothing to the current literature indicating that Vasectomy is safe.
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.
This is in keeping with the risk of fainting of well under 1% of men who undergo vasectomy in my practice.
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.
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
This paper attempted to answer the question as to whether strong painkillers need to be described regularly after vasectomy.
Some Vasectomists prescribe strong painkillers regularly after vasectomy. By “strong pain killer” we are referring to opiate containing painkillers such as panadeine forte, Endone or tramadol. Other Vasectomists do not prescribe strong painkillers afterVasectomy. We therefore have 2 separate groups of patients who were studied following their vasectomy for the use of stronger pain killers.
102 patients received a prescription for strong painkillers after their vasectomy and 126 did not. The results were:
- There was no difference between the two groups in the experience of scrotal pain following the vasectomy
- On the other hand, and then who received a prescription for strong painkillers were more likely to get addicted to them afterwards.
Prescriptions for strong painkillers are not required after vasectomy.
This study was performed in the US where the use of strong painkillers might be higher than Australia or The UK.
There is an epidemic of people who are addicted to prescribed opiates in The US. There is no place for routine prescribing of strong painkillers after a vasectomy. A single script can easily turn into a long term addict. Just take some nurofen if required.
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%).
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.
All forms of contraception can fail, particularly condoms and the pill. 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)