27 February 2006
Vasectomy - The Phacts And Phallacies
by Katherine Burnett-Watson
Vasectomy – the word itself can strike fear in the heart of even the most macho of men, but how much of this fear is real and how much is imagined? Medical experts have long claimed that this form of sterilization is the most reliable, safest and easiest to perform, and yet vasectomy seems to be the farthest thing from many men’s thoughts when it comes to putting an end to baby-making.
Why am I writing an article about vasectomy for a women’s health web site? Because although vasectomy is a procedure carried out on men, the decision to have sterilization surgery is almost entirely a result of the desire for heterosexual couples to refrain from having more children. And although tubal ligation (getting your tubes tied) might seem like a more appropriate subject for this website, there are many things women don’t know about vasectomy that help make it a more attractive form of sterilization than tubal ligation.
It’s difficult to get an accurate figure on the number of vasectomies performed in the United States, as many are done in private clinics. However, the Department of Health and Human Services published a report in 2005 on the most commonly-used primary methods of birth control, listing the top four methods, in order, as the Pill (28 percent), Tubal Ligation (23 percent), Condom (17 percent) and Vasectomy (16 percent).
These figures were obtained from a collection of extrapolated doctor’s surveys and telephone surveys, and seem to suggest that the choice of sterilization method is roughly split between men and women, but many doctors specializing in sterilization report at least a 50 percent greater number of women seeking medical sterilization than men.
While many would not be surprised to learn that twice as many women as men undergo sterilization as a permanent means of contraception, they may be surprised to learn the comparative figures relating to the two procedures in regards to safety, complexity, reliability and recovery time.
Firstly, no one has ever died from having a vasectomy. This might sound like a strange and facetious fact to mention, but given that between 10 and 15 women die in the U.S. every year as a direct result of problems experienced during tubal ligation surgery, it’s a fact worth mentioning. This risk of death comes from the fact that tubal ligation surgery requires the patient to be under general anesthetic, and death is a result of either hypoventilation (inadequate oxygen-intake) or cardiopulmonary arrest (the sudden cessation of both heart and lung function).
Even if morbidity is taken out of the equation, the safety and health factors in favor of vasectomy over tubal ligation are compelling. Recovery from vasectomy usually requires that the patient refrain from heavy physical activity for approximately 48 hours, whereas tubal ligation requires women to limit physical activity and heavy lifting for at least one week following surgery.
Men joke about getting “the snip” on the table at the doctor’s office, but this is in fact precisely how the procedure is performed. Under local anesthetic, a vasectomy is performed using one of two methods, either conventional (traditional), or the more recent “no scalpel” vasectomy.
The traditional vasectomy is a minor surgical procedure and is usually completed within 30 minutes. The surgeon uses a scalpel to make one or two incisions in the skin of the scrotum to access and expose the tiny vas deferens tubes from each testicle. The vas deferens is lifted, cut and tied, and often cauterized. The cut tubes are then returned to the scrotal sac and the incisions are then closed with three or four stitches.
In a no scalpel vasectomy (NSV), the procedure does not involve a scalpel, but a small opening is still made. The doctor locates the patient's vas deferens under the skin of the scrotum by hand, and holds the tiny tube in place with a small clamp. Small pointed forceps separate the layers of tissue and then create a tiny puncture in the skin to form an opening for the vas deferens to be gently lifted out, then cut, tied, clipped and/or cauterized and put back into place.
The opening in the skin may then be closed with sutures, but because the skin puncture is much smaller than a conventional incision, it closes much more quickly.
The main difference between the two surgeries is that the techniques used in NSV reduces the amount of manipulation of the scrotum, testes and surrounding flesh, therefore resulting in less bruising and swelling, and therefore less patient discomfort.
Tubal ligation, on the other hand, is a much more complicated procedure. Commonly referred to as “getting your tubes tied” (in reference to the first method used for tubal ligation which involved tying the fallopian tubes so no eggs could progress through them), the procedure today involves cutting the fallopian tubes or sealing them through cauterization. These methods require incisions to be made, and are performed either via laparoscopy (where small incisions are made near the navel for viewing equipment and scalpel to be inserted) or laparotomy (and mini-laparotomy) where a incision between two and five inches in size is made in the lower abdomen (usually below the bikini line). Each of these procedures are performed under general anesthetic.
A method that is relatively new in the field is a no-incision method referred to as Hysteroscopic Tubal Sterilization (HTS). It involves the insertion of two small, soft metallic coils (micro-inserts) through the vagina, cervix, and uterus into the fallopian tubes. The procedure requires the use of local as opposed to general anesthetic. Once in place, the coils cause scar tissue to grow, blocking the tubes. Although not as invasive as tubal ligation, due to the newness of the procedure, the long-term effects of this form of sterilization are not known.
On the effectiveness front, vasectomy is way out ahead. Vasectomy has a failure rate of around one percent, while tubal ligation’s is around two percent. While this might sound like a small difference, when dealing with a procedure that is meant to be permanent, that one percent is very important. Sterilization through vasectomy is not immediate. It can take weeks (and in some cases, months) for residual sperm in the vas deferens to be ejaculated, so doctors recommend follow-up tests after vasectomy to determine the amount of sperm still present in ejaculate.
While it’s easy to provide statistics promoting vasectomy as a safer and easier alternative to tubal ligation, the reality of vasectomy is much more than just a simple surgical procedure.
From their early childhood, boys are aware of their genitals. They are told their penis and testicles are what makes them a boy, and eventually a man. Their genitals are at the center of their masculinity. So when it comes to their genitals - and the idea of them coming in contact with sharp instruments - it’s no wonder men aren’t all that keen.
We’re different. By the time we’re adults, we’re accustomed to the rigors of examination and handling that go along with having female genitals. Now, I don’t mean it to sound like women are putting their vaginas out there for everyone to have a poke and a prod, but a woman’s potential experiences involving their genitals and trained professionals are almost infinite. Menstruation, pap smears, pelvic examinations, STD checks, abortion, shaving and waxing, fertility testing and treatments, childbirth… the list goes on. The closest men come to having their genitals looked at by others in a way other than sexual is at their annual check up – with the old “turn your head and cough”.
Sexual function is a major concern for men, so it’s no surprise that they have concerns about vasectomy and how it will affect their masculinity and sexual performance, including ejaculation. But sperm make up only a tiny portion of the seminal fluid that is released at ejaculation. In men who have not had a vasectomy, ejaculate contains sperm from the testes, seminal fluid from the seminal vesicles and fluid from the prostate gland. Once a vasectomy has been performed, the only “missing ingredient” in ejaculate is the sperm, which cannot travel up the vas deferens, but is halted at the point in the vas deferens where the vasectomy occurred, and is absorbed back into the system. In the case of an open-ended vasectomy, the vas deferens opening nearest the testicles is left open, so sperm can be released into the body and then reabsorbed. When both ends of the vas deferens are closed during surgery (closed-end vasectomy) sperm are physically stopped from leaving the testicles and are reabsorbed.
View an animation explaining ejaculation.|
A vasectomy does not change the volume, color, or consistency of the ejaculate. Nor will the quality, intensity and duration of a man's orgasm change after a vasectomy.
View an animation explaining vasectomy.
Because local anesthetic is used during the procedure, a vasectomy itself is not painful. Some men report being able to feel “tugging” or “manipulation” of their testes during the procedure, much like the sensations reported by women who have had an epidural during vaginal or caesarian delivery childbirth. After the anesthetic wears off though, it may be quite different. Every person is unique and so is their level of pain tolerance. Some men report only mild discomfort in the following few days after vasectomy, while others says they have the pain and nausea associated with a testicular injury that continues for up to two weeks.
A small percentage of men (around 2 percent) report what doctors call post vasectomy pain syndrome, which is ongoing discomfort and pain associated with vasectomy. This can be as a result of rough surgery which leaves nerve damage to the testicles, painful pressure build-up upon ejaculation from sperm being unable to escape through the vas deferens (in the case of closed-end vasectomy), or the vasectomy being performed too close to the testes.
The possibility of disease needs to be considered as well. There have been studies suggesting an increased risk of prostate and testicular cancer in men who have had a vasectomy, although there have been other studies suggesting this is not the case. Prostate cancer is the most common cancer in American men, and the second leading cause of cancer death, after lung cancer, while testicular cancer accounts for only one percent of cancers in American men. While it has been reported that men who have had vasectomies are slightly more likely to be found to have prostate or testicular cancer, researchers believe that this slight increase indicates what is referred to as “detection bias”. Men having a vasectomy receive testicular and prostate examinations in the lead up to their surgery. Therefore, detection of these cancers is more likely in men getting vasectomies than those who are not.
What happens if a man wants his vasectomy reversed? While vasectomy should be seen as a permanent procedure, a vasectomy can be reversed through a procedure called vasovasostomy, where the severed vas deferens are rejoined, or vasoepididymostomy, which is a similar procedure but bypasses any scar tissue that may have developed as a result of the vasectomy.
The chances of successfully conceiving a child after reversal surgery are very dependent on time, and the quality of the sperm. A vasectomy reversal has a greater chance of success if the vasectomy was performed recently. As time passes, the statistical likelihood of a pregnancy following a vasectomy reversal declines. The most significant decline occurs at 15 years or more where pregnancy rates are typically about 30 percent.
Also, over time, the body's natural response to accumulated (not ejaculated) sperm in the testicles may result in damage to the shape, number and motility of sperm. The potency (number and quality of sperm released in seminal fluid) are just as important as the success of the reconnection.
So, is vasectomy right for your man? Typically, both men and women are involved in the decision to have a sterilization procedure as a means of continuing a sexual relationship without the risk of pregnancy, whether it’s a vasectomy or tubal ligation. Vasectomy is safer, easier to perform and (slightly) more reliable than tubal ligation, but making a decision based purely on medical statistics is not recommended. For many men, such a decision requires a lot of soul-searching and research before taking the plunge and getting “the snip”.