CUA GUIDELINE: VASECTOMY 2016
See 2015 AUA Guideline on Vasectomy Notes
Patient Counselling
- Patient must be told that the vasectomy should be viewed as a permanent form of contraception with a high probability of reversibility. Preoperative sperm-banking and post-operative vasectomy reversal and sperm retrieval (for subsequent in vitro fertilization) can be discussed if patients are concerned about the permanent nature of the procedure.
- No specific age of consent; any man with the legal capacity to provide informed consent may undergo a vasectomy. Consider offering young men more time to reflect on their decision prior to performing the surgery.
Procedure
- No-scalpel vasectomy is associated with a significantly lower risk of postoperative complications (hematoma, pain, infection) than conventional incisional vasectomy; local anesthesia is usually sufficient
- Risk of failure: cautery of the vas < fascial interposition < no interposition; fascial interposition may increase the complication rate of vasectomy.
- Special concern is warranted in men that have undergone or may undergo an ipsilateral varicocelectomy. After varicocelectomy, the deferential veins may be the sole source of testicular venous return [in proper varicocelectomy, all spermatic cord veins are ligated except the deferential vein] and it is also possible to damage the testicular artery(ies), leaving the deferential artery as the principal arterial supply to the testis. Thus, when a vasectomy is performed in men who have undergone or may undergo varicocelectomy in the future, it is strongly advisable to isolate the vas deferens carefully at the time of vasectomy and completely exclude the associated deferential arteries and veins so as to avoid potential injury to the deferential vasculature and minimize the risk of ipsilateral testicular injury
- Men should be told to remain in the clinic for 15‒20 minutes after the vasectomy
- Complications (5):
- Infection (0.2‒1.5%)
- Bleeding or hematoma (4‒20%)
- Chronic scrotal pain (1‒14%)
- Early failure (0.2‒5%), defined as the presence of motile sperm in the ejaculate at 3-6 months post-vasectomy
- Late failure (0.05‒1%), defined as the presence of motile sperm in the ejaculate after documented azoospermia in two post-vasectomy semen analyses.
Post-vasectomy testing
- See Figure 1 from Original CUA Guideline
- Should be conducted 3 months after vasectomy (AUA guidelines say 2-4 months range). Patients must be reminded to use other contraceptive measures until post-vasectomy semen testing has confirmed absence of motile sperm.
- Patients should be told that semen samples should be collected after an abstinence period of 2-7 days, how to collect the semen sample, maintaining the sample at body temperature, and submitting the sample within 30‒60 minutes after production.
- The laboratory should examine a freshly produced seminal fluid specimen by direct microscopy and if no sperm are seen, the centrifuged sample should be examined for the presence of motile and immotile sperm. The evaluation of 2 post-operative semen samples is a better predictor of success than the evaluation of a single semen sample
- Vasectomy success (can abandon contraception): 1 azoospermic OR 2 ejaculates with rare (<100,000) non-motile sperm
- Couples should be reminded about the risk of late failure despite azoospermia or rare immotile sperm on initial testing. In most cases, late failure is first identified as a pregnancy and later confirmed by semen analysis documenting presence of motile sperm.
- The reappearance of sperm (mostly immotile) after documented azoospermia in 2 post-vasectomy semen samples may occur in up to 10% of patients. The reappearance (or persistence) of immotile sperm years after vasectomy has not been associated with documented pregnancies.
- Vasectomy failure: presence of ANY motile sperm OR >100,000 non-motile sperm
- Patients must continue the use of other contraceptive measures and repeat semen analysis in 4-8 weeks
- If repeat testing shows
- Azoospermia or <100,000 non-motile sperm, contraception can be abandoned
- Persistence of motile or > 100,000 non-motile sperm at 6 months after the initial procedure, a repeat vasectomy is indicated
