Editing CUA: Vasectomy (2016) (section)

== Pre-operative practice ==

* '''Obtain a preoperative consultation in person, preferably, or by telephone or electronic communication'''
** '''History'''
*** '''General medical history (particularly risk factors for bleeding (liver disease, bleeding diathesis, anti-coagulation medications, etc.)''' '''and reproductive history'''
*** '''Reproductive status of the patient's female partner;''' if the chance for pregnancy in the female partner is poor, the need for vasectomy may be less than the couple initially expected.
*** '''Determine if family planning is complete.''' If the female partner is pregnant at the time of the preoperative consultation, the couple may be advised to consider delaying the vasectomy until after delivery to avoid regret about vasectomy, which might occur if the pregnancy is lost unexpectedly. In the US, there is no requirement for spousal or partner involvement in preoperative consultation, but patients should be advised that partner or spousal involvement is desirable.
*** '''In Canada, there is 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.
** '''Physical exam of genitalia'''
** '''Preoperative laboratory tests are not required''' unless indicated by the medical history (preoperative coagulation tests should be considered if the patient has risk factors for bleeding)
* '''Pre-operative counselling (3):'''
*# '''Vasectomy is intended to be a permanent form of contraception with a high probability of reversibility'''
*#* '''Alternative methods of contraception''' (permanent (tubal ligation) and non-permanent (barrier methods, oral or injectable contraceptive for partner)) '''are available'''
*#* '''Options for fertility after vasectomy include vasectomy reversal and sperm retrieval with in vitro fertilization. These options are not always successful, and they may be expensive'''
*#** After vasectomy, impaired fertility due to anti-sperm antibodies is infrequent and that the presence of serum anti-sperm antibodies should not be considered a deterrent to vasectomy reversal
*#** 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.
*# '''Vasectomy does not produce immediate sterility'''
*#* Time from vasectomy to azoospermia or '''rare non-motile sperm (RNMS)''' can vary from weeks to months
*#* '''Post-vasectomy semen analysis showing azoospermia or RNMS is necessary for the surgeon to be able to tell the patient if he can rely on his vasectomy for contraception'''.
*#* '''Men or their partners should use other contraceptive methods until vasectomy success is confirmed by post-vasectomy semen analysis.'''
*# '''Risk of complications (5)'''
*## '''Symptomatic hematoma and infection: 1-2%'''
*##* Rates vary with the surgeon’s experience and the criteria used to diagnose these conditions
*##* Rates of epididymitis are generally low
*## '''Chronic scrotal pain: 1-2%'''
*##* Associated with negative impact on quality of life
*##* Medical or surgical therapy is usually, but not always, effective in improving this chronic pain. '''Few men require surgical treatment for chronic scrotal pain that may occur after vasectomy'''
*## '''Failure''' (defined as failure to achieve azoopsermia or RNMS, or the occurrence of pregnancy)
*##* '''Early failure: defined as the presence of motile sperm in the ejaculate at 3-6 months post-vasectomy; 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
*##* '''Late failure: defined as the presence of motile sperm in the ejaculate after documented azoospermia in two post-vasectomy semen analyses; even after vas occlusion is confirmed, vasectomy is not 100% reliable in preventing pregnancy; the risk of pregnancy after vasectomy is ≈1/2000 for men who have post-vasectomy semen analysis showing azoospermia or rare non-motile sperm'''
*## '''Symptomatic nodule''' < 5%
*##* Presumed to be a sperm granuloma or a suture granuloma if a ligature was used to occlude the transected testicular end of the vas
*##* '''Acute pain spontaneously resolves in 2-3 months or less in most cases'''
*##* '''Treatment for a painful nodule at the vasectomy site is symptomatic therapy with anti-inflammatory agents and analgesics if needed'''
*##* '''Persistent pain at the vasectomy site is rare and may respond to excision and repeat vasectomy'''
*## '''Change in sexual function'''
*##* '''Increase in frequency or improvement in sexual satisfaction in half or more of patients and a decrease in frequency of intercourse and in sexual habits in only 5%'''
*##* No evidence that vasectomy increases the risk of erectile dysfunction, reduced or absent orgasmic sensation, decreased ejaculate volume, reduced sexual interest, decreased genital sensation and/or diminished sexual pleasure
*#* No evidence that vasectomy influences hormones (testosterone, FSH, LH), lipids, bone mineral density
*#* No evidence that vasectomy is associated with risk of prostate cancer, coronary heart disease, stroke, hypertension, dementia or testicular cancer