Is It Time for a Vasectomy?

As a guy, whether to get a vasectomy is one of your biggest decisions. This isn’t merely a thought experiment for me. As I write this, I’m one of the half-million American men this year healing from my own vasectomy.

So we’re on the same page, let’s review the basics. A vasectomy involves accessing the man’s sperm carrying tubes (vas deferens). They’re accessed through the scrotum, severed, and then often cauterized with a heating element.

Here’s a video of some actual vasectomies being performed by Dr. Doug Stein, one of the folks behind World Vasectomy Day.

For us guys, sterilization is so much easier than it is for women — who commonly undergo general anesthesia and take on the risks associated with navigating nearby organs. With a vasectomy though, not only is the process of accessing and cutting the vas deferens easier, it can even be difficult to detect a scar afterwards.

Vasectomies are also much cheaper. About $1,000 compared to over $5,000 for tubal ligations — though the Affordable Care Act takes care of the cost for most women in the US with health insurance. We’ve talked before about how this coverage is strangely not the same for men.

There is a best practice for vasectomies. Consider the two parts of the procedure: (1) getting to the vas and (2) blocking or closing it off (called occlusion).

To get to the vas, the no-scalpel method is recommended. (The older approach used a scalpel.) A no-scalpel method means that the doctor just punctures the scrotum using a sharp dissecting clamp called a hemostat, and that gives access to the

sperm-carrying vas deferens tube. The puncture wound is so small that sutures generally aren’t required. This approach reduces infections and a number of other complications — which are low to begin with.

To close off the vas, the preferred method is to cauterize (burn closed) the inside lining of the vas. One of the simplest approaches here is with a handheld cautery device, small enough to take AA batteries.

In order to avoid post-vasectomy pain syndrome — a chronic pain at the testes — some doctors prefer to close off the vas deferens farther away from the epididymis (where sperm is stored). For the same reason, other doctors prefer to leave the testicular end of the vas open. There’s evidence to suggest that this decision concerning the vas might reduce the small risk of chronic pain. The idea behind changing where the vas is severed is that by creating a longer strand of vas deferens tube on the end connected to the epididymis, this leaves more space for sperm to occupy. All that translates to less pressure against the epididymis.

When picking a vasectomist, you’ll also want someone who’s practiced up. Find someone who does at least 50 vasectomies a year. Like any other surgery, there’s a skill component to vasectomies.

Be sure to wait before unprotected sex with your partner and get the recommended semen analysis. If you live a long way from the doctor and live in the US, you can ask your doctor about the SpermCheck test. It’s a kit you can use at home to see if your vasectomy was successful. It takes 15–25 ejaculations to clear the vas deferens tubes of sperm. Until then, pre-existing sperm can mix in with the ejaculate.

Among men who confirm an infertile sperm count following a vasectomy, the pregnancy rate is very low. The overall pregnancy rates are between one in a thousand and one in four thousand. (The one in four thousand rate came from a study that used paternity testing.)

Compare that to the best-case scenario of one-in-50 for perfect condom users experiencing a pregnancy each year. Vasectomies are the best contraceptive men have by far. Even tubal ligations for women have a pregnancy rate of about one in 200.

So vasectomies are really safe, and they work — particularly if you’re mindful of your vasectomist and how your surgery is done.

But what if you change your mind? That happens. You may even want to play it safe ahead of time.

One of the easiest ways to play it safe is to use sperm banking. Before you have the vasectomy, you can go to a sperm bank and pay a fee for them to store your sperm. Then, if you decide to use the sperm, you and your partner can attempt to have a child in a few different ways.

You can try intravaginal insemination, which involves depositing the sperm in the vagina. There’s intrauterine insemination which involves depositing sperm directly in the uterus. And finally, there’s in vitro fertilization which is where the egg and sperm are fertilized in a lab and then transferred into the woman’s uterus. These can all be costly, with the more effective approaches being costlier.

Another option if you change your mind is to have the vasectomy reversed (called a vasovasostomy). The success rate for a healthy sperm count after a reversal is actually pretty good. It’s around 80–90%, even when some time has passed. But the difference from 100% is not trivial. And so a vasectomy should still be treated as a permanent decision. Additionally, a vasectomy reversal is more invasive than a vasectomy, typically not covered by insurance, and is significantly more expensive, running around $5,000.

Because of our current lack of options, we’ve heard of some men getting a vasectomy and then freezing their sperm, with the intent of having children using that sperm. That’s a safe route when it comes to avoiding unwanted pregnancies.

The downside to that safe route is that in order to keep your options open you’re paying for the storage costs the whole time. And if you try to play it safe by keeping more samples, then that can add even more cost. Finally, your chances of successfully achieving a pregnancy will be lower than through traditional conception.

Like most decisions, there are no guarantees. But what you can do, is appreciate the risks involved and make an informed decision. We hope that in the long run, however, that MCI will help speed up the development of a new reliable and reversible method, so you and your partner will have better options to work with.

Originally published at www.malecontraceptive.org on April 29, 2016.