Vasectomy NY, Vasectomy Reversal
Vasectomy
A vasectomy is an operation that makes a man permanently unable to get a woman pregnant. It involves cutting the 2 tubes called vas deferens so that sperm can no longer get into the semen.

 

Where to get a Vasectomy by Dr. Fisch named “Best Doctors in America" and "New York Magazine Top Doctors" the past 9 years? At the Vacectomy Center

Conveniently located in the heart of New York at 944 Park Avenue, New York, NY 10028, (212)879-0800. The Vasectomy Center, a Vasectomy Clinic by Harry Fisch MD specializes exclusively in non invasive, no scalpel no needle Vasectomy. To provide the best results we use the most advanced technique. No-scalpel vasectomy is different from a conventional vasectomy in that is less invasive and therefore less painful.

 

* The patient's guide for vasectomy.

* No scalpel no needle Vasectomy

* Defining the Standard for Vasectomy Success a presentation by Harry Fisch MD.is a PowerPoint presentation of what men can expect from a vasectomy.

 

 
Existing technique vs. The Vasectomy Center's non invasive, no scalpel no needle Vasectomy:  
With Needle Vasectomy   No Needle Vasectomy
The traditional method of vasectomy involves inserting a needle into the scrotum to anesthetize the area around each vas deferens prior to surgery - a key reason why the procedure can be painful.   With the new, no needle approach to vasectomy, the physician can anesthetize the surgical area with a jet anesthetic device, which delivers the numbing agent without use of a needle.
No-scalpel vasectomy. An improved vasectomy method, devised by a Chinese surgeon, has been widely used in China since 1974. This so-called nonsurgical or no-scalpel vasectomy was introduced into the United States in 1988, and many doctors are now using the technique here.

At the Vasectomy Center of New York we use a refinement of the no-scalpel method that doesn’t involve any needles at all. An instrument called a MadaJet delivers a stream of anesthetic so fine that it penetrates the skin and numbs a dime-sized patch of scrotal skin. Then the doctor feels for the vas under the skin of the scrotum and holds it in place with a small clamp. A special instrument is used to make a tiny puncture in the skin and stretch the opening so the vas can be cut and tied.

This approach produces very little bleeding, and no stitches are needed to close the punctures, which heal quickly by themselves. The newer method also produces less pain and fewer complications than conventional vasectomy. No-scalpel, No-Needle Vasectomy Information

If you have questions or would like a brochure or a consultation, please contact Madelon at the Vasectomy Center.


Managing the vasectomy patient: From preoperative counseling through postoperative follow-up:

TABLE OF CONTENTS
  1. PREVALENCE
  2. MANAGEMENT
  3. VASECTOMY FAILURES
  4. POSTVASECTOMY SEMEN ANALYSIS
  5. CONCLUSION
  6. UROLOGIC
  7. REFERENCES
Dr. Harry Fisch on
CBSNEWS Vasectomy 101
Vasectomy, a form of male sterilization utilizing bilateral disruption of the vas deferens to halt the transmission of spermatozoa during ejaculation, is an outpatient procedure that can be performed in the office setting under local anesthesia, with most patients reporting only minimal postoperative pain. Unlike many of the other methods of contraception, which require continuous usage or repeat administrations, vasectomy needs to be performed only once for a man to be rendered durably sterile.
Despite advances in other methods of family planning during the last several decades, vasectomy has remained among the most popular forms of contraception. The safety, simplicity, and durability of the procedure make it an attractive option for patients and physicians alike. However, many controversies remain regarding the appropriate management of patients after the procedure. This article discusses the importance of preoperative counseling and reviews vasectomy techniques and outcomes after sterilization.
1. PREVALENCE
Worldwide, it has been estimated that 5% of all married couples of reproductive age—or approximately 42 to 60 million people—depend on vasectomy as their sole contraceptive method.1,2 This number varies widely between countries, with the highest rate of vasectomy (23% of men) reported in New Zealand.3
Vasectomies are much more common in white men than in black men (14% vs. 2%).4 In the United States, 11% of women of reproductive age rely on vasectomy for family planning. Those most likely to elect vasectomy as their contraceptive method of choice include women between 30 and 45 years of age, married women, and women with at least a high school education.5
2. MANAGEMENT
Vasectomy can be performed under local anesthesia with relative ease, and the patient may return to his normal level of activity within several days of the procedure.
Preoperative counseling. Given the finality of vasectomy, thorough preoperative counseling regarding the risks and benefits of the procedure and alternatives to it is imperative. In addition, reasonable expectations regarding postoperative recovery should be fostered. Patients should be forewarned about the need for continued postoperative surveillance. After counseling, the patient should be able to demonstrate a clear understanding of the time delay between surgery and achievement of azoospermia and of the need for postoperative semen analyses to confirm the absence of spermatozoa.
In addition, every patient should be able to demonstrate a clear understanding of the potential complications that may result from the procedure. Specifically, the risk of chronic inflammation and postvasectomy pain syndrome (PVPS) should be discussed. Patients with PVPS present with intermittent or constant pain in 1 or both testicles after vasectomy, lasting for 3 or more months.
PVPS is considered relatively uncommon following vasectomy, although the incidence has been suggested to be as high as 19%.6 The exact mechanism of the syndrome remains unknown, but theories involving epididymal congestion, painful sperm granulomas, vascular stasis, and nerve impingement have been put forth.
Most patients with PVPS can be managed conservatively with reassurance, nonsteroidal anti-inflammatory drugs, scrotal support, or nerve blocks. However, patients who do not respond to these measures may need secondary surgical procedures such as vasectomy reversal, epididymectomy, or spermatic cord denervation.6-9
In the past, some urologists counseled men under age 35 about a potentially increased risk of prostate cancer later in life. Although several studies published in the early 1990s reported an increased risk of prostate cancer in men having undergone vasectomy,10-12 various large-scale epidemiologic studies carried out under the auspices of the American Urological Association (AUA) have since shown no proof of a relationship between vasectomy and prostate cancer risk.13-15 Similarly, although it was suggested in the early 1980s that vasectomy may be associated with the development of atherosclerosis and cardiovascular disease, this notion has long since been dispelled.16,17
PVPS is considered relatively uncommon following vasectomy, although the incidence has been suggested to be as high as 19%.6 The exact mechanism of the syndrome remains unknown, but theories involving epididymal congestion, painful sperm granulomas, vascular stasis, and nerve impingement have been put forth.
Finally, while several realistic options for the re-establishment of vasal continuity do exist, vasectomy is still considered a permanent form of male sterilization. As such, every candidate must consider his individual circumstances, both current and future, before deciding to proceed. Prior to undergoing vasectomy, every patient should be made aware of the option of "fertility insurance" by means of semen cryopreservation.
The goal of preoperative counseling should not be to dissuade or scare the patient from undergoing vasectomy. Rather, the goal should be to provide him with the knowledge necessary to make a fully informed decision. When done appropriately, preoperative counseling can result in patients who are more satisfied, more compliant, and less litigious than those who receive inadequate or no counseling.
Surgical technique. The vasectomy procedure is begun by palpation of the vas deferens through the scrotal skin. The vas is then secured with the surgeon's fingers and the scrotal skin is opened. Access to the vas deferens may be obtained using either the conventional incisional method or the no-scalpel method popularized by Li and colleagues in the late 1980s.18 With the conventional method, a scalpel is used to make an approximately 1-cm incision either in the midline (if a single incision is used) or in each hemiscrotum (if 2 separate incisions are used). With the no-scalpel technique, a specialized sharp forceps is used to puncture the scrotal skin, thereby creating a hole through which the vasectomy can be performed.
After the vas deferens is identified, it is brought out through the scrotal incision and divided. A variable length of vas is resected, and the remaining free ends are occluded. To accomplish vasal occlusion, the cut ends may be secured with nonabsorbable suture, cautery, and/or metal clips. Many urologists also interpose fascia between the cut ends to minimize the risk of vasal recanalization. The crucial step for vasectomy success is vasal occlusion; the exact method of occlusion is a matter of preference.
3. VASECTOMY FAILURES
Vasectomy is the most reliable practical method of permanent contraception. However, vasectomy failures have been reported. Most sources estimate the occurrence of undesired pregnancy following vasectomy to be approximately 1 in 2,000 cases.19-21 This failure rate of less than 0.1% compares favorably with the 1.85% failure rate associated with tubal ligation.22
Vasectomy failures are divided into 2 categories: early and late. Early failures occur within the first few months following vasectomy and are usually attributed to unprotected intercourse prior to obtaining a negative semen analysis. A vas inadvertently missed during the procedure can also cause early failure. This may occur if the surgeon excises 2 portions from 1 vas (when using a single midline incision) or if the surgeon ligates a structure other than the vas.
Late failures may occur years to decades after vasectomy and are most often attributed to recanalization of the vas deferens. The majority of vasectomy failures are early failures and occur in men who are ineffectively counseled regarding the delay between vasectomy and achievement of azoospermia.
4. POSTVASECTOMY SEMEN ANALYSIS
While most urologists agree on the need for a semen analysis to verify the achievement of azoospermia after vasectomy, there is no consensus on the exact timing for it. Most physicians use an arbitrarily determined time period or an arbitrary number of ejaculations before obtaining a semen analysis. In a survey of 1,800 physicians performing vasectomy in the United States in 1995, Haws and associates found that postvasectomy semen analysis was obtained at 6 weeks or less by 59% of the physicians, at 7 to 9 weeks by 29%, and at 9 weeks or more by 12%.23
Managing a Vasectomy Rate of achievement of azoospermia. While most physicians obtain the postvasectomy semen analysis within 6 weeks, a review of the available literature suggests that this may be too soon to determine whether the procedure was a success. Figure 1, incorporating data from 12 peer-reviewed studies,24-35 shows the rate of development of postvasectomy azoospermia plotted as a function of time. Three months after vasectomy, only 72% of men have achieved azoospermia. Six months after vasectomy, this number increases to 85%; and by 1 year after vasectomy, 99% of men are azoospermic. This slow, constant rate suggests that the number of ejaculations after vasectomy may have only minor impact on the achievement of azoospermia.
Similarly, it has been shown that there is no association between the method of vasal occlusion or length of vas excised and the length of time required for a man to achieve azoospermia following a vasectomy.23,36-39 Given the relatively slow rate of achievement of postvasectomy azoospermia, our current practice is to obtain a semen analysis no sooner than 3 months after vasectomy.
The significance of azoospermia. Postvasectomy semen analysis may show any 1 of 3 findings:
complete absence of spermatozoa (azoospermia),
presence of motile spermatozoa, or
presence of nonmotile spermatozoa.
The presence of motile spermatozoa 3 to 6 months after vasectomy indicates vasectomy failure due to technical error or to early recanalization.40
The significance of nonmotile spermatozoa detected on semen analysis depends on how long after the procedure they are found. In the early postvasectomy period, this finding is thought to be caused by the release of nonviable residual spermatozoa in the distal reproductive tract.28 If found a significant amount of time after vasectomy, nonmotile spermatozoa generally indicate recanalization of the vas deferens.41 However, it is important to understand that the isolated finding of nonmotile spermatozoa does not necessarily signal vasectomy failure. Vasectomy
As shown in Table 1,25,28,39,41,42 multiple investigators have reported on the reappearance of rare nonmotile spermatozoa years to decades after vasectomy in men previously documented to be azoospermic. It is widely believed that the presence of a small number of nonmotile spermatozoa in vasectomized men is a normal and usual sequela of vasectomy. Additionally, it has been shown that the risk of pregnancy from nonmotile spermatozoa is only 0.05%—which is identical to the risk of pregnancy after 2 azoospermic semen analyses.19,43
Although the AUA has not to date issued guidelines for the management of postvasectomy patients, current guidelines from the British Andrology Society recommend routine centrifugation of all postvasectomy semen specimens to increase the likelihood of detecting rare nonmotile spermatozoa.32 While semen centrifugation is a useful sperm-harvesting technique for intracytoplasmic sperm injection in men with obstructive or nonobstructive azoospermia,44 it is not currently the US clinical standard of care for postvasectomy patients. Centrifugation is an effective means of detecting rare nonmotile spermatozoa, but, as discussed earlier, the presence of rare nonmotile spermatozoa after vasectomy is of only trivial significance and should not alter patient management.
5. CONCLUSION
Vasectomy remains among the safest, easiest, and surest methods of male sterilization. As such, it is one of the most popular methods of permanent contraception worldwide. However, despite the popularity of the technique, there has been a notable lack of consensus on the appropriate management of patients after vasectomy. We recommend waiting at least 3 months after vasectomy to assess azoospermia by semen analysis. A semen analysis indicating the complete absence of spermatozoa or the presence of only rare nonmotile spermatozoa is considered a marker of vasectomy success. Routine centrifugation of azoospermic semen to detect rare nonmotile spermatozoa is not currently considered the clinical standard of care in the United States.
It is clear that multiple issues must be addressed after vasectomy. In a patient's mind, the judicious handling of these issues can make the difference between a successful sterilization and an unpleasant experience. When vasectomy is no longer represented to patients as a procedure but rather as a process, they may be more appropriately counseled on the facts—that continued follow-up after vasectomy is essential, sterility after vasectomy cannot be guaranteed, and the possibilities of spontaneous recanalization or PVPS, although small, do exist.
6. UROlogic
Due to its simplicity, safety, and effectiveness, vasectomy has remained among the most popular forms of contraception. The failure rate is typically less than 0.1%, comparing favorably with the 1.85% failure rate for tubal ligation.

Thorough preoperative counseling regarding the risks, benefits, alternatives, and permanency of vasectomy is imperative.

Reasonable expectations should be fostered in patients regarding postoperative recovery, and patients should be informed of the time delay between treatment and achievement of azoospermia and the need for postoperative semen analyses to confirm azoospermia.

Obtaining the postvasectomy semen analysis within 6 weeks may be too soon to confirm success of treatment. At 3 months follow-up, only 72% of men have achieved azoospermia.

The majority of vasectomy failures are early failures in men who are ineffectively counseled regarding the delay between vasectomy and azoospermia.

Late vasectomy failures or the presence of motile spermatozoa may indicate recanalization of the vas deferens.
REFERENCES

1. Liskin I, Renoir E, Blackburn R. Vasectomy—new opportunities. Population Reports. 1992;5:1-23.

2. Liu X, Li S. Vasal sterilization in China. Contraception. 1993;48(3):255-265.

3. Schlegel PN, Goldstein M. Vasectomy. In: Schoupe D, Haseltine FP, eds. Contraception. New York: Springer-Verlag, 1993:181-191.

4. Piccinino LJ, Mosher WD. Trends in contraceptive use in the United States: 1982-1995. Fam Plann Perspect. 1998;30(1):4-10, 46.

5. Schwingl PJ, Guess HA. Safety and effectiveness of vasectomy. Fertil Steril. 2000;73(5):923-936.

6. Ahmed I, Rasheed S, White C, et al. The incidence of post-vasectomy chronic testicular pain and the role of nerve stripping (denervation) of the spermatic cord in its management. Br J Urol. 1997;79(2):269-270.

7. Myers SA, Mershon CE, Fuchs EF. Vasectomy reversal for treatment of the post-vasectomy pain syndrome. J Urol. 1997;157(2):518-520.

8. Nangia AK, Myles JL, Thomas AJ Jr. Vasectomy reversal for the postvasectomy pain syndrome: a clinical and histological evaluation. J Urol. 2000;164(6): 1939-1942.

9. Chen TF, Ball RY. Epididymectomy for post-vasectomy pain: histological review. Br J Urol. 1991; 68(4):407-413.

10. Mettlin C, Natarajan M, Huben R. Vasectomy and prostate cancer risk. Am J Epidemiol. 1990;132(6): 1062-1065.

11. Rosenberg L, Palmer JR, Zauber AG, et al. The relation of vasectomy to the risk of cancer. Am J Epidemiol. 1994;140(5):431-438.

12. Giovannucci E, Tosteson TD, Speizer FE, et al. A long-term study of mortality in men who have undergone vasectomy. N Engl J Med. 1992;326(21): 1392-1398.

13. Stone N, Blum DS, DeAntoni EP, et al. Prostate cancer risk factor analysis among > 50,000 men in a national study of prostate-specific antigen (PSA). J Urol. 1994;151(5 suppl):278A. Abstract 201.

14. Bernal-Delgado E, Latour-Perez J, Pradas-Arnal F, et al. The association between vasectomy and prostate cancer: a systematic review of the literature. Fertil Steril. 1998;70(2):191-200.

15. Lesko SM, Louik C, Vezina R, et al. Vasectomy and prostate cancer. J Urol. 1999;161(6):1848-1852; discussion 1852-1853.

16. Clarkson TB, Alexander NJ. Does vasectomy increase the risk of atherosclerosis? J Cardiovasc Med. 1980;5(11):999-1002.

17. Coady SA, Sharrett AR, Zheng ZJ, et al. Vasectomy, inflammation, atherosclerosis and long-term followup for cardiovascular diseases: no associations in the atherosclerosis risk in communities study. J Urol. 2002;167(1):204-207.

18. Li SQ, Goldstein M, Zhu J, et al. The no-scalpel vasectomy. J Urol. 1991;145(2):341-344.

19. Haldar N, Cranston D, Turner E, et al. How reliable is vasectomy? Long-term follow-up of vasectomised men. Lancet. 2000;356(9223):43-44.

20. Smith JC, Cranston D, O'Brien T, et al. Fatherhood without apparent spermatozoa after vasectomy. Lancet. 1994;344(8914):30.

21. Weiske WH. Vasectomy. Andrologia. 2002; 33:125-134.

22. Peterson HB, Xia Z, Hughes JM, et al. The risk of pregnancy after tubal sterilization: findings from the US Collaborative Review of Sterilization. Am J Obstet Gynecol. 1996;174(4):1161-1168; discussion 1168-1170.

23. Haws JM, Morgan GT, Pollack AE, et al. Clinical aspects of vasectomies performed in the United States in 1995. Urology. 1998;52(4):685-691.

24. Alderman PM. The lurking sperm. A review of failures in 8879 vasectomies performed by one physician. JAMA. 1988;259(21):3142-3144.

25. O'Brien TS, Cranston D, Ashwin P, et al. Temporary reappearance of sperm 12 months after vasectomy clearance. Br J Urol. 1995;76(3):371-372.

26. Alcaraz A, Arango O. Cancer and other risks of vasectomy. Eur J Contracept Reprod Health Care. 1996; 1(4):311-318.

27. Cortes M, Flick A, Barone MA, et al. Results of a pilot study of time to azoospermia after vasectomy in Mexico City. Contraception. 1997;56(4):215-222.

28. DeKnijff DW, Vrijhof HJ, Arends J, et al. Persistence or reappearance of nonmotile sperm after vasectomy: does it have clinical consequences? Fertil Steril. 1997;67(2):332-335.

29. Finger WR. Time to azoospermia may be longer than often assumed. Network. 1997;18(1):15.

30. Smith AG, Crooks J, Singh NP, et al. Is the timing of postvasectomy seminal analysis important? Br J Urol. 1998;81(3):458-460.

31. Badrakumar C, Gogoi NK, Sundaram SK. Semen analysis after vasectomy: when and how many? Br J Urol. 2000;86(4):479-481.

32. Hancock P, McLaughlin E. British Andrology Society. British Andrology Society guidelines for the assessment of post vasectomy semen samples (2002). J Clin Pathol. 2002;55(11):812-816.

33. Mason RG, Dodds L, Swami SK. Sterile water irrigation of the distal vas deferens at vasectomy: does it accelerate clearance of sperm? A prospective randomized trial. Urology. 2002;59(3):424-427.

34. Nazerali H, Thapa S, Hays M, et al. Vasectomy effectiveness in Nepal: a retrospective study. Contraception. 2003;67(5):397-401.

35. Barone MA, Nazerali H, Cortes M, et al. A prospective study of time and number of ejaculations to azoospermia after vasectomy by ligation and excision. J Urol. 2003;170(3):892-896.

36. Clenney TL, Higgins JC. Vasectomy techniques. Amer Fam Phys. 1999;60(1):137-152.

37. Esho JO, Ireland GW, Cass AS. Vasectomy. Comparison of ligation and fulguration methods. Urology. 1974;3(3):337-338.

38. Esho JO, Cass AS. Recanalization rate following methods of vasectomy using interposition of fascial sheath of vas deferens. J Urol. 1978;120(2):178-179.

39. Labrecque M, Hoang D, Turcot L. Association between length of the vas deferens excised during vasectomy and the risk of postvasectomy recanalization. Fertil Steril. 2003;79(4):1003-1007.

40. Edwards IS. Earlier testing after vasectomy, based on the absence of motile sperm. Fertil Steril. 1993; 59(2):431-436.

41. Lemack GE, Goldstein M. Presence of sperm in the pre-vasectomy reversal semen analysis: incidence and implications. J Urol. 1996;155(1):167-169.

42. Freund MJ, Weidmann JE, Goldstein M, et al. Microrecanalization after vasectomy in man. J Androl. 1989;10(2):120-132.

43. Benger JR, Swami SK, Gingell JC. Persistent spermatozoa after vasectomy: a survey of British urologists. Br J Urol. 1995;76(3):376-379.

44. Jaffe TM, Kim ED, Hoekstra TH, et al. Sperm pellet analysis: a technique to detect the presence of sperm in men considered to have azoospermia by routine semen analysis. J Urol. 1998;159(5):1548-1550.

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