Vasectomy

Vasectomy, being a non-therapeutic procedure, was once considered an illegal operation in the UK, irrespective of consent (Lord Justice Denning 1954).¹ There are as still some countries in which it is illegal, such as Egypt and Jordan.

Ensure that the couple have completed their family, as reversal is difficult and unreliable. Obtain the written consent of both partners, having previously given them clear written guidance.²

• Sterilise the skin and palpate for the vas near the neck of the scrotum and move it as near to the skin as possible.
• Holding the vas in this position, infiltrate the skin and tissue with 1-2 ml lignocaine around the vas and in a proximal direction.
• Make a small incision vertically in the skin down to the vas.
• Draw a 5cm loop of vas through the incision and clamp both proximally and distally. Cut and remove a short segment and send it off for histology to confirm that a segment of vas has been removed.
• Ligate the upper end of the vas with a non-absorbable ligature.
• Ligate the lower end as above and tie back on itself to minimise the risk of re-anastomosis.
• Some surgeons interpose a layer of fascia between the two cut ends. This further minimises the risk of failure.
• Confirm haemostasis and close with an absorbable suture.
• Confirmation of success requires at least two successive negative sperm counts at least one month apart after 20-25 ejaculations. Advise the patient to continue with alternative methods of contraception during this time.

Other techniques

• No-Scalpel Vasectomy In this method, the vas deferens is delivered via a puncture made in the scrotum, and then divided. Clamps rather than sutures are often used to seal the wound.^4,5 There is some evidence that this method results in fewer side effects, and may be more aesthetically acceptable to some patients.⁶
• Intraluminal Cautery⁶ Electric or thermal intraluminal cautery without separation of the vasa is the current method of choice at Marie Stopes International health centres.

Failure rate

• Ligation of the vas,cauterisation of the ends and fascial interposition has the lowest failure rate of 0.3%.⁶
• The no-scalpel technique has a similar failure rate.⁷
• The failure rate of intralumen cautery is quoted as 'less than 1 per cent'.⁶

Other complications³

• Mild bleeding into the scrotum: one in 400
• Major bleeding into the scrotum: one in 1000
• Infection: one in 100
• Epididymitis: one in 100
• Sperm granuloma: one in 500 - seen as tender scrotal swelling near proximal end of vas and requires further excision
• Persistent pain: one in 1,000
• Fournier gangrene - a rare form of necrotising fasciitis following vasectomy, requiring emergency treatment with intravenous antibiotics⁸