Vasectomy Procedure

Vasectomy is permanent male contraception in which the vas deferens is cut and occluded on each side so that sperm cannot reach the seminal fluid. It is done under local anaesthesia, takes about 15 to 20 minutes, and is about 99.8 percent effective. It does not become effective until about 3 months after the procedure, so another method is needed until semen analysis confirms clearance.

Indications. A man who has completed his family or does not want children, understands that the procedure is permanent and gives voluntary informed consent.

Who should not have a vasectomy now. Men who are unsure about future fertility, who cannot give voluntary informed consent, or who cannot tolerate surgery (for example, an uncontrolled bleeding disorder).

Conditions needing care.

• Delay until treated: local scrotal skin infection, active sexually transmitted infection, balanitis, epididymitis, orchitis, systemic infection, filariasis with scrotal swelling.

• Caution, with an experienced provider: large varicocele or hydrocele, inguinal hernia, previous scrotal surgery or injury, undescended testis, bleeding disorder, anticoagulant treatment.

• Men with HIV who are clinically well (stage 1 or 2), and men with sickle cell disease, can have a vasectomy.

Counselling and consent. Counsel on:

• permanence and the small risk of regret, especially in young men and those in new relationships
• the 3-month delay and need for backup
• the lack of protection against STIs and HIV
• failure (about 1 in 500 after clearance, from recanalisation)
• the options of reversible methods.

Written, signed consent is required. Spousal consent is not required. The man must be able to withdraw consent at any time.

Preparation. Examine the scrotum, vas deferens and penis; clean and clip hair at the site if needed.

Equipment:

• sterile gloves and drape
• antiseptic (chlorhexidine 2% in alcohol or povidone-iodine 10%)
• lidocaine 1% with needle and syringe
• a no-scalpel vasectomy set (ring clamp, dissecting forceps) or scalpel and artery forceps
• sutures for ligation (absorbable 3-0 or 4-0)
• electrocautery if used
• dressings, scrotal support, and a sterile specimen container for later analysis.

Anaesthesia. Inject lidocaine 1% 5 to 10 mL in total (maximum 4.5 mg/kg) into the skin and around each vas through the scrotal skin, and wait 2 to 3 minutes.

No-scalpel technique.

• Palpate and fix the vas under the skin with a ring clamp.

• Pierce the skin with the pointed dissecting forceps and stretch the opening.

• Lift the vas, strip the sheath and expose a short length.

• Occlude the vas: cut a segment of about 1 cm and tie both ends with ligature, or cauterise the lumen, and place the cut ends in different tissue planes (fascial interposition) to reduce recanalisation.

• Return the vas to the scrotum, check haemostasis and repeat on the other side through the same opening.

• No suture is needed for the skin; apply a dressing.

Scalpel technique. Make one or two small incisions in the scrotum, deliver each vas, cut and occlude it in the same way, check haemostasis and close the skin with fine absorbable sutures.

Documentation. Record the technique, the length of vas removed, the occlusion method and any problem.

Complications and responses.

Vasovagal reaction. Stop, lay flat with legs raised, monitor.

Allergy to anaesthetic. Adrenaline 0.5 mg intramuscularly into the anterolateral thigh.

Instructions.

• Rest for 1 to 2 days; use scrotal support (for example, supportive underwear) for 2 to 3 days.

• Apply a cold pack for 20 minutes every few hours for the first 24 hours.

• Keep the wound dry for 24 to 48 hours.

• Paracetamol 1 g orally every 6 hours (maximum 4 g daily) and ibuprofen 400 mg orally every 8 hours with food if needed.

• Avoid heavy lifting and strenuous exercise for 1 week; resume sex when comfortable, usually after about 1 week.

• Return for fever, increasing pain, swelling, discharge or bleeding.

Backup. The patient and partner must use a reliable method (condoms) until clearance is confirmed. A partner using an IUD continues it for 3 months after the vasectomy.

Semen analysis. Test about 3 months after the procedure and after at least 20 ejaculations. Clearance is confirmed by azoospermia, or occasional non-motile sperm only (under 100,000 sperm/mL on a fresh sample). If motile sperm are present, continue backup and repeat analysis every 4 weeks; if motile sperm persist beyond 6 months, consider repeat vasectomy.

Follow up. A wound check at 1 to 2 weeks and the semen analysis result review.

Special groups. Men living with HIV need condoms for HIV and STI protection. Young men and men without children need extra counselling. Postvasectomy pain is uncommon but needs early treatment.

Referral and escalation. Refer persistent pain, recurrent infection, failed clearance, complex scrotal anatomy and men who want reversal.