Vasectomy

Vasectomy is a surgical procedure in which the vas deferens is cut and tied so that sperm cannot mix with seminal fluid. It is performed under local anaesthesia in a minor theatre. It is a permanent method for men who have completed their family, with no effect on libido, erection, ejaculation or health, and no protection against sexually transmitted infections or HIV.

Techniques. Scalpel vasectomy uses one or two small scrotal incisions. No-scalpel vasectomy uses a single puncture with a sharp haemostat and a ring clamp to fix the vas, and usually causes less bleeding, haematoma and infection.

Mechanism. Sperm cannot pass from the testis to the seminal vesicle and urethra, so the ejaculate contains no sperm once clearance is reached.

Effectiveness. First-year pregnancies are 0.15 per 100 women with typical use and 0.1 per 100 women with perfect use. Protection is not immediate because sperm remain in the tract beyond the cut. Another method is needed for 3 months.

Return to fertility. The procedure is virtually irreversible. Reversal is not assured to succeed, and sperm return does not guarantee pregnancy.

Indications. A man of reproductive age who has fathered the number of children he wants, understands permanence and consents voluntarily.

Not suitable. A man uncertain about future fertility, a man unable to give voluntary informed consent, and a man who cannot withstand surgery, for example with a bleeding disorder.

Counselling content for the clinician to cover.

• Permanence, low success of reversal, and options of reversible long-acting methods for the couple.
• Failure rate and the need for 3 months of backup before clearance.
• No protection against sexually transmitted infections or HIV, so condoms remain needed where risk exists.
• Effects on sex drive and performance are absent.
• Early risks of pain, bleeding, haematoma and infection, and rare chronic pain.
• Regret, particularly with young age, no children, relationship change or pressure.
• Voluntariness, absence of incentives, and the right to withdraw before the procedure.

Accept. Reproductive age with completed family and voluntary consent, including men at high risk of HIV, HIV clinical stage 1 or 2, and sickle cell disease.

Caution. Single men, men with no living children, men under 18 years (give assent with consent in line with the law), depressive disorders, diabetes (higher risk of wound infection), past scrotal injury, large varicocele or hydrocele (difficult palpation of the cord).

Delay. Local skin infection, active sexually transmitted infection, balanitis, epididymitis, orchitis, systemic infection or gastroenteritis, filariasis or elephantiasis involving the scrotum, intrascrotal mass. Treat or correct, then proceed, and provide a temporary method.

Special. Coagulation disorders, HIV clinical stage 3 or 4, previous scrotal injury, large varicocele or hydrocele or cryptorchidism needing extensive surgery to locate the vas, inguinal hernia (vasectomy may be done at the time of hernia repair).

History and examination. Fertility history, bleeding tendency, sexually transmitted infection, scrotal surgery or trauma, medicines, anaesthetic allergy. Examine the penis, scrotal skin, testes, epididymides and both vasa for palpability, hernia, varicocele and hydrocele.

Investigations. None are routine. Coagulation tests with a bleeding history. Offer HIV testing with counselling.

Regimen line. Procedure: no-scalpel or scalpel vasectomy with occlusion of both vasa. Anaesthesia: lidocaine 1% (10 mg/mL) infiltrated into the skin and around each vas, usually 5 to 10 mL in total, up to 4.5 mg/kg without adrenaline (maximum 300 mg, 30 mL) or 7 mg/kg with adrenaline (maximum 500 mg), reduced in liver disease, avoided in documented allergy. Start: any time. Protection: after 3 months. Backup: condoms or another method for 3 months. Missed-use rules: not applicable.

Partner’s method. She may continue her method, and a woman with an intrauterine device keeps it for 3 months after her partner’s vasectomy.

Preparation. Written consent, wash and clip the scrotum, set up sterile field, check emergency equipment.

Provider and facility. Trained providers only, with a minor theatre, instruments, infection prevention, emergency drugs and referral. Outreach sites must link to a facility able to manage complications. A surgeon performs no more than 15 procedures in a day and one theatre no more than 30.

Aftercare instructions. Scrotal support for several days, cold compress for the first 24 hours, rest for 1 to 2 days, no heavy lifting or strenuous exercise for about 1 week, and sex when comfortable with condoms in use until clearance. Keep the wound clean and dry.

Follow up. Wound review within 1 week. Return for semen analysis or confirmation of clearance at 3 months.

Expected effects. Scrotal bruising, swelling and discomfort for several days.

Infection regimen. Cefalexin 500 mg orally every 6 hours for 5 to 7 days, maximum 4 g daily, reduced to 250 mg every 8 to 12 hours when creatinine clearance is 15 to 29 mL/min and 250 mg every 24 hours under 15 mL/min. In severe penicillin allergy give clindamycin 300 mg orally every 6 hours for 5 to 7 days, maximum 1.8 g daily. Epididymitis from a sexually transmitted infection needs treatment of the cause.

Pain regimen. Ibuprofen 400 mg orally every 8 hours with food for 3 to 5 days, maximum 1.2 g daily for short courses, avoided with peptic ulcer, anticoagulation or creatinine clearance under 30 mL/min. Paracetamol 1 g every 6 hours, maximum 4 g daily (3 g in liver disease).

Referral and escalation. Refer expanding haematoma, abscess not responding to drainage, persistent chronic pain, and men in the Special class when the facility lacks the team and equipment.