Despite male fears, vasectomy is a simple and near to 100% effective form of contraception
As much as parents love their children, there comes a time when most couples decide that enough is enough.
The exact moment that this occurs varies – the pleasant surprise of the unplanned 4th pregnancy, or the “missed period” scare which turns out to be a false alarm, or the realisation that one more baby would mean having to trade in the hatchback for a bus.
At this point, conversations are usually triggered between mums, dads and their GPs about contraceptive options.
The withdrawal method and other natural methods of contraception are usually considered too unreliable to give security in this scenario, and even condoms can lead to approximately 18 unplanned pregnancies in real world use per 100 women in one year.
The combined oral contraceptive pill is not perfect either, with a failure rate of 6-9 pregnancies per 100 women per year, along with not uncommon and often troublesome side effects. Long-acting reversible contraceptives (LARCs), such as the sub-cutaneous implant Implanon©, or the Mirena© hormonal intra-uterine device, are highly efficacious, with failure rates of under 1% and for many women, these provide an ideal option.
However, a significant number of women will experience unpleasant side effects. For example, nearly a third of users of the hormonal IUD will experience irregular bleeding or spotting, nearly 15% will have vaginal discharge, and over 20% will complain of abdominal pain.
Other side effects, each reported in over 5% of women using the IUD, are back pain, ovarian cysts, headache, nausea, bloating, breast pain, weight gain, acne, lowering of mood and loss of libido (its own form of contraception). Users of the implant experience similar side effects, with symptoms severe enough to lead to removal of the implant in over 11% of users due to irregular bleeding, 6% due to mood disturbance and in 2.3% due to weight gain. At this point, when couples have found female and barrier contraceptives lacking, dads in the corner of the room may begin to sweat and nervously cross their legs.
However, vasectomy is an ideal option for contraception. Despite the fears that frequently exist in the mind of the male, and the horror stories shared around barbeques about scrotums resembling spacehoppers, vasectomy provides close to 100% efficacy.
Compared with the options mentioned above, vasectomy is also associated with very few adverse impacts both in the short and long term.
The procedure is relatively easy to perform under local anaesthetic and requires very little “down-time”. It is not a painful procedure, with the clear majority of patients experiencing little or no discomfort during the procedure, and only mild discomfort for an average of three days after the procedure.
According to the literature, and survey data from my own patients, normal activity can be resumed quickly. Complication rates are low, with infection rates of less than 1% and haematoma rates of less than 0.5%. There is no evidence of an increased risk of cardiovascular disease or urological cancers. Neither is there a reduction in testosterone levels or sexual function. The procedure can be easily performed in a primary care setting, and Australia-wide, only 40% of vasectomies are performed by specialist surgeons or urologists. In Queensland, the figure is 18% and in the ACT, specialists performed only 7% of vasectomies in 2016.
When couples have found female and barrier contraceptives lacking, dads in the corner of the room may begin to sweat and nervously cross their legs
Technique
A simple method commonly used to perform a vasectomy is the No-Scalpel Vasectomy technique, which was introduced in the Sichuan Province of China in 1974 by Dr Li Shunqiang. It involves the use of sharp-tipped dissecting forceps that puncture the scrotal skin, and are then used to retract the skin and muscle to create a window through which the vas deferens can be isolated and delivered. This puncture and retraction process results in less disruption to blood vessels, therefore causing less bleeding, and negates the need for scrotal sutures. The technique is designed to be performed in an office-type set up using local anaesthesia alone. It takes approximately 15 mins on average, and as no sedation or general anaesthetic agents are used, patients are able to mobilise straight afterwards and can even drive themselves home.
There are only a few contra-indications to No-Scalpel Vasectomy – large hydroceles or varicoceles, active infection, scarred scrotal skin or an inability to palpate both vasa.
Ongoing use of other forms of contraception is advised until semen is shown to be sperm-free on analysis, which is usually performed at least three months after the procedure. Note the patient must have ejaculated more than 20 times over this period.
In 10-20% of cases, persistent occasional non-motile sperm can still be seen at three months. Repeat testing is advised in these cases at monthly intervals. Some people will maintain the appearance of these persistent non-viable sperm on a long-term basis, and can be counselled that although conception is theoretically possible, there are no documented cases of successful pregnancy in this circumstance to date.
The advantages of the No-Scalpel Vasectomy technique are borne out in the literature and a Cochrane review, which say the method is associated with less peri- and post-operative pain, haematoma formation and infection rates than other methods.
Efficacy is linked to surgical factors, such as the method of ligating the vas deferens, with cauterisation likely to be the best option. Other surgical tweaks may also help. Fascial interposition reduces the risk of recanalisation and failure. Using a single scrotal opening reduces complication rates, such as beeding or infection. Using no-needle anaesthetic techniques or even topical anaesthetic improves the patient experience.
At present, there are no formal training routes for GPs wishing to learn this procedure. Most GPs who perform vasectomies learned the procedure either on an ad-hoc basis from other GPs or trainers, or from previous experience in hospital-based training posts.
In the UK, a formal process of training, mentorship and accreditation for GP vasectomists is run through the Faculty of Sexual and Reproductive Health of the Royal College of Obstetricians and Gynaecologists, involving knowledge accumulation, observing procedures and performing procedures under supervision.
Ideally, a similar program will be established here, and the days of “see one, snip one, teach one” will be well behind us.
Dr Gun Soin is GP Editor for The Medical Republic and general practitioner in Dee Why, NSW
References available on request
