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Vasectomy is the most common form of male contraception in this country. Each year, about half a million men in the United States who want to practice reliable birth control without placing the burden on their female partners undergo this relatively simple surgical procedure.

Vasectomy is the clinical term given to the process of dividing the tubes that deliver sperm from testes. The procedure typically takes about half an hour and involves minimal surgery. Generally, the patient heals quickly with relatively few complications or failures, and no discernible negative impact on sexual performance.

Physiology

To understand how a vasectomy works, it is helpful to have a basic understanding of the parts of the male reproductive system and how they function.

The testicles - or testes - are the paired male organs that produce sperm. They are located in an external sac at the base of the penis called the scrotum. Each testicle is connected to a small, coiled tube called the epididymis, where sperm are stored for as long as six weeks as they mature. The epididymes, in turn, are connected to the prostate gland by a pair of tubes called the vas deferens. The vas deferens are part of a larger bundle of tissues, blood vessels, nerves and lymphatic channels called the spermatic cord.

At sexual climax, seminal fluid produced by the prostate gland mixes with sperm from the testes to form semen. The semen then is ejaculated through the penis.

What a Vasectomy Does and Doesn't Do

In a vasectomy, the surgeon cuts and ties off the ends of the vas deferens. This prevents sperm from mixing with the seminal fluid. At ejaculation then, the semen is devoid of sperm. Although the testes will continue to produce sperm, they can no longer pass through the vas deferens. Instead, they die and are absorbed into the body.

Because semen consists of about 95% seminal fluid, there is virtually no discernible difference in the ejaculate. Similarly, because the testes continue to produce the male hormone testosterone, which is absorbed into the bloodstream, the procedure also has no effect on a man's sex drive.

Preparing for a Vasectomy

Doctors usually require their vasectomy patients to do three things on the day of their surgery.

Shave - To prevent infection, the patient should shave a 2- to 3-inch area of hair from the scrotum at the point where the penis joins the scrotum. The patient should shower thoroughly after shaving to wash away all the cut hair. Bring a pair of tight jockey shorts or an athletic supporter - This is necessary to provide support for the affected area after surgery and to facilitate the placement of bandages. Because they provide no support, boxer shorts are unsuitable. Arrange for a ride home - While the patient may feel capable of driving himself, this is inadvisable. Some men feel discomfort sooner after their surgery than others, and safe driving requires one's complete attention. Most physicians will permit a spouse or partner to be in the room during the procedure, and it makes sense for that person to drive the patient home, allowing him to rest comfortably without having to divide his attention between traffic and any postoperative discomfort.

Additionally, patients are advised to abstain from the use of aspirin and anti-inflammatory analgesics, such as ibuprofen, for a week before surgery. These medications tend to "thin" the blood and can cause excessive postoperative bleeding in the area of the incision.

How a Vasectomy Is Performed

A typical vasectomy is done on an outpatient basis. The urologist or surgeon first numbs the scrotum and vas deferens with a local anesthetic. Then, one or two incisions about half a centimeter long are made on each side of the scrotum. The vas deferens are located, a one-centimeter section is removed and the upper end is tied off. Sutures or stitches are used to close the incision in the scrotum. The ties around the vas deferens usually dissolve over a period of 4 to 6 weeks.

"No-Scalpel" Vasectomy

In recent years, many physicians have adopted a new surgical technique called "no-scalpel" vasectomy. This process uses a special clamp to encircle and hold the vas deferens without making an incision. A special forceps is used to penetrate the scrotum, then opened to stretch the skin, providing a small puncture through which the vas deferens can be gently lifted out, cut, sutured or cauterized, and put back in place. Because no incision has been made, the tiny opening quickly closes without the need for sutures.

Compared to the conventional vasectomy, the "no-scalpel" approach is slightly quicker (about 10 to 20 minutes), causes less postoperative discomfort and lower incidences of bleeding or infection.

What to Expect During the Postoperative Period

Doctors typically advise their vasectomy patients to go home immediately and lie down, elevating their feet. Although it isn't necessary to remain immobile, excessive motion, such as that caused by walking around, increases the chance of inflammation in the scrotum and/or the area around the incision.

It is normal for the patient to feel some moderate discomfort during the first day or two after his anesthetic wears off. Ice packs, applied 15 minutes on and 15 minutes off, can help keep swelling to a minimum, and mild over-the-counter painkillers like acetaminophen can be used every 4 hours as needed. Stronger painkillers can be prescribed by the doctor, if necessary.

Patients are advised against the use of aspirin and anti-inflammatory analgesics, such as ibuprofen, for at least a day or two after surgery because they tend to "thin" the blood and can cause bleeding in the area of the incision.

The patient can remove his bandage or dressing the day after surgery, although he should continue to wear his undershorts for support. It may be necessary to place gauze inside the shorts for a few days to protect against any bleeding or seepage from the incision as it heals.

It is all right to shower the next day. The patient should not take a bath or go swimming for several days, however.

In general, strenuous exercise and heavy lifting should be avoided for 2 or 3 days - longer if discomfort persists. Thereafter, the degree of discomfort should guide one's activity, including athletic and sexual activity. Although patients typically can return to work within 3 days, most report that it takes them at least a week before they feel completely "normal" again.

Sterility

It is important for the patient to realize that the vasectomy does not produce instant sterilization. A substantial amount of sperm still remain in the vas deferens below the portion that was removed. In most men, it takes from 10 to 14 ejaculations over the next 2 months or so before a sperm count of zero is reached. The patient typically is asked to produce a semen sample for analysis about 8 weeks after surgery. Until then, another form of reliable birth control should be practiced. Doctors typically consider the procedure successful when the patient produces two negative sperm samples, taken 2 weeks apart.

In rare cases, patients continue to show sperm in their samples for up to a year after surgery. This may be the result of poor sperm migration out of the vas deferens after surgery, or it may indicate that the severed ends of the vas deferens have reattached themselves to one another, a condition called recanalization. The only solution to this problem is a repeat vasectomy.

Possible Complications

Although complications are rare with vasectomies, any surgical procedure, no matter how simple, carries some degree of risk. Some patients experience more pain, bleeding or inflammation than others, and their discomfort may persist longer than normal. Often this is caused by a buildup of back pressure within the vas deferens, and will eventually subside.

Occasionally a condition called sperm granuloma will develop, in which residual sperm find their way out of the tied ends of the vas deferens, producing irritation and a small nodule. These usually heal with time, although surgical removal is occasionally required.

Vasectomy and Prostate Cancer

In recent years, a controversy has been reported in some medical journals, suggesting that men who undergo a vasectomy may face an increased risk of prostate cancer many years later. Other studies have failed to confirm this, and the research which initially suggested a connection between vasectomy and prostate cancer contained few details to explain the mechanism by which such cancer might result. At present then, the hypothesis can only be said to remain unproved.

Nevertheless, as a precaution, the American Urological Association (AUA) recommends that men over age 40 who have had a vasectomy more than 20 years previously, should have an annual test for prostate cancer. This is precisely the same recommendation the AUA and the American Cancer Society makes for all men age 50 to 70.

Can a Vasectomy be Reversed?

While the intent of a vasectomy is to produce a permanent condition of male sterility, there are two microsurgical procedures that have been successful at restoring the flow of sperm through the vas deferens. Most vasectomy reversals are done on an outpatient basis.

The most common, called vasovasostomy, involves stitching the disconnected ends of the vas deferens back together with ultra-fine sutures. This procedure uses microsurgical methods involving a microscopic camera and very small tools.

The other reversal procedure, called vasoepididymostomy, is performed when inflammation or scarring from the original vasectomy blocks the epididymis - the tubular structure connecting the testes to the vas deferens. In this microsurgical procedure, the blockage is bypassed by surgically connecting the vas deferens directly to the epididymis in a new location.