SURGICAL APPROACH

NSV is a minor procedure and is usually performed on an outpatient basis. Local anesthesia is the method of choice for management of pain. The vas is isolated through a “three-finger technique” for positioning the vas into a subcutaneous position. Vas is then grasped with the ringed clamp and scrotal skin is punctured using the sharp dissecting forceps. To isolate and deliver vas, ligation with excision (LE) and fascial interposition (FI) is the usual method of occlusion. Cauterization is another method of occlusion. After both vasa have been occluded and returned to the scrotum, puncture site is pinched tightly for a minute, a sterile gauge dressing is done with a tape or a band-aid. Scrotal support is optional.

TIMING OF PROCEDURE

NSV can be done at any convenient time on healthy and eligible clients.

FACILITIES AND PERSONNEL

NSV can be performed in hospitals, primary health care centers (PHCC), health post (HP), integrated family planning service centers (IFPSC), single purpose clinics, doctors’ clinics, and temporary or mobile facilities. There are certain minimum requirements, including running or potable water; adequate light source; toilet facilities and trimming areas; separate reception, counseling, examination and postoperative areas; auxiliary facilities such as instrument processing and storage area; and a clean, screened surgical room, isolated from the other facilities. In addition, certain equipment and instruments should be available for use in the operating room and staff should be trained in its use.

The NSV procedure must be performed by a doctor who has been specially trained to provide the service. An assistant, a nurse or an auxiliary health worker, usually assist the surgeon in the operation.

PERMANENCY

NSV should be considered permanent (irreversible). Vasectomy should not be offered or promoted as a reversible method. It is possible in some cases to reverse the procedure, that is, rejoin the ligated vas deferens. Even when such services are available, however, the clients may not be able to afford it, may not be a proper surgical candidate or the reversal attempt may not be successful. Therefore, couples who are considering NSV should be certain that they do not wish to have anymore children.

Because NSV should be considered a permanent procedure, men requesting it should be well counseled and have sufficient time to think about their decision. Some requests will come from highly motivated clients (e.g. from men whose wives may have medical conditions, those who have repeated cesarean sections, those with completed family size). Generally, these self-motivated clients need little more than a review of the information and verification that the decision was made after careful thought. In a few instances, requests may come from men who do not have a clear idea about the procedure. In this situation, great care should be taken with counseling, including exploring the client’s motive which may not be clear initially. All clients should give their informed consent only after careful exploration of the matter so that no person makes the decision for voluntary sterilization without fully comprehending that it is permanent (i.e., it is not reversible).

Historically, Sir Astley Cooper was the first to perform vasectomy on a dog in 1823, while Reginald Harrison performed the first vasectomy, in 1924, in a man for the treatment of benign prostatic hypertrophy.

The No-Scalpel Vasectomy (NSV), also called keyhole vasectomy or vasectomy without knife, was introduced in 1974 in China (of the Chongqing Family Planning Scientific Research Institute, located in Sichuan Province) by Dr. Shunqiang Li with the aim of reducing men’s fear related to the incision and increasing vasectomy use in China. At that time, vasectomy was unpopular with Chinese men, and tubal occlusion was the predominant method of voluntary sterilization. Today in Sichuan, vasectomies out number tubal ligation by a ratio of four to one; in the rest of China, tubal occlusion is still a popular method with the ratio of five to one. Subsequently an international team of experts visited Dr. Li Shunqiang in 1985 and observed his refined vasectomy technique and were convinced that the technique should become the standard approach for vasectomy. One of the team members, Dr. Phaitun Gojaseni, introduced the No Scalpel technique in Thailand and Dr. Marc Goldstein, performed the first NSV in the United States. NSV technique then slowly spread to European, African and Asian countries. Over time, the technique gained popularity and it is now a preferred method of male sterilization in many countries.

The procedure is done under local anesthesia. It is a safe and minimally invasive procedure with a much lower complication rate than that of the conventional vasectomy. It is estimated that since 1974 NSV has been accepted by over 15 million men worldwide (10 million Chinese). Of the approximately half a million vasectomies performed in the United States in 2002 were No-Scalpel Vasectomy. NSV is believed to decrease apprehension towards vasectomy among men as incision is not performed (Antarsh, 1988). Over the years clinical reports have also documented the safety, efficiency and convenience to clients of the NSV procedure.

Differences between Incision and No-Scalpel Vasectomy Techniques

NSV is both safe and effective. It requires specially adapted but simple instruments and specific skills to perform. It is appropriate for most settings where the instruments and trained staff are available.

The advantages of NSV over Incisional Vasectomy include:

The effectiveness of a contraceptive method usually is the most important factor, both for the individual (or couple) trying to choose a method and for the service provider. For valid comparison of effectiveness to be made among the most commonly used methods, failure rates must be presented not only for individuals using the methods consistently and correctly, but also for typical users. Vasectomy is one of the most effective methods of contraception. Various studies show variation in effectiveness. Further studies a Global Hand Book 2011 explain effectiveness as below.

One of the most effective methods but carries a small risk of failure:

• Where men cannot have their semen examined 3 months after the procedure to see if it still contains sperm, pregnancy rates are about 2 to 3 per 100 women over the first year after their partners have had a vasectomy. This means that 97 to 98 of every 100 women whose partners have had vasectomies will not become pregnant.

• Where men can have their semen examined after vasectomy, less than 1 pregnancy per 100 women over the first year after their partners have had vasectomies (2 per 1,000). This means that 998 of every 1,000 women whose partners have had vasectomies will not become pregnant.

Vasectomy is not fully effective for 3 months after the procedure.

• Some pregnancies occur within the first year because the couple does not use condoms or another effective method consistently and correctly in the first 3 months, before the vasectomy is fully effective.

A small risk of pregnancy remains beyond the first year after the vasectomy and until the man’s partner reaches menopause.

• Over 3 years of use: About 4 pregnancies per 100 women

If the partner of a man who has had a vasectomy becomes pregnant, it may be because:

• The couple did not always use another method during the first 3 months after the procedure

• The provider made a mistake

• The cut ends of the vas deferens grew back together

Fertility does not return because vasectomy generally cannot be stopped or reversed. The procedure is intended to be permanent. Reversal surgery is difficult, expensive, and not available in most areas. When performed, reversal surgery often does not lead to pregnancy.

Evidence also shows that combined ligation and excision (LE) with fascial interposition (FI) increases the efficiency than simply with ligation and excision. Ligation and excision without fascial interposition is no longer recommended (Sokal et al., 2004a). There is consensus in the literature that cauterization is an effective vasectomy method which was found to significantly reduce failures compared with ligation and excision with fascial interposition. The studies reported that the risk of early recanalisation was lowest when cauterisation was used.

SAFETY

NSV in the hands of a well-trained clinician is a safe, highly effective approach for voluntary sterilization. Because it is usually done under local anesthesia and the ready accessibility of the vas, it is much safer procedure than female sterilization techniques. Less than 0.4 % of men (Nirapathpongporn et al., 1990) experience the complication of either infection or hematoma formation.

Client assessment before the procedure also reduces the likelihood of complications. Factors that may complicate NSV include previous genital tract surgeries/injuries and congenital disorders.

The NSV approach to the vas resulted in less bleeding, hematoma, infection, and pain as well as a shorter operation time and had a quicker resumption of sexual activity than with the traditional incision technique.

SIDE EFFECTS

There are few side effects associated with NSV. Initial pain or discomfort associated with the surgery generally ends within a few days. Granuloma formation is relatively rare and a self-limiting complaint.

Long-Term Health Effects

Over the years, there have been concerns about possible negative health consequences resulting from vasectomy. However, results of large, well-designed studies have consistently shown no adverse effects of vasectomy on the risks of heart disease, testicular or prostate cancer, immune system disorders, and a host of other conditions. Men requesting the procedure can thus be reassured that there is no long-term healthrisk associated with the procedure.

External Organs of the Male Genito-Urinary System

Figure 1-1 shows the external male organs. The penis contains the urethra and specialized highly vascular tissue necessary for achieving erection. The scrotum, the only other visible external male reproductive organ, is divided into two sacs (scrotal sacs). Each sac contains one testis.

During vasectomy, a puncture is made in the scrotum to allow access to the vasa (ductus) deferentia. The opening is made midway between the base of the penis and the top of the testes on the median raphe. This puncture site is chosen because (1) there is easy access to the vasa through the scrotal sac, and (2) it avoids risk of injury to the epididymides and the testicles.

Internal Organs of the Male Genito-urinary System

As can be seen in Figure 1-2, the male internal reproductive organs are made up of three groups: the testes, the ducts, and the accessory glands.

The testes (also called testicles or male gonads) produce sperm and the male sex hormone testosterone. After vasectomy, the testes continue to produce both sperms and hormones.

Table 1-4. Normal Values for a Semen Analysis Normal Seminal Parameters (Source: WHO)

The second group of organs is a series of connected ducts: the epididymides, the vasa deferentia, and the urethra. The two epididymides (which begin at and are connected to the testes) are each connected to one of the vasa deferentia. At the prostate, they come together and are connected to the urethra and the accessory glands. The epididymides and vasa deferentia carry sperm to mix with secretions from the accessory glands. The urethra carries the sperm and seminal fluid out of the body during ejaculation. The urethra also carries urine.

The vas begins at the epididymis and ends at the base of the prostate, where it is joined by the seminal vesicle. Together, the vas and seminal vesicle ducts form the ejaculatory duct. The ejaculatory duct opens into the urethra to allow the passage of sperm and seminal fluid during ejaculation. When using the three-finger technique, you can easily feel the vas by rolling the spermatic cord between your thumb and third finger.

The third group of internal organs is called the accessory glands. These include: the seminal vesicles, the prostate, and the bulbourethral glands (Figure 1-2). These glands secrete the seminal fluid that carries sperm through the urethra during ejaculation.

The Spermatic Cord

The spermatic cord is composed of arteries, veins, lymphatics, nerves, and the excretory duct of the testis. The spermatic cord is ensheathed in three layers of tissue- (1) external spermatic fascia, (2) cremasteric muscle and (3) internal spermatic fascia (Fig. xxx).

Internal Spermatic Fascia (Transversalis/Endoabdominal Fascia): Internal Spermatic Fascia is a thin layer, which loosely invests the cord; it is a continuation downward of the transversalis fascia.

Cremasteric Fascia (Fascia of Internal Oblique Muscle) : The Cremaster consists of scattered bundles of muscular fibers connected together into a continuous covering by intermediate areolar tissue The cremasteric fascia contains loops of cremasteric muscle, which draws the testis superiorly in the scrotum when it is cold.

External Spermatic Fascia (Aponeurosis of the External Oblique Muscle): The external spermatic fascia (intercrural or intercolumnar fascia) is a thin membrane, prolonged downward around the surface of the cord and testis. It is separated from the dartos by loose areolar tissue.

Step in vasectomy is to identify the vas deferens so that it can be anesthetisized and occluded. During the injection of local anesthetic and during NSV, care should be taken to avoid the testicular artery and veins located within the internal spermatic fascia (see Figure 8-11 in Chapter 8). The internal spermatic fascia is used for fascial interposition.

The vas deferens is located within the spermatic cord. It can be easily palpated and differentiated from other structures in the cord (spermatic fascia, arteries, and veins), as it is a firm, thick structure within the spermatic cord.

The vas is approximately 35 cm long and 2-3 mm in diameter. The small diameter of the lumen of the vas presents the main challenge to vasectomy reversal and needs microsurgical techniques. The success of vasectomy reversal is low (pregnancy rates range from 35-57 percent). Even when microsurgical techniques are used, success is often limited (the success rate of microsurgical techniques is between 38 and 82 percent).

Physiological changes after vasectomy

After vasectomy, the male sexual and reproductive physiology remains unaffected, aside from the desired change in fertility. The nerves involved in erection are not endangered during the procedure so after NSV there is no effect on erection. Seminal fluid, which forms the largest part of ejaculatory fluid, continues to be produced. The client will not notice any reduction in the amount of ejaculatory fluid.

Sperm production continues, even though the sperm’s passage through the reproductive system has been blocked. These sperm are absorbed into the tissue and tubes of the epididymis.

Sometimes sperm blockage causes pressure to build up in the epididymis and its tubes, causing these structures to distend and, in time, rupture. Ruptures are usually asymptomatic and not problematic. The sperm granulomas that can form at the site of the rupture do not usually require treatment. Although some vasectomists believe that this buildup can be avoided by leaving the testicular end of the vas open, the effect of this open-ended technique on failure rates has not been adequately studied.

Vasectomy causes a breakdown in the blood-testes barrier that leads to increased levels of serum antisperm antibodies in most men who have had a vasectomy. If a man has vasectomy reversal, the presence of these antibodies can inhibit pregnancy, even if the vasa are successfully reconnected. However, sperm antibodies have no known impact on general health and sexual performance.