Archive for the ‘complications of vasectomy’ Category

Issues To Consider Regarding Vasectomy

October 12, 2014

Men who consider a vasectomy often ask questions about the risks involved. This blog will discuss the risks and the consequences of vasectomy and what every man needs to know before proceeding with the procedure.

There are three main concerns regarding the long-term consequences or general health hazards of vasectomy. These concerns have arisen mainly from isolated studies over the past 50 years. Remember that it is important to show that several things be true when trying to link two medical conditions: a) that the link makes physiological sense and that this is shown in either animal models or in humans, and b) there should be excellent evidence of this link in populations of humans.

Heart Disease Risk

In 1979 a study was published that suggested that atherosclerosis or coronary artery disease might occur prematurely after vasectomy in monkeys. In this small study, monkeys fed high cholesterol diets were found to have what appeared to be increased amounts of atherosclerosis following vasectomy. Subsequent animal studies did not agree with these initial findings, and large epidemiological studies, including an extensive study of U.S physicians followed for 259,000 person-years have concluded that neither early atherosclerosis nor heart attacks or strokes occur more frequently in men who have had vasectomies compared to men who have not.

It is true is that after vasectomy, approximately 60-70% of men develop a form of allergy to their sperm in the form of antisperm antibodies. The body, either during the vasectomy or after, is exposed to sperm proteins that it commonly does not see and antibodies against these proteins can be observed in some patients. However, it has not been shown conclusively that the presence of these antibodies has any significant effect on other organs.

Prostate Cancer Risk

There has been much discussion over the past 15 years about whether vasectomy is associated with the development of prostate cancer later in life. The Journal of the American Medical Association published 2 reports suggesting that men who have had a vasectomy may be at risk for developing prostate cancer. Both studies were coauthored by Dr. Edward Giovannucci. One study evaluated men married to female nurses: men with vasectomies were compared to men without. The second study evaluated men in the health professions (veterinarians, pharmacists etc) who had had a vasectomy, and, again compared them with other male health professionals who had not had vasectomies. In both studies, there appeared to be an increased risk of developing prostate cancer in men who had a vasectomy more than 20-22 years before. On the contrary, several other studies, including several in the U.S showed no statistically significant increase in the risk of prostate cancer following vasectomy. Indeed, it was suggested in the same JAMA issues that a true cause-and-effect relationship could occur by chance alone, or because of biases (selectivity) or other unaccounted variables in these two studies.

Concerns raised from these studies include the fact that the men in the study might not represent the larger population of all men who get vasectomies. This means that the study cannot be used with certainty to predict a similar occurrence in the general population. It is also possible that the men who had had vasectomies in these studies would be more likely to see a urologist rather than an internist or family practice physician for later evaluation of a urologic problem than the men who had not had vasectomies. Urologists are better at finding prostate abnormalities than other kinds of physicians and therefore cancer might have been detected earlier than it would have otherwise. This is called “detection bias.” It has also been suggested this study design makes it impossible to identify all of the factors that might contribute to this end result with two events (vasectomy and cancer) occurring several decades apart. A prospective study is really necessary here to answer the question. A prospective study evaluates groups of patients at the time they have the vasectomy and follows them regularly for years to see, if indeed, cancers do occur. This is the most powerful way to study this relationship, but was not used in the Giovannucci papers. In addition, no study has ever established that there is an increased risk of death after prostate cancer following vasectomy.

Because the question of a relationship between vasectomy and prostate cancer was raised, the American Urological Association first recommended that men who had a vasectomy more than 20 years ago or who were > 40 years of age at the time of vasectomy have an annual examination of their prostates as well as a blood test for prostate cancer (serum Prostate Specific Antigen or PSA). However, given the recent lack of support for this relationship between vasectomy and prostate cancer, this recommendation has been revoked. Finally, no mechanism is known, nor is there any animal model proof of the plausibility of the link between these conditions.

Dementia Risk

There is a recent, single, small paper that has linked vasectomy to the later development of a rare form of Alzheimer’s disease. The issue is that a researcher found that, among a group of patients suffering a form of dementia called primary progressive aphasia (PPA) that is often confused for Alzheimer’s disease, the men had a higher percentage of vasectomy than was thought normal. The study found that 40% of 47 men with PPA had had a vasectomy, while among another 57 men from the community without PPA there was a vasectomy rate of 16%. What this means is simply that the rate of vasectomy among PPA patients is a little over 2 fold higher than in otherwise healthy patients. This study did not find an increased rate of vasectomy in patients with Alzheimer’s.

The most common form of dementia caused by brain deterioration in individuals over age 65 is Alzheimer’s disease. A very unusual form of Alzheimer’s disease is called primary progressive aphasia. This condition robs people of their ability to speak and understand language, but they are still able to maintain their hobbies and perform other complicated tasks for a long time. By contrast, Alzheimer’s patients lose their memory, interest in hobbies, family life and become idle.

A “mechanism” for the association between PPA and vasectomy was also proposed in the study. It involves the fact that men can have antibodies form to sperm after having a vasectomy (see above risks) and these antibodies may somehow cross-react with the brain and cause PPA. There is no animal model data to support this theory, however.

Problems with this study are similar to that described for prostate cancer risk and vasectomy. How unique were these patients that they gathered from all over the US twice annually to participate in a support group with such rare disease? We really need a prospective study to show this relationship as retrospective studies have too much “bias” or too many uncontrolled issues that could produce the same result. In addition, the study groups were very small: fewer than 20 PPA patients had a vasectomy and fewer than 10 healthy patients had a vasectomy. It is hard to generalize at all from so few patients in a study. Also, the study methods were faulty in that the vasectomy condition should have been confirmed by reviewing the medical charts on the PPA patients, since their disease alters their ability to understand, hear and remember what has happened to them! Indeed, like the issue of prostate cancer and vasectomy, this issue will take at least a decade or two to confirm or disprove.

Bottom Line: Vasectomy remains an effective method of sterilization. Certainly there are risks with any procedure and the risks of prostate cancer, dementia, and heart disease need to be considered by every man who wishes to proceed with the vasectomy.

The Safety of Vasectomy Using No Scalpel, No-Needle Technique

October 12, 2014

Vasectomy remains one of the most effective and safest methods of contraception. The only technique that would be cheaper is the diaphragm and abstinence. Both of which have a high failure rate. The next few blogs will discuss the safety of vasectomy.

Besides the fact that a vasectomy is very popular, one must remember that there is no form of fertility control, except abstinence, which is completely free of potential complications. In all, vasectomy remains one of the safest and best forms of permanent contraception, provided that the patient is aware of and understands the potential risks associated with the procedure. The side effects and complications of vasectomy are divided into “early” and “late” categories, depending on when they occur. The risks and complications of the procedure, including potential vasectomy pain, are examined below in greater detail.

Vasectomy and Pain

Men worry about pain and discomfort during and after the procedure. In my practice less than 5% of respondents said they had pain, much lower than the well-recognized and commonly published rate. In addition, seldom do any of the men require post operative pain medication. I suggest bed rest and ice over the scrotum the day of the procedure and non-steroidal anti-inflammatory medication such as Tylenol or Aleve for post operative pain.

Early Complications

Shortly after the procedure there may be mild discomfort, and most men are able to return to work in 1-2 days. A small amount of oozing (light bleeding, less than the size of a quarter) and swelling in the area of the tiny opening are not unusual. This should subside within 72 hours. Occasionally, the skin of the scrotum and base of the penis turn black and blue. This is not painful, lasts only a few days, and goes away without treatment. For a period of 7 days following the vasectomy, sex should be avoided. Strenuous exercise (for example climbing, riding motorcycles or bicycles, playing tennis or racquetball) should also be avoided for 7 days, and nothing heavier than 8-10 pounds should be lifted after the procedure until day 7 when all activities including heavy lifting can begin.

Rarely (less than 1%), a small blood vessel may bleed into the scrotum and continue to bleed and form a clot of blood (hematoma). A small clot will be reabsorbed by the body with time, but a large one usually requires drainage through a surgical procedure.

Importantly, the vasectomy procedure is not always 100% effective in preventing pregnancy because, on rare occasions, the cut ends of the vas may rejoin. This occurs very infrequently; the published rate is about 1 in every 600 vasectomies. My vasectomy failure rate, defined as either persistent motile sperm in the ejaculate or a pregnancy after the procedure, is less than 1/1000 cases.

Since sperm can survive for several months in the vas deferens above the point where they were interrupted, it is very important that another form of contraceptive is used until sterility is assured. To determine whether the ejaculate is devoid of sperm, an ejaculate must be brought in for formal microscopic examination after the procedure. Since “clearing the tubes” through ejaculation is a relatively inefficient process, it make take 15 ejaculations to empty the system entirely of sperm. In terms of time after the procedure, roughly 90% of men will have no sperm in the ejaculate 3 months later. This is the reason we ask men to provide us with a semen sample after 15 ejaculations or 3 months after the vasectomy. Occasionally, it may take 6 months or longer after the procedure to flush out all the sperm. The semen specimen must demonstrate no sperm before unprotected intercourse is permitted.

Bottom Line: Vasectomy is a safe form of sterilization and there are few complications.  Each man who considers proceeding with a vasectomy needs to weigh the benefits vs. the risks and complications associated with the procedure.  Most men will find that the procedure is the best way to proceed with contraception.