Office Based Vasectomy in Family Medicine Greg Herman, M.D. April 28, 2006

What is a vasectomy? surgical interruption of sperm outflow by removal of vas deferens sections common and safe form of permanent family planning over 500,000 performed per year (all physicians) methods: with and without scalpel

Who does this? Urologists-only 9% do not perform General Surgeons-mostly in rural America FPs-mostly in South and West (more rural areas) but based upon training FP Programs 44% have programs to train (158 programs, 28 req) 35 programs average over 10, 65 average 5 or less 74% of FPs surveyed did not offer

Selecting Candidates Stable marriage (FP advantage) Mature, mutual decision Cannot envision more children or a situation requiring reversal Must be considered a PERMANENT option

Counseling visit Complete medical history including medications Social history Physical Exam with attn to GU system INFORMED CONSENT

Did you know??? Percentage of US citizens over age 25 with a college degree. 26.7% (US Census Bureau,2003)

INFORMED CONSENT description of procedure patient requested/joint decision intent to be permanent complications infection/bleeding/hematoma pain further surgery or hospitalization failure/safe sex/sperm count

INFORMED CONSENT Discuss other alternatives Long term complications same success rate as tubal, easier, fewer complications, less expensive Long term complications ASCVD, prostate CA, others unknown Reemphasize sperm count as the final common pathway Answer all questions and document counseling and patient understanding

Short and Long Term Effects Heart Disease Monkey studies show possible relationship great vessels, not coronaries 11 human studies, no relationship Cancer Prostate- 2 studies, not controlled, show relationship not cause/effect testicular-? (age group)

Did you know??? Percentage of children aged 10-14 who have tried smoking because they saw it in a movie. 38% (Newsweek, 2005)

Short and Long Term Effects GU effects testes, epididymus, rete testis: congestion sperm granulomas, vas deferens dilation Hormonal none except down regulation of gonadal activity (?libido) Urolithiasis not well established

Did You Know?? Total US battle deaths from WW II?? 291,557 Death toll from tsunamis in South East Asia >165,000 Death toll from Sept 11, 2001 attacks 3063

Short and Long Term Effects Immunologic 50-70% develop antisperm antibodies no increase in CTDs possible effect with vasovasostomy Psychological effects pro and con, counseling a factor

Preparation Shower day of procedure Clip scrotal hair (do not shave) NPO 2 hours prior Premed with valium or similar No ASA or similar for 7 days

Techniques Standard Schmidt Open end (Erey) cut (2.5 cm), tie or clip 1-3 % fail, high rate of sperm granuloma (25%) Schmidt no excision, cauterize, sheath on urethral end low granuloma rate, not easily reversible Open end (Erey) similar to Schmidt, testicular end open lower pressures, few granulomas, easy to reverse

Techniques Cut, tie, burn and bury (desc by Raiffer) low failure rate No scalpel technique (China 1974) easy, fast once trained low complication rate (0.4% vs 3.1%) special tools

After the Procedure Rest, ice packs, leg elevation for 24-48 hrs Scrotal support, pain control No lifting, running or heavy exercise for 1 week, office work ok in 48 hrs in most cases Gradual return to SAFE SEX as tolerated (usually 2-7 days) hematospermia common

Follow Up 6 weeks for exam and semen analysis should have at least 10 ejaculations must examine fresh sample (<24 hrs) Occasional sperm vs purist 100,000/cc or 2-5/HPF some disregard if “non-motile”

Did you know??? Average cost of an ED visit (nation wide) $565 Money, 2005

Failures 0 to 1.57% (recent literature) persistant sperm spontaneous recanalization accessory vas Treatment of failure = repeat procedure

Reversal Vasovasostomy Difficult, expensive, elective (no coverage) Only 30-60% success rate (10-90% range in literature) Similar success to tubal reversal

QUESTIONS

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