1. Office Based Vasectomy in Family Medicine
Greg Herman, M.D.
May 2, 2008
The STFM Group on Procedures and Hospital Medicine

2. NO FINACIAL
DISCLOSURES

3. Objectives
Participants will become familiar with the vasectomy procedure
Participants will review the pros and cons of learning and teaching vasectomy in a residency program
We will review our curricular format
Participants will review the cost effectiveness of performing vasectomy
Participants will have the opportunity to evaluate models to teach and practice vasectomy skills

4. Our Curriculum Self study/reading Didactic lecture
Procedure days with models (1-2 times)
Resident recruiting and counseling of cases
Real cases with preceptor

5. 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

6. 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

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

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

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

11. 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

13. 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

14. INFORMED CONSENT Discuss sperm banking as a possibility
Answer all questions and document counseling and patient understanding
Discuss reversal

15. 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)

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

17. 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

18. 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

19. 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

21. 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

22. 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

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

24. 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

26. 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”

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

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

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

30. What about revenue?
Average charge for vasectomy (55250) in NJ is $500 for FM docs
$1500 for GU docs
Reimbursement varies by company, our average is $400

31. What about costs? Skin procedure equipment--$ minimal
Special tools--$250/set
Electrocautery--$500
Jet injector--$500
Malpractice premiums—varies by state/region and practitioner history, assume $2000/yr for our purposes (northeast)

32. Bottom Line Assume conservative estimates
Only about 10 procedures/year are needed to “break even”.

33. QUESTIONS

34. The End……