Daniel Stulberg MD University of New Mexico July 6 2016 Goals Objectives Participants will Understand the technique of no scalpel vasectomy Know the risks of vasectomy Know the benefits of vasectomy ID: 524531
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Slide1
Vasectomy
Daniel
Stulberg
, MD
University of New Mexico
July 6, 2016Slide2
Goals Objectives
Participants
will…
Understand the technique of no scalpel vasectomy
Know the risks of vasectomy
Know the benefits of vasectomySlide3
What is Vasectomy?
Surgically cutting or blocking the Vas Deferens to stop the flow of Sperm from the testicleSlide4
Who?
Desire permanent (Yes discuss reversal later)
Stable relationship
Usually after 30
Already have children
Medically stable – no coagulopathy
Normal anatomy
Palpable mobile vas
Hernia?
Varicocele?Slide5
Other Options
Abstinence
Condoms
Diaphragm
Rhythm
Female hormonal
IUD
Female sterilization
Vasalgel
Mechanical valveSlide6
Comparison with BTL
Tubal ligation has 14 deaths per year versus zero “attributable” deaths per year for vasectomies
Tubal ligation has a higher rate of major morbidity
Vasectomies have a higher rate of minor complications
Average cost of vasectomy $500
Average cost of tubal ligation $1500-$3500
Failure rate in tubals is 0.4%, but can lead to ectopic pregnancies
Reversal rates are similar
Success of vasectomy can be easily checked with sperm count
From Scott
M.
Strayer
,
MD
UVASlide7
Risks
Usual – Bleeding, infection, pain, damage to nearby structures
Specific
Failure = Pregnancy
Spermatocele
Later pain
Congestion
Swelling
Antisperm
antibodiesSlide8
Rumors not Risks
Coronary artery disease
Prostate cancer - Association not causative
Sexual dysfunction
Noticeable change in semenSlide9
Why?
Permanent
Safe
Outpatient
Relatively inexpensive
$500 OCP’s $9 x12=106
No need for ongoing measuresSlide10
Confirmation
Semenalysis
gold standard
Unspun 6
wks
and 20 ejaculations
Tri-core and Quest Diagnostics centrifuge samples
12 weeks and 20 ejaculations
46% compliance
Vas segments - ? pathologySlide11
Vasectomy pregnancy failure rate of 0.1%
Early-unprotected intercourse prior to obtaining a negative semen analysis
Recanalization
of the vas deferens
Tubal ligation pregnancy failure rate of 1.85%
Vasectomy is Not Guaranteed
Trussell
J et al,
Contraceptive Technology
1998
Peterson HB et al, NEJM 1997
Weiske
,
Andrologia
2001
Schwingl
and Guess,
Fert
and
Steril 2000
From Henry
Fisch
, MD Columbia UniversitySlide12
“Clinical aspects of vasectomies performed
in the United States in 1995”
Most physicians requested the first semen analysis too soon!
<
6 weeks - 59%
7-9 weeks - 29%
> 9 weeks - 12%
Only ¾ of men are
azoospermic
at 3 months
Haws et al,
Urology
1998
From Henry
Fisch
, MD Columbia UniversitySlide13
EngenderHealth
What is the Best Vas Occlusion Technique?
Recent results based on semen analysis:
Retrospective review
Clips -
7.1% (103/1453)
Cautery -
0.09% (1/1165)
Prospective, non-comparative study
Ligation & excision alone - 11.5% (25/217)
Sources: Labrecque et al. J Urol 2002; Barone et al. J Urol in press, 2003
From John PileSlide14
EngenderHealth
Vasectomy Failure and Recanalization Rates
Recanalization based on qualitative assessment by 3 masked reviewers Failure defined as > 10 million sperm/mL at 12 weeks or later
From John PileSlide15
EngenderHealth
Severe Oligospermia at 12-14 Weeks and 20 Ejaculation After Vasectomy
From John PileSlide16
Tube Treatment Summary
Tie both tubes 1.5-19%
Cauterize prostatic end,
fascial
interposition,
testicular
end open 0.02-2.4%
Ligation and
fascial
interposition <16.7% Cauterize both tubes 4.8%Cautery and
fascial
interposition <1.4%
Remove segment, intraluminal cautery <1%Slide17
No Scalpel
Developed in China
Less bleeding
Less infection
Less time
Less stitchingSlide18
Complication Rates of
No-Scalpel
and
Incision
Vasectomy
Techniques
Bleeding/hematoma
(%)
Infection
(%)
No-scalpel Incision No-scalpel Incision
Christensen
, et al,
9.5
15.9 7.1 11.4
2002
9
(RCT)
Nirapathpongporn
, et
al, 0.3 1.7 0.15 1.34
199010 (NRCT)Sokal, et al, 1.8 12.2 0.2 1.5199911 (RCT)From Paul Dassow AAFP 2006Slide19
Counsel & Pre Op
AAFP Handout
Questionnaire
Pt
understanding
? Sig other involvement
Sperm banking
Phys
exam
No aspirin or NSAIDS
Bring supportive underwear
No shaving requiredSlide20
Counseling/Questionnaire
Welcome to the Center for Reproductive Health
Vasectomy History Questionnaire
Your visit today is about getting a vasectomy. You should read the hand out “Vasectomy: What to Expect” if you have not already read it. After that, please answer the following questions by filling in the blanks or circling the answer.
How old are you? _________________
Please list any major medical problems that you have
_______________________________________
_______________________________________
Please list any allergies to medications, iodine, stitches or anesthetics that you have _______________________________________
Please list any medications that you take
_______________________________________
_______________________________________
Have you taken any aspirin in the last 5 days? Yes or No
Have you taken any anti-inflammatory medications like ibuprofen, Motrin, Naprosyn or others in the last 2 days? Yes or NoSlide21
Are you married or in a stable relationship? Yes or No
How many children do you have? __________
Do you want to have any more children? Yes or No
Do you understand that vasectomy is to cut the tubes carrying your sperm so that you cannot biologically father any more children? Yes or No
Do you understand that it will take 12 weeks for the sperm present in your tubes to “wash out” and that you should use a form of contraception until after you have had your semen tested and found to be clear of any sperm? Yes or No
Do you understand that vasectomy reversal is complicated surgery that may not work and that you should not proceed with vasectomy if you think that you will change your mind about biologically fathering children in the future? Yes or No
Do you wish to proceed with elective sterilization by vasectomy? Yes or No
If you do not desire to proceed with this procedure please contact the staff. Otherwise, please read through the consent form, but do not sign it until you are with the physician, and we will assist you shortly.
Thank you.Slide22
Post Op/Discharge Instructions
Couch potato first day
2 days easy at home
No heavy lifting/running 1 week
No sex 1 week
No bath or soaking 1 week – shower OK
Nothing between legs 1 week
Ice is niceSlide23
Instrument Set UpSlide24Slide25Slide26Slide27Slide28
ProcedureSlide29Slide30Slide31Slide32Slide33Slide34Slide35Slide36Slide37Slide38Slide39Slide40Slide41Slide42Slide43Slide44
Need to see cellsSlide45Slide46
Variations & Styles
Scalpel t
echnique
Midline
No needle
Tubes for pathSlide47
Regrets
Cryopreservation
$500 to start
$200/
yr
to store
ReversalSlide48
Reversal
Vasovasostomy
Difficult, expensive, elective (no coverage
)
2-4 hours $5-10,000
Only 30-60% success rate (10-90% range in literature)
Similar success to tubal reversal
From Greg Herman, MD STFM 2008Slide49Slide50
Resources
AAFP
pt
ed
Video of history of No scalpel technique and procedure exampleSlide51
Case Discussions
20-year-old male with three children by three different partners on Medicaid
35-year-old man with two children and only one testicle on physical examination
23-year-old man with zero children, no current partner adamant regarding his desire for vasectomySlide52
20-year-old male with three children by three different partners on MedicaidSlide53
20-year-old male with three children by three different partners on
Medicaid
Federal consent form at least 30 days prior not more than 180 days
At least 21 for federal payment
Self-pay?Slide54
35-year-old man with two children and only one testicle on physical
examinationSlide55
35-year-old man with two children and only one testicle on physical
examination
Possible undescended testicle versus absent testicle
Cancer risk of undescended testicle
Possible failure if second testes functioning cryptorchidism, atrophic testesSlide56
23-year-old man with zero children, no current partner adamant regarding his desire for
vasectomySlide57
23-year-old man with zero children, no current partner adamant regarding his desire for
vasectomy
Higher likelihood of regret
Higher likelihood of reversal
Listen to patient’s perspective
Consider note from patients PCP
Consider visit with family counselor