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Ask an Expert: Dr. Puneet Masson, MD, Talks Vasectomies

Masson_Puneet_MD_32Two years ago, a filmmaker and a physician created World Vasectomy Day, an annual observance on November 7 to increase patient awareness regarding vasectomies and make them more available in remote parts of the world. Now in its second year, this day has the support of more than 200 physicians in 30 countries who agree that a vasectomy is worth considering for some men who seek a permanent form of contraception.

Although permanent sterilization may not be the best choice for all men, some supporters argue that vasectomies would decrease some of the more than 3.3 millon unplanned pregnancies that occur each year in the United States. 

Sometimes the procedure follows some logical trends. For instance, tough economic times can prompt men and their partners to make a decision to limit their family size: The number of vasectomies performed in the United States increased 35 percent during the 2007-2009 recession. Other times, the surgery’s popularity can increase for unexpected reasons. ESPN reports cases of “Vas Madness” in March, as some urologists may see a spike in patients seeking a vasectomy so they can be at home watching college basketball games while recovering from the procedure.

I checked in with Puneet Masson, MD, assistant professor of urology and director of the Male Fertility Program for Penn Fertility Care, to clear up some misconceptions and answer questions about the procedure. Masson, along with Keith N. Van Arsdalen, MD, professor of urology and director of the Male Infertility and Evaluation Center, Joseph F. Harryhill, MD, FACS, assistant professor of surgery, and Victor L. Carpiniello, MD, FACS, clinical professor of urology, are highly experienced in these procedures and routinely perform vasectomies.

News blog: Can you briefly walk me through the procedure?

Masson: Vasectomy is a 20-minute procedure that can be performed with local anesthesia in an office-based setting or under intravenous sedation, depending on patient and urologist preferences. Local anesthesia is usually administered with a small needle directly to the scrotal skin and spermatic cord.

After the patient is comfortable, the vas deferens is carefully isolated and secured, and a small skin incision is made over it. Several techniques exist to disconnect the vas deferens which include cutting, clipping, cauterizing, tying, and interposing the structure. Usually, urologists employ some combination of these techniques to permanently disrupt flow of sperm from the testicle to upstream structures. Afterwards, the soft tissues and skin are carefully closed and the identical procedure is repeated on the other side of the scrotum.

 

News Blog: What should a man consider when deciding whether to get a vasectomy?

Masson: Vasectomy is the fourth most common method of contraception used in the US, following condoms, birth control pills, and tubal ligation. Compared to other methods of permanent contraception, vasectomy is the safest, simplest, and least expensive. It should be considered permanent contraception, so men should only undergo the procedure if they are 100 percent certain that they desire no more children. A man can also cryopreserve sperm if there is any concern that someday he may desire more children, and other options to achieve fatherhood do exist through vasectomy reversals and surgical sperm extraction procedures.

 

News blog: What is the most common misconception about vasectomies?

Masson: The biggest misconception that I’ve come across is that it will affect male sexual functioning, particularly ejaculation. Only 5 to 10 percent of the ejaculate comes from the testicle; the vast majority of semen comes from upstream structures such as the prostate and seminal vesicles. Thus, the only difference in the semen of the post-vasectomized patient is that there should not be any sperm in the ejaculate. Erections, orgasm, and ejaculation should otherwise be unaffected.

 

News blog: What are the biggest side-effects associated with vasectomies?

Masson: Side effects that should be discussed with all patients include complications such as symptomatic hematoma and infection, which have a reported incidence of 1 to 2 percent. These do vary with surgeon experience and are usually mild, and are very treatable if recognized early. Additionally, some men, for reasons that we do not understand, may develop chronic scrotal pain. The reported incidence of this “post-vasectomy pain syndrome” is approximately 1 to 2 percent, and can be quite variable in its presentation. Men with post-vasectomy pain syndrome do have medical and surgical options, and for the most part, these options are effective in improving this poorly understood chronic pain. Some of these men may require additional surgery, but that is very rare.

 

News blog: What's the success rate of the procedure?

Masson: Vasectomies are greater than 99 percent effective and are intended to be a permanent form of contraception. The risk of pregnancy after vasectomy is approximately 1 in 2,000 men. What is important to understand here is that vasectomy does not produce immediate sterility. Following a vasectomy, men are asked to avoid any ejaculations for one week, and then should undergo a post-vasectomy semen analysis approximately 8 to 16 weeks later before they can be “cleared” by their urologist. Some men may require longer for sperm disappearance from the semen, and if any motile sperm persist 6 months or longer after a vasectomy, a repeat bilateral vasectomy should be considered.

 

News blog: How do vasectomy reversals work? How successful are they?

Masson: During a vasectomy reversal, the vas deferens is reconnected so that the man’s ejaculate contains sperm. A microsurgical vasectomy reversal typically takes four to six hours and is done under general anesthesia. Due to swelling in the vas deferens, which occurs as a natural part of healing, it may take up to a year before sperm are visible in the ejaculate. If a more complicated connection is done (vas to epididymis), it may take up to 18 months. What all patients should understand is that there is no guarantee that a pregnancy will be conceived through natural means following a vasectomy reversal. Though most studies report a ‘natural’ pregnancy rate between 50 and 70 percent, some couples may still choose to participate in assisted reproductive therapy following a vasectomy reversal and undergo in utero insemination (IUI) and/or in vitro fertilization.

The other option is surgical sperm extraction, which involves obtaining the sperm directly from the testicle or epididymis, and can typically be done under local anesthesia or intravenous sedation. This usually takes under 1 hour but any surgically extracted sperm must be used in conjunction with in vitro fertilization.

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