Recent developments in vasectomy

Abstract

Introduction Vasectomy is one of the safest and most effective permanent contraceptive methods available. Compared with tubal ligation, which is usually done under general anaesthesia and entails surgery within a woman's peritoneal cavity, vasectomy is safer and men recover more quickly from the procedure. Vasectomies are usually done under local anaesthesia in outpatient settings, and men usually go home within an hour of the surgery. None the less, for various reasons, vasectomy procedures are less common than tubal ligation procedures in most countries. Surgical techniques used for vasectomy vary widely throughout the world. The two main components of vasectomy are isolation of the vas deferens from the scrotum and subsequent vas occlusion. However, more than 30 different combinations of vas occlusion techniques probably exist,1 and poor quality studies, heterogeneous study designs, and conflicting results have made it difficult to determine which are the most effective.2 The most common technique, especially in low resource settings, is suture ligation with excision of a small segment of the vas.3 Few data are available on exact rates of use, but recent observations and interviews with surgeons in Asia suggest that at least 95% of all vasectomies in India, Nepal, and Bangladesh are done using ligation and excision (Michel Labrecque, Laval University, written communication, 28 May 2004). In contrast, data from 1995 indicate that only about 18% of vasectomies in the United States are done using this technique.4 Although vasectomy has traditionally been thought to have overall failure rates of 1-3% or lower,5–7 recent research indicates higher failure rates for ligation and excision.8–10 Because of a concern that vasectomy failure rates with ligation and excision could be higher than generally acknowledged, Family Health International and EngenderHealth convened a meeting of vasectomy experts in April 2001 in Durham, North Carolina. Family Health International and EngenderHealth are non-profit, non-governmental organisations devoted to improving global reproductive health. As a result of the experts' recommendations in 2001, additional research was conducted, and new data are now available. To review the latest findings, a second meeting of vasectomy experts was convened in December 2003 in Washington, DC. We describe here the outcomes of discussions from that meeting. Summary points In fascial interposition, the sheath covering the vas is pulled over one severed end and the sheath is closed to create a natural tissue barrier Ligation and excision of a small segment of the vas plus fascial interposition is more effective at occluding the vas than is ligation and excision alone Thermal cautery or electrocautery of the vas lumen is also more effective than ligation and excision alone; inexpensive, battery powered thermal cautery devices are commercially available Recent evidence suggests that cautery plus fascial interposition is more effective than ligation and excision plus fascial interposition, but fascial interposition is technically challenging; research is needed to determine where cautery alone fits into this hierarchy