ANDROLOGIA 33, 125±134 (2001)
ACCEPTED: OCTOBER 17, 2000
Private Practice, Stuttgart, Germany
Key words. Clearance of spermatozoaÐlong-term effects of vasectomyÐpostvasectomy complicationsÐsurgical
procedureÐvolume of post-operative ejaculate
Summary. Vasectomy is regarded as the
the USA, nearly 7% of al married couples
safest method now available for male fertility
choose vasectomy as their form of birth control.
control. Almost 100 million men worldwide have
The global increase in the acceptance of
relied on vasectomy for family planning. This
vasectomy as the most effective means of male
review discusses all currently relevant operative
family planning has naturally stimulated intense
techniques, including no-scalpel vasectomy, com-
interest in the consequences of this procedure.
plications, possible long-term effects on the testis
Vasectomy and its sequelae are therefore amongst
and epididymis, and diseases for which associa-
the most studied areas of modern medicine.
tions with vasectomy have been suggested, such
This review discusses currently relevant opera-
as arteriosclerosis, autoimmune diseases and can-
tive techniques, complications, and possible
cer of the prostate and testis. Other topics of
long-term effects on the testis and epididymis, as
discussion include the timing of post-operative
well as diseases suggested to be associated with
semen analysis, patient noncompliance con-
cerning post-operative controls, persistent cryp-
tozoospermia and transient reappearance of
spermatozoa after vasectomy, vasectomy failure
Information and legal situation
and legal aspects.
Voluntary vasectomy, for the purpose of family
planning, is readily accessible. There are no
legal regulations concerning the age or size of
family for which sterilization is permitted. Pre-
Vasectomy is the safest method now available
operative information is a decisive factor, with
for male fertility control. In 1991, the number of
special consideration given to the patient's
sterilized men was estimated to be 50 mil ion
age, his marital situation or partner relationship
worldwide (WHO, 1991). Since then, 60 million
and his irrevocable decision to seek permanent
men have reportedly undergone vasectomy by
contraception, because there will never be a
means of the no-scalpel method alone (Arellano
refertilization rate of 100%.
et al., 1997). Although precise numbers are cur-
All alternative options for preventing preg-
rently not available, it is assumed that more than
nancy should be discussed, as wel as side-effects
100 million men have chosen vasectomy as a
and risks. Consultation with the wife or partner
means of birth control. In Germany, vasectomy
is desirable, although it is not legally required
accounts for 2% of all contraceptive methods,
that the wife agrees to the intervention. It is
while the worldwide rate is 10% (WHO, 1991).
most important to inform the patient of the
In Germany, the woman still bears the main
necessity for post-operative ejaculate analyses,
burden of contraception (pill 60%; coil 10%). In
because the success of the operation cannot be
con®rmed without two subsequent demonstra-
tions of azoospermia. Insuf®cient control of
Correspondence: Dr Wolf-Hartmut Weiske, KoÈnig-Karl-Str.
38, 70372 Stuttgart, Germany. Tel:+49 711568090;
the ejaculate is the most frequent cause of
Fax:+49 711564046; E-mail: WeiskeWH@t-online.de
unintended pregnancy after vasectomy.
U.S. Copyright Clearance Center Code Statement: 0303-4569/2001/3303-0125 $15.00/0
The patient must also be informed that sper-
observation, the `U-turn' of the vas ends appears
matozoa may reappear in the ejaculate as a
to be unnecessary.
result of spontaneous recanalization. Paternity as
The fulguration technique inaugurated by
a consequence of recanalization can occur at
Schmidt (1966) consists of thermal damage to
any time after vasectomy and does not depend
the mucosa of the vas deferens by insertion of a
on the surgical procedure (Verhulst & Hoekstra,
diathermic needle, resulting in cicatricial occlu-
1999). It has proved useful that these points be
sion via an in¯ammatory reaction. The two ends
con®rmed by the patient's consent in the form
of the vas deferens are fulgurated over a distance
of a signature.
of about 1 cm. A U-shaped segment of the vas is
resected and the testicular remnant is ligated
(Weiske, 1994). This procedure offers the advan-
tage of being minimally invasive, which results
in an extremely low complication rate (0.3%
haematoma) (Schmidt & Free, 1978; Schmidt,
A vasectomy technique should provide maxi-
1995). This means that the patient does not
mum safety as regards sterility (azoospermia)
require analgesics and can return to normal activ-
and minimal post-operative complications. The
ity after only 1 day. Another advantage is that
operation is usually performed as an outpatient
tissue damage is restricted to the ends of the
procedure under local anaesthesia. From a medi-
deferent duct, thus creating optimal conditions
cal point of view there is no reason to perform
for reversal of vasectomy, as observed in 12 of
vasectomy under full anaesthesia. Vasectomy
our own patients.
reversal surgery if desired (considering a divorce
The best-known minimal invasive technique is
rate of more than 30%) should not be impeded
the `no-scalpel vasectomy' from China (Li et al.,
by excessive resection of the deferent duct.
1991). By means of a special clamp, the skin
The method most commonly used in
covering the vas deferens is perforated and sepa-
Germany, the ligation technique (Fig. 1), consists
rated, followed by opening of the sheath layer.
of identi®cation of the vas, resection of 2±4 cm,
Thereafter, the vas is grasped with special for-
ligation of the vas ends and turning the ends
ceps. The subsequent procedure is similar to that
round into a U-shape. In hundreds of vasectomy
of the fulguration technique described above.
reversal procedures on our own patients, this
This method is currently the least traumatic pro-
U-shaped part of the vas deferens has never
cedure, and is increasingly being used worldwide
been observed. It appears that pressure-related
(Holt & Higgins, 1996; Skriver et al., 1997;
necrosis occurs in these segments of the vas
Kumar et al., 1999; Sokal et al., 1999), because
deferens, so that ®nally there is only scar
the complication rate of 0.4% is much lower
tissue (Fig. 2). As a logical consequence of this
than that after conventional vasectomy (3.4%),
although in the `good hands' of an experienced
surgeon the incidence of complications for
no-scalpel vasectomy is virtually the same as
that for the standard incision method (0.3%)
Figure 1. Techniques of vasectomy by resection and ligation of the
Figure 2. Findings during reversal of vasectomy performed 29 h
vas ends. (a) Ligation of the U-shaped vas ends. (b) Ligation of the vas
before via ligation of the U-shaped vas ends. Ligation decreases the
ends and resection of vas deferens (2±4 cm). (c) Interposition of fascia so
blood circulation in the vas ends and the tissue becomes necrotic. One
both ends are in different layers.
of the threads is already free and two open lumina of the vas are visible.
ANDROLOGIA 33, 125±134 (2001)
REVIEW ON VASECTOMY
(Alderman & Morrison, 1999). In 1995, about
The reason for repeated vasectomy is actually
494 000 vasectomies were performed in the
a matter of indifference to him.
USA, in 29% of which the no-scalpel method
From a legal point of view, histological exami-
was used (Haws et al., 1998). Since then, more
nation of the resected part of the vas deferens
than 60 million no-scalpel vasectomies have been
proves only that the vasectomy was carried
performed in 26 countries (Arellano et al., 1997).
out on the structure of the vas. It does not pro-
To date, open-ended vascetomy, the clip tech-
vide any information on whether the surgical
nique and occlusion techniques (acrylate and
procedure itself was properly done.
polyurethene elastomere) have not been gener-
ally accepted in Europe. Either the methods are
considered not safe enough (open-ended vasect-
omy presenting with a failure rate of 4%;
Shapiro & Silber, 1979; Goldstein, 1983), or the
Whether there are any post-operative complica-
use of agents for chemical vas occlusion poses
tions will primarily depend on the surgeon's
pharmacological problems. However, Australian
experience rather than on the method used.
authors (Errey & Edward, 1986) have reported
The percentages shown in Table 1 have been
only one failure (0.02%) in 4330 open-ended
reported (Leader et al., 1974; Philip et al., 1984;
vasectomies, so this method cannot be generally
Kendrick et al., 1987).
rejected. Tissue interposition between the ends
Post-vasectomy pain syndrome is a well-
of the vas was essential. This method was devel-
recognized clinical entity. Reports of pain involv-
oped to avoid epididymal congestion and thus
ing the testis and epididymis after vasectomy
the occurrence of sperm granulomas (Shapiro &
over a long period of time, worsening during
sexual activity, are in the range of 3±8% (Myers
Recently, vasectomy has also been performed
et al., 1997). Common conservative therapy
by laparoscopy procedures. In our opinion, the
includes scrotal support, nonsteroidal anti-
related expenditure and risks are only justi®ed in
in¯ammatory drugs and spermatic cord block.
combination with another indication, such as
In severe cases, surgical treatment has been
surgical hernia repair (Kasirajan et al., 1999).
reported, including vasectomy reversal, open-
A review of the literature demonstrates that
ended vasectomy (decreasing hydrostatic pres-
vasectomy is successful in 97.2 to 99% of all
sure in the epididymis), epididymectomy and,
cases, irrespective of the method used. Most sta-
as a last resort, orchiectomy, which has a cure
tistics show a failure rate of less than 1% (Smith,
rate of up to 76% (Myers et al., 1997). Among
1996; Schwingl 2000). It seems that interposition
our own patients, similar complaints have been
of connective tissue between the two ends of the
noted only occasionally in more than 2000
vas, rather than the length of the resected part,
vasectomized men; the patients complaining of
is crucial for success (Hallan & May, 1988). An
pain were always treated conservatively.
additional factor that should not be underesti-
mated is the experience and skill of the surgeon.
Physicians who do not perform many vasec-
Post-operative semen analysis
tomies have higher complication rates (Kendrick
et al., 1987).
Post-vasectomy semen examination always con-
sists of analysis of the sediment of the ejaculate,
in order that single spermatozoa should not be
Histological examination of the excised vas
overlooked (2000 r.p.m. for 10 min). Different
To ful®l the need for safety, it is a common
Table 1. Post-operative complication percentages
procedure to have the resected part examined
histologically to show that the vasectomy was
performed properly. This measure is not legally
required. It causes unnecessary expense with-
out providing signi®cant bene®ts. In case of
a so-called identi®cation error, the ®rst semen
analysis will show numerous motile spermatozoa
which will continue to appear in follow-up
examinations. This costly practice will not
Vas cutaneous adhesion
Spontaneous late recanalization
protect the patient from late recanalization.
ANDROLOGIA 33, 125±134 (2001)
recommendations have been made concerning
probability of a positive semen analysis, this
the number and time of post-operative semen
demand is unlikely to be met.
analyses for assessment of the surgical results.
Data in the literature range from one to three
follow-ups, at intervals of 6 weeks, for up to 1 year.
Patient noncompliance after vasectomy
The number of ejaculations appears to be essen-
tial. In a study of 13 vasectomized men (Freund
The importance of post-vasectomy semen ana-
& Davis, 1969), the patients were asked to pro-
lyses is discussed in broad terms with each
duce 10 ejaculations within the shortest possible
patient. The man then signs an agreement that
time. Absence of spermatozoa was noted after
he can only be considered infertile after two
6±10 ejaculates following vasectomy. Apart from
consecutive negative semen analyses. Likewise,
the additional technical demand, this natural
the physician is not legally liable until azoosper-
clearance of the seminal duct may be one of the
mia has been demonstrated twice. It is therefore
reasons why irrigation of the abdominal vas seg-
surprising how vasectomized patients behave
ment with nitrofurazone or bidistilled water,
with regard to the requested follow-ups; they are
inaugurated by Albert & Seebode (1977) and in
noncompliant rather than compliant. 14±36% of
Germany promoted by Carl (1998), has not
the men never returned for a semen analysis
gained general acceptance.
(Belker et al., 1990; Weiske, 1994; Maatman et al.,
In one of the most extensive studies
1997). One or two examinations were performed
(Alderman, 1989) comprising 5233 vasectomized
in approximately one-third of cases. Only 3% of
men with at least 12 post-operative ejaculations,
the patients were seen at the recommended yearly
azoospermia was observed only after 3, 6 and
follow-up (Maatman et al., 1997). The partners
12 months in 75, 90 and 99% of cases, respec-
of eight of 1892 vasectomized men experienced
tively. These results may be explained by the
pregnancy (Maatman et al., 1997). None of the
age of the patients and their frequency of
eight men met the criterion of two consecutive
negative semen analyses 1 month apart.
The 1999 guidelines of the German Society of
No studies are available on the reasons for this
Urology recommend the following procedure.
noncompliance. Possible causes include psycho-
The ®rst post-operative semen analysis is made
logical factors such as aversion to masturbation,
after 6 weeks and with at least 12 ejaculations,
con®dence in the physician who certainly has
because the seminal duct is thought to be
done a good job, and ®nally the low failure rate
cleared of residual spermatozoa by that time
of less than 1%, which is also known to the
(Freund & Davis, 1969; Maatman et al., 1997).
patient. Changes in the partner relationship and
health problems causing inability to perform
Eight per cent of vasectomized men are found to
intercourse may also play a role. But perhaps it
be azoospermic at ®rst follow-up (Goldstein,
is simply because of the irresponsible carelessness
1995). A second examination is performed after
of vasectomized men that post-operative follow-up
12 weeks. If sediment analysis reveals that both
examinations are missed.
ejaculates are devoid of spermatozoa, the opera-
tion is regarded as successful, clinically and
legally. A third control after 6 months is recom-
Persistent cryptozoospermia after
mended to enable recognition of early recanali-
zation. The second control is important as it
may reveal reappearance of sperm cells in some
In rare cases, azoospermia is not achieved even
men (8%) who were found to be azoospermic on
after 6 months or longer. The sediment con-
®rst examination (De Kniff et al., 1997).
tinues to contain immotile, and sometimes even
If motile spermatozoa are present in samples
motile, spermatozoa, indicating cryptozoosper-
taken after 6 weeks, this is indicative of sponta-
mia or severe OAT syndrome. The anatomical
neous recanalization because sperm cells become
background for this observation is very small
immotile after 3 weeks at the latest (Goldstein,
channels and slits in the connective tissue and
1995). Therefore, these must be `younger' cells
scar tissue between the vas ends, especially in
that are related to the epididymis.
the case of chronic in¯ammation (Fig. 3). The
It has occasionally been recommended that
problem is how the patient should be advised.
annual semen analyses should be carried out to
First of all, it is important to consider whether
screen for the rare patients with late recanaliza-
his spermatozoa are motile or immotile. The
tion (Maatman et al., 1997). Considering the
risk of pregnancy with nonmotile spermatozoa
attendant expense and the extremely low
has been estimated to be less than that with
ANDROLOGIA 33, 125±134 (2001)
REVIEW ON VASECTOMY
is properly discussed and documented. If the
patient wishes for `a hundred per cent' safety, a
repeat operation is mandatory. A `wait-and-see
approach' is also possible, especially in consid-
eration of the partner's fertility status. Sponta-
neous azoospermia can even occur several years
later (Alderman, 1989).
Transient reappearance of spermatozoa
Smith et al. (1994) reported paternity after vasec-
tomy despite negative semen analyses. Births
occurred 1±5 years after vasectomy. In all cases,
post-operative semen analyses (two or three) and
those after conception had been negative. There-
fore, spermatozoa must have passed through in
the meantime. A possible explanation for this
phenomenon can be derived from histomorpho-
logical investigations of deferent duct tissue at
the site of previous vasectomy (Fritz & Weiske,
1996). More than 75% of vas ends examined
showed signs of persistent chronic in¯ammation,
and 20% showed signs of ductal regeneration
products in the sense of `microrecanalization'
(Freund et al., 1989). It is feasible that regenera-
tion products in combination with chronic
in¯ammation allow intermittent passage of sper-
matozoa, resulting in transient fertility of the
affected man. This thesis is supported by a study
on the occurrence of spermatozoa in the ejacu-
late before vasectomy reversal. Spermatozoa
were demonstrated in more than 90% of the
ejaculates after ultracentrifugation, and in 9.7%
after common sediment analysis (Lemack &
Goldstein, 1996). Our own investigations on
conventionally centrifuged ejaculates obtained
before vasectomy reversal revealed occasional,
immotile, dead (eosin staining) spermatozoa in
three of 100 patients (unpublished data).
Figure 3. Cross-sections of the testicular ends of the vas during
vasectomy reversal. (a) Normal cross-section of the vas deferens with
Causes of vasectomy failure
intact intratubular mucosa of the inner lumen. (b) Cross-section closer
to the vas end shows scar tissue with very small `channels' and slits,
The most frequent cause of undesired pregnancy
partially covered by prismatic epithelia (regenerated ducts). These
regenerated new small ducts could be the cause of so-called late
after vasectomy is unprotected intercourse prior
regeneration, followed by spermatozoa in the ejaculate. (c) Cross-section
to demonstration of azoospermia. Spontaneous
of the ®nal part of the vas end showing mostly scar tissue with signs of
recanalization is considered a rare event; a
chronic in¯ammation. At the left margin is a typical regenerated duct
covered with prismatic epithelia. These ®ndings were obtained up to the
distinction should be made between early
abdominal end of the vas.
recanalization in the ®rst 3 months, i.e. before
post-operative azoospermia is achieved, and late
spontaneous late recanalization (Benger et al.,
recanalization after demonstration of azoo-
1995). Motile spermatozoa are a typical sign of
spermia. In individual cases, recanalization was
the continuity of the seminal duct and, conse-
observed 5±8 years after vasectomy (Alderman,
quently, revasectomy should be performed. Men
1989), but these are extremely rare events. The
with immotile spermatozoa could be offered a
histological structure related to recanalization
special clearance, provided the risk of pregnancy
presents ductal regeneration products in the
ANDROLOGIA 33, 125±134 (2001)
sense of sperm granuloma and very seldom an
organ as the rise of pressure in the epididymal
open vas deferens (Fig. 2).
tubules can lead to ruptures (`blow-outs') and
Vasectomy failure can also be caused by a
subsequent formation of sperm granuloma
so-called identi®cation error, which means that
(Flickinger et al., 1994; McDonald, 1996). The
it was not the vas deferens but another structure
probability of the occurrence of such epidi-
(e.g. the vas) that was operated on. In such
dymal blow-outs increases with the interval
cases, post-operative clearance of sperm cells
since vasectomy, reaching a critical point after
will never occur, and a repeat operation will
be necessary to ensure severance of the vas
The signi®cance of phagocytosis of epididymal
spermatozoa by intraluminal macrophages is still
unclear (McDonald, 1996). It is a known fact
Ejaculate volume before and after
that some men undergoing vasectomy reversal
have no spermatozoa during the operation but
later show normal semen analysis. Since there is
The ejaculate consists of a mixture of secretions
obviously no epididymal obstruction in these
from the seminal vesicles (60%), the prostate
cases, clearance of spermatozoa by phagocytosis
(30%) and Cowper's and LittreÂ's glands (5%), as
may be a plausible explanation.
well as the testis and epididymis (5%). The fre-
By contrast, vasectomized animals may show
quent patient concern of reduced volume or
severe alterations. While the epididymis of rab-
even absence of ejaculate after vasectomy is
bits and guinea pigs can distend signi®cantly so
therefore unfounded. A signi®cant post-operative
that sperm granuloma are seldom demonstrable,
reduction in ejaculate volume is virtually never
rats, with lower distensibility of the epidi-
found, as shown by examination of pre- and post-
dymal tract, show ruptures and formation of
vasectomy semen analyses in 204 men under-
sperm granuloma as early as 3 weeks after the
going vasectomy (Weiske, 1994). Pre-operative
semen analysis revealed a mean volume
of 2.87 ml (0.8±7.8 ml) as against 2.58 ml
(0.8±6.2 ml) after the operation. This is a differ-
Alleged long-term effects of vasectomy
ence of 0.29 ml or 10%. Taking the largest post-
operative volumes for evaluation, a mean value
of 3.29 ml is obtained, which is markedly higher
Approximately 70% of vasectomized patients
than that before operation. A possible reason for
develop anti-sperm antibodies (Heidenreich et al.,
this difference is that obtaining ejaculate on the
1994), with a maximum after 6±8 weeks
day of operation was stressful.
(Flickinger et al., 1994). This is a classic immune
response to antigens. Spermatozoa are antigens
Vasectomy and reproductive tract
because of the blood±testis barrier and the fact
that they are produced after immune system
Following vasectomy, the testis continues to pro-
development. In the majority of patients, the
duce spermatozoa. Because of the occluded vas
anti-sperm antibody titre gradually declines to
deferens, there is only limited space for these
moderate values. In our own studies on more
spermatozoa (epididymis and convoluted part of
than 500 men who requested vasectomy reversal,
the vas), which leads to increased intraluminal
signi®cantly increased serum anti-sperm anti-
pressure, especially in the epididymis. The fate
body titres were observed in 13% of the patients.
of the epididymis depends on the elasticity of the
epididymal tubule, the amount of spermatozoa
produced, and the resorptive capacity of the epi-
didymis. The pressure built up in the epididymis
The assumption that arteriosclerosis develops
is not transmitted to the testis so the seminifer-
more extensively in vasectomized men is based
ous tubules are unaffected. Therefore, spermato-
on a study on monkeys (Alexander & Clarkson,
genesis remains unchanged (Weiske & Schulze,
1978). On a high-fat diet, arterioscleroticchanges
1996; Weiske, 2000). In this respect, there is a
in the cerebral arteries were more pronounced
signi®cant difference between humans and ani-
in animals that had been vasectomized. In an
mals, some species of which show severe testicu-
extensive study (Massey et al., 1984), 10 590
lar alterations up to testicular atrophy after
vasectomized patients were compared with the
vasectomy (Aydos et al., 1998; Whyte et al., 1998).
same number of nonvasectomized men (same
In humans, the epididymis is the vulnerable
age and race) and examined for 54 diseases of
ANDROLOGIA 33, 125±134 (2001)
REVIEW ON VASECTOMY
the large organs. The median vasectomy interval
positive relation between testicular cancer and
was 7.9 years; 3436 men had been vasectomized
vasectomy was demonstrated, this was related to
more than 10 years before. The results of the
epidemiological causes. Statistically it is very
study showed a similar or lower rate of cardio-
dif®cult to establish a signi®cant correlation,
vascular diseases, neoplasms and immune-related
particularly because the incidence of testicular
diseases in the vasectomized group. Diabetes
carcinoma is 2±8 per 100 000 men. In a large
mellitus and general mortality were lower in the
cohort study of more than 73 000 men, no
vasectomized group. A slightly higher morbidity
increased risk of testicular cancer after vasect-
rate in vasectomized men was noted for epididy-
omy was observed (Mùller et al., 1994). Testicu-
mitis and orchitis. These results were con®rmed
lar cancer originates from carcinoma in situ
by further studies in smaller patient groups, so it
(CIS). It is believed that CIS is a malignant
can be stated today that vasectomy is not asso-
gonocyte formed during embryogenesis. Vasect-
ciated with an increased risk of arteriosclerosis
omy might precipitate the development of testi-
or autoimmune diseases.
cular cancer from the pre-invasive CIS lesion
A study by Manson et al., (1999) included
( Jùrgensen et al., 1993).
22 071 US physicians aged 40±84 years. Of
the 4546 men with vasectomy, 1159 had under-
gone the procedure at least 15 years previously.
Vasectomy and cancer of the prostate
The results of this study provide reassuring
In two cohort studies (Giovannucci et al., 1993a, b)
evidence that vasectomy does not increase the
and another two investigations (Mettlin et al.,
risk of vardiovascular disease, even 15 or more
1990; Rosenberg et al., 1990) it was found that
years following the procedure.
vasectomized men have an increased risk of
developing prostate cancer. Patients with a
Vasectomy and hormone metabolism
vasectomy interval of more than 20 years are
thought to be particularly affected (Giovannucci
Testosterone production by Leydig cells remains
et al., 1992). With regard to mortality, there
unaffected by vasectomy (Association for Volun-
were no signi®cant differences. Later `population-
tary Sterilization, 1980). A multiethnic case±
based case±control studies' (John et al., 1995;
control study ( John et al., 1995) revealed lower
Zhu et al., 1996) failed to demonstrate that
serum concentrations of sex hormone-binding
vasectomized men are at increased risk of the
globulin (SHBG) and a higher ratio of dihydro-
development of prostatic carcinoma. Rosenberg
testosterone to testosterone in vasectomized men
et al. (1994) concluded that the present data
than in nonvasectomized control subjects. Simi-
provide little support for a connection between
lar results indicating a signi®cant elevation of
vasectomy and the risk of prostate cancer or
dihydrotestosterone levels in vasectomized men
were obtained in a pilot study by Mo et al.
Bernal-Delgado et al. (1998) performed a
(1995). This altered endocrine pro®le in vasecto-
meta-analysis of all essential studies on vasect-
mized men needs further evaluation in longi-
omy and prostate cancer in the literature;
tudinal studies. To date there is no biological
the authors concluded that there is no causal
indication of why vasectomy alone should in¯u-
relation between prostatic carcinoma and
ence the conversion rate of testosterone to
Similarly, a recent population-based control
study in Massachusetts (Lesko et al., 1999) did
Vasectomy and psychological alterations
not con®rm the hypothesis that vasectomy
increases the risk of prostate cancer in men older
Concerning psychological alterations, these are
than 55 years.
usually changes that already existed before
Why were such different results obtained
vasectomy. An extensive pre-operative discussion
regarding this important issue? Differences may
can elucidate psychological problems and conse-
be due to bias in selection of study participants
quently allow consideration of whether vasect-
and study controls, in obtaining information
omy should be performed at a later date or not
about study participants (questionnaire, tele-
phone interview, etc.) and in confounding the
vasectomy±prostate cancer relationship. In the
Vasectomy and testicular cancer
USA and Western Europe, vasectomy is per-
formed by urologists. Therefore, pre-operative
Studies concerning carcinoma of the testis
rectal examination and check-ups are more
are controversial. In all investigations where a
likely to be performed in these patients than in
ANDROLOGIA 33, 125±134 (2001)
men who are not operated on by a urologist. In
reversal would be expected to be much higher
their meta-analysis, Bernal-Delgado et al. (1998)
observed a signi®cantly higher risk of prostate
Vasectomy reversal procedures, performed in
carcinoma (PCA) after vasectomy in hospital-
specialized centres, are very successful, offering
based studies (relative risk=1.98; 95% con®-
patency rates from 75 to 95% and pregnancy
dence interval 1.37±2.86) and no increased risk
rates between 40 and 75% (Weiske, 2000). The
in population-based studies (relative risk=1.12;
costs of these operations are lower than those of
95% con®dence interval 0.96±1.32).
contraceptives during the average vasectomy
Vasectomized men are more sexually active,
interval of 7±9 years ( Jequier, 1998; Pryor,
have better health and live longer (Giovannucci
1998). In our opinion, it is not justi®ed to have
et al., 1992). Therefore, they are seen less fre-
ejaculates cryopreserved before vasectomy, as
quently in hospitals than nonvasectomized men.
has occasionally been recommended ( Jequier,
However, a prolonged life is associated with
1998), because 95% of vasectomized men never
the risk of developing PCA in old age. In a
wish reversal. Furthermore, cryopreservation
recent editorial by Peterson & Howards (1998)
would cause additional expense which would
from the Atlanta National Center for Chronic
amount to the cost of reversal, taking the aver-
Disease Prevention and Health Promotion, it
age vasectomy interval of 7±9 years as a basis.
was concluded that `¼ the results of studies
There is another, quite different reason for
on vasectomy±prostate cancer relationship are
refusing pre-operative cryopreservation. The
inconsistent and the observed associations
patient's decision for vasectomy must be de®nite
among most positive studies are weak in epide-
at the time of operation. The offer of cryo-
miologic terms'. Thus, the al eged causal rela-
preservation diminishes its seriousness, leaving a
tionship between vasectomy and PCA remains
`back door' which is not conducive to profound
doubtful, and is likely to be dismissed in the near
future, as was the suggested association between
vasectomy and arteriosclerosis, which took
10 years to be disproved. Therefore, it is not
surprising that couples, especially in the USA,
continue to regard vasectomy as a safe and
Albert PS, Seebode J (1977) Nitrofurantoine: Vas irrigation as
simple method of contraception (Piccinino &
adjunct in vasectomy. Urology 10:450±451.
Alderman PM (1989) General and anomalous sperm disap-
Mosher, 1998; Magnani et al., 1999).
pearance characteristics found in a large vasectomy series.
In a statement by the American Association of
Fertil Steril 51:859±862.
Urology, which was supported by the German
Alderman PM, Morrison GE (1999) Standard incision or
Society of Urology, it was recommended that
no-scalpel vasectomy? J Fam Pract 48:719±721.
preventive examinations should be performed
Alexander NJ, Clarkson ZB (1978) Vasectomy increases the
severity of diet-induced atherosclerosis in Macaca fascicularis.
from the age of 40 onwards. At present there is
no reason for vasectomized men to undergo
Arellano LS, Gonzalez BJL, Hernandez OA, Moreno AO,
reversal of vasectomy. However, prior to vasect-
Espinosa PJ (1997) No-scalpel vasectomy: review of the
omy the patient should be informed about perti-
®rst 1,000 cases in a family medicine unit. Arch Med Res
nent studies, leaving the ®nal decision to him.
Association for Voluntary Sterilization (1980) Current status of
A prostate cancer risk factor analysis in more
the endocrinological effects of vasectomy. Biomed Bull
than 500 000 men in a national study of prostate-
speci®c antigen failed to demonstrate a relation-
Aydos K, Soygur T, Kupeli B, Unsal A, Tolunay O, Erdem E,
ship between prostate carcinoma and vasectomy
Guven C, Kupeli S (1998) Testicular effects of vasectomy in
(Stone et al., 1994).
rats: an ultrastructural and immunohistochemical study.
Belker AM, Sexter MS, Sweitzer SJ, Raff MJ (1990) The high
rate of noncompliance for post-vasectomy semen examina-
Is vasectomy of long-term bene®t?
tion: medical and legal considerations. J Urol 144:284±286.
Benger AU, Swami SK Gingell JC (1995) Persistent sperma-
About 5% of vasectomized men consider under-
tozoa after vasectomy: a survey of British urologists. Br J Urol
going vasectomy reversal (Engelmann et al., 1989).
Bernal-Delgado E, Latour-PeÂrez J, Pradas-Arnal F, GoÂmez-
In 90% of these cases, a new marriage to a
LoÂpez LI (1998) The association between vasectomy and
younger woman and a wish for children are
prostate cancer: a systematic review of the literature. Fertil
the reasons. Considering a divorce rate of up to
50% in Western countries, this percentage is
Carl P (1998) Bemerkungen zur Arbeit von S. Kliesch et al.
Urologe B 38:275.
rather low, suggesting that vasectomized men
De Kniff DW, Vrijhof HJ, Arends J, Janknegt RA (1997)
have stable partnerships; otherwise, the wish for
Persistence or reappearance of nonmotile sperm after
ANDROLOGIA 33, 125±134 (2001)
REVIEW ON VASECTOMY
vasectomy: does it have clinical consequences? Fertil Steril
Lemack GE, Goldstein M (1996) Presence of sperm in the
pre-vasectomy reversal semen analysis: incidence and
Engelmann U, Deindl F, Hertle F, Wilbert D, Senge T
implications. J Urol 155:167±169.
(1989) Die Refertilisierungssituation in der Bundesrepublik
Lesko SM, Louik C, Vezina R, Rosenberg L, Shapiro S (1999)
DeutschlandÐErgebnisse einer Umfrage. Urologe B
Vasectomy and prostate cancer. J Urol 161:1848±1852.
Li SQ, Goldstein M, Zhu J, Huber D (1991) The no-scalpel
Errey BB, Edward IS (1986) Open-ended vasectomy: an
vasectomy. J Urol 145:341±344.
assessment. Fertil Steril 43:843.
McDonald SW (1996) Vasectomy review: sequelae in the
Flickinger CJ, Herr JC, Baran ML, Howards SS (1994)
human epdidymis and ductus deferens. Clin Anat
Testicular development and the formation of spermatic
granulomas of the epididymis after obstruction of the vas
Maatman TJ, Aldrin L, Carothers GG (1997) Patient
deferens in immature rats. J Urol 154:539±1544.
noncompliance after vasectomy. Fertil Steril 68:552±555.
Freund M, Davis JE (1969) Disappearance rate of spermatozoa
Magnani RJ, Haws JM, Morgan GT, Gargiullo PM, Pollack
from the ejaculate following vasectomy. Fertil Steril
AE, Koonin LM (1999) Vasectomy in the United States,
1991 and 1995. Am J Public Health 89:92±94.
Freund MJ, Weidmann JE, Goldstein M, Marmar J, Santulli R,
Manson JE, Ridker PM, Spelsberg A, Ajani U, Lotufo PA,
Oliveira N (1989) Microrecanalization after vasectomy in
Hennekens CH (1999) Vasectomy and subsequent cardio-
man. J Androl 10:120±132.
vascular disease in US physicians. Contraception
Fritz P, Weiske WH (1996) Histomorphologische Ver-
aÈnderungen im Bereich fruÈherer Vasektomien. Akt Urol
Massey FJ, Bernstein GSO, Fallon WM, Schumann LM,
Coulson AH, Crozier R, Mandel JS, Benjamin RB, Berendes
Giovannucci E, Tosteson TD, Speizer FE, Vessy MP, Colditz
HW, Chang PC, Detels R, Emslander RF, Korelitz J,
GA (1992) A long-term study of mortality in men who have
Kurland LT, Lepow IH, Quiroga J, Schmidt S, Spivey GH,
undergone vasectomy. N Engl J Med 326:1392±1398.
Sullivan T (1984) Vasectomy and health; results from a large
Giovannucci E, Ascherio A, Rimm EB, Colditz GA, Stampfer
cohort study. JAMA 252:1023±1029.
MJ, Willett WC (1993a) A prospective cohort study of
Mettlin C, Natarajan M, Huben R (1990) Vasectomy and
vasectomy and prostate cancer in U.S. men. JAMA
prostate cancer risk. Am J Epidemiol 132:1956±1961.
Mo ZN, Huang X, Zhang SC, Yang JR (1995) Early and
Giovannucci E, Tosteson TD, Speizer FE, Ascherio A, Vessy
late long-term effects of vasectomy on serum testo-
MP, Colditz GA (1993b) A retrospective cohort study of
sterone, dihydrotestosterone, luteinizing hormone and
vasectomy and prostate cancer in U.S. men. JAMA
follicle-stimulating hormone levels. J Urol 154:2065±2069.
Mùller H, Knudsen LB, Lynge E (1994) Risk of testicular
Goldstein M (1983) Vasectomy failure using an open-ended
cancer after vasectomy: cohort study of over 73 000 men.
technique. Fertil Steril 40:699.
Br Med J 309:295±299.
Goldstein M (1995) Surgery of Male Infertility. W.B. Saunders
Myers SA, Mershon CE, Fuchs EF (1997) Vasectomy reversal
Co., Philadelphia, p 39.
for treatment of the post-vasectomy pain syndrome. J Urol
Hallan RI, May ARL (1988) Vasectomy: how much is enough?
Br J Urol 62:377±379.
Peterson HB, Howards SS (1998) Vasectomy and prostate
Haws JM, Morgan GT, Pollack AE, Koonun LM, Magnani RJ,
cancer: the evidence to date. Fertil Steril 70:201±203.
Gargiullo PM (1998) Clinical aspects of vasectomies
Philip T, Guillebaud J, Budd D (1984) Complications of
performed in the United States in 1995. Urology
vasectomy: review of 16 000 patients. Br J Urol
Heidenreich A, Bon®g R, Wilbert DM, Strohmeier WL,
Piccinino LJ, Mosher WD (1998) Trends in contraceptive use in
Engelmann UH (1994) Risk factors for antisperm antibodies
the United States: 1982±95. Fam Plan Perspect 30:46.
in infertile men. Am J Reprod Immunol 31:69±76.
Pryor JP (1998) Vasectomy. An effective form of contraception.
Holt BA, Higgins AF (1996) Minimally invasive vasectomy.
Hum Reprod 13:1759±1760.
Br J Urol 77:585±586.
Rosenberg L, Palmer JR, Zauber AG, Warshauer ME, Stolley
Jequier AM (1998) Is vasectomy of long-term bene®t? Hum
PD, Shapiro S (1990) Vasectomy and the risk of prostate
cancer. Am J Epidemiol 132:1051±1055.
John EM, Whittemore AS, Wu AH, Kolonel LN, Hislop TG,
Rosenberg L, Palmer JR, Zauber AG, Warshauer ME, Strom
Howe GR, West DW, Hankin J, Dreon DM, Teh CZ et al.
BL, Harlap S, Shapiro A (1994) The relation of vasectomy to
(1995) Vasectomy and prostate cancer: results from a
the risk of cancer. Am J Epidemiol 140:431±438.
multiethnic case control study. J Natl Cancer Inst
Schmidt SS (1966) Techniques and complications of elective
vasectomy. Fertil Steril 17:467±482.
Jùrgensen N, Giwercman A, Hansen SW, Skakkebaek NE
Schmidt SS (1995) Vasectomy by section, luminal fulguration
(1993) Testicular cancer after vasectomy: origin from
and fascial interposition: results from 6248 cases. Br J Urol
carcinoma in situ of the testis. Eur J Cancer 29:1062±1064.
Kasirajan K, Govindrajan S, Erzurum VZ, Lopez J, Lopez R
Schmidt SS, Free MJ (1978) The bipolar needle for vasectomy.
(1999) Synchronous laparoscopic vasectomy and hernia
I. Experience with the ®rst 1000 cases. Fertil Steril
repair. J Laparoendosc Ad Surg Tech A 9:177±180.
Kendrick JS, Ginzales B, Huber DH, Grubb G, Rubin GL
Schwingl PJ, Guess HA (2000) Safety and effectiveness of
(1987) Complications of vasectomies in the United States.
vasectomy. Fertil Steril 73:923±936.
J Fam Pract 25:245±248.
Shapiro EI, Silber SJ (1979) Open-ended vasectomy, sperm
Kumar V, Kaza EM, Singh I, Singhal S, Kumaran V (1999) An
granuloma, and postvasectomy orchialgia. Fertil Steril
evaluation of the no-scalpel vasectomy technique. BJU Int
Skriver M, Skovasgaard F, Miskowiak J (1997) Conven-
Leader AJ, Axelrad SD, Frankowski R, Mumford ST (1974)
tional or Li vasectomy: a questionnaire study. Br J Urol
Complications of 2,711 vasectomies. J Urol 111:365±369.
ANDROLOGIA 33, 125±134 (2001)
Smith JC (1996) Long-term complications of vasectomy. Curr
Weiske WH (1994) Minimal invasive Vasektomie mittels
Opin Urol 6:344±346.
Fulgurationstechnik. Urologe B 34:448±452.
Smith JC, Cranston D, O'Brien T, Guillebaud J, Hindmarsh J,
Weiske WH (2000) Mikrochirurgische Refertilisierung nach
Turner AG (1994) Fatherhood without apparent
VasektomieÐaktueller Stand. J Fertil Reprod 10:7±14.
spermatozoa after vasectomy. Lancet 344:30.
Weiske WH, Schulze W (1996) Spermatogenese nach
Sokal D, McMullen S, Gates D, Dominik R (1999) A
Vasektomie. Urologe A Suppl. 1:S63.
comparative study of the no scalpel and standard incision
Whyte J, Sarrat E, Torres A, Diaz P, Ortitz PP, Cisneros A,
approaches to vasectomy in 5 countries. The Male
Whyte A, Mazo R (1998) Vasectomia experimental: com-
Sterilization Investigator Team. J Urol 162:1621±1625.
paracion de la estructura testicular mediante diferentes
Stone N, Blum DS, DeAntoni EP, Crawford ED, Schmid K,
tecnicas quirurgicas. Actas Urol Esp 22:178±183.
Eisenberger MA, Berger ER, Jefferson P, Staggers F,
World Health Organization (1991) Noticeboard: vasectomy
Gambert SR (1994) Prostate cancer risk factor analysis
and cancer. Lancet 338:1586.
among >50,000 men in a national study of prostate-speci®c
Zhu K, Stanford JL, Daling JR, McKnight B, Stergachis A,
antigen (PSA). J Urol 151:278A.
Brawer MK, Weiss NS (1996) Vasectomy and prostate
Verhulst AP, Hoekstra JW (1999) Paternity after bilateral
cancer: a case-control study in a health maintenance
vasectomy. BJU Int 83:280±282.
organization. Am J Epidemiol 144:717±722.
ANDROLOGIA 33, 125±134 (2001)