David C. Sokal

Vasectomy: AUA Guideline

PURPOSE The purpose of this guideline is to provide guidance to clinicians who offer vasectomy services. MATERIALS AND METHODS A systematic review of the literature using the search dates January 1949-August 2011 was conducted to identify peer-reviewed publications relevant to vasectomy. The search identified almost 2,000 titles and abstracts. Application of inclusion/exclusion criteria yielded an evidence base of 275 articles. Evidence-based practices for vasectomy were defined when evidence was available. When evidence was insufficient or absent, expert opinion-based practices were defined by Panel consensus. The Panel sought to define the minimum and necessary concepts for pre-vasectomy counseling; optimum methods for anesthesia, vas isolation, vas occlusion and post-vasectomy follow up; and rates of complications of vasectomy. This guideline was peer reviewed by 55 independent experts during the guideline development process. RESULTS Vas isolation should be performed using a minimally-invasive vasectomy technique such as the no-scalpel vasectomy technique. Vas occlusion should be performed by any one of four techniques that are associated with occlusive failure rates consistently below 1%. These are mucosal cautery of both ends of the divided vas without ligation or clips (1) with or (2) without fascial interposition; (3) open testicular end of the divided vas with MC of abdominal end with FI and without ligation or clips; and (4) non-divisional extended electrocautery. Patients may stop using other methods of contraception when one uncentrifuged fresh semen specimen shows azoospermia or ≤ 100,000 non-motile sperm/mL. CONCLUSIONS Vasectomy should be considered for permanent contraception much more frequently than is the current practice in the U.S. and many other nations. The full text of this guideline is available to the public at http://www.auanet.org/content/media/vasectomy.pdf.

Cancer and Birth Defects Near the Drake Superfund Site, Pennsylvania

The Drake Superfund site in Clinton County, Pennsylvania, has been contaminated with the carcinogens beta-naphthylamine, benzidene, and benzene. The authors reviewed county-wide, age-adjusted, sex-, race-, and site-specific cancer mortality rates for the years 1950-1959, 1960-1969, and 1970-1979, and type-specific birth defects incidence rates for 1973-1978. During the 1970s, a significantly increased number of bladder cancer deaths occurred among white males in Clinton County, and a significantly increased number of other cancer deaths occurred in the general population of Clinton and three surrounding counties. There were no statistically significant clusters of any specific birth defect or of all birth defects. County-wide data on cancer and birth defects can be used for initially screening counties with Superfund sites, but more definitive studies are needed to assess the actual health effects caused by these sites.

Recent developments in vasectomy

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 womans 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 …

Transcervical quinacrine sterilization : clinical experience

Objective: To review the use of quinacrine pellets for non‐surgical female sterilization. Background: The transcervical insertion of quinacrine pellets has been under study for over 15 years. It could potentially expand access to sterilization services, because it is relatively simple to administer, with the use of a modified IUD inserter, and is inexpensive. Methods: Published and unpublished data are reviewed. Results: The short‐term safety of transcervical quinacrine appears to be better than surgical sterilization, but it is less effective, especially among women under 35, and there are virtually no data on its reversibility. Thus, it is probably most appropriate for older women, aged 35 and over, but it could be an option for others where access to surgical sterilization is limited. Conclusion: The use of quinacrine pellets for female sterilization needs to be reviewed by appropriate regulatory authorities, especially with regard to long‐term safety issues, and additional clinical studies are needed to better define a standardized regimen.

Vasectomy effectiveness in Nepal: a retrospective study

The main purpose of this retrospective, cross-sectional study was to evaluate the effectiveness of vasectomy in an ongoing public sector program in Nepal. We evaluated semen samples from men who had previously had a vasectomy, and asked about the occurrence of pregnancies in the mens partners. In addition, the surgeons who performed the vasectomies completed a questionnaire about their techniques. A two-stage stratified sampling procedure was used to select 1263 men from among over 30,000 men, who had previously undergone a no-scalpel vasectomy, mostly by ligation and excision, in 32 districts between July 1996 and June 1999. Semen samples were preserved and analyzed at a central laboratory. A US andrology laboratory validated the lab results. Twenty-three men (2.3%, 95% confidence interval [CI] 1.1-3.6) had >/=500,000 sperm/mL in their semen. Fifteen of those men reported pregnancies conceived after their vasectomy. In addition, six men with azoospermia reported pregnancies for which conception occurred within 3 months after vasectomy. Eleven men with azoospermia reported pregnancies for which conception occurred more than 3 months after vasectomy. Reported pregnancy was more likely in younger partners. The life table pregnancy rates for all men interviewed were 0.7 (95% CI 0.2-1.1), 1.7 (95% CI 1.4-2.1) and 4.2% (95% CI 3.2-5.2) at 3, 12 and 36 months, respectively. In low-resource, programmatic settings, vasectomy failure rates may be higher than commonly cited rates, especially in younger populations. Additional research is needed to determine if other occlusion techniques could reduce failure rates. Counseling on vasectomy should always convey the possibility of failure and partner pregnancy.

Simulating the Control of a Heterosexual HIV Epidemic in a Severely Affected East African City

We compared three intervention strategies for preventing heterosexual transmission of the human immunodeficiency virus (HIV) using deterministic and stochastic models to simulate the epidemic of acquired immunodeficiency syndromes (AIDS). We estimated demographic, biological, and behavioral parameters for a severely affected east African city early in the epidemic, and used these parameter values in computing the spread of HIV under five scenarios: (1) a baseline scenario with no public health interventions; three single-intervention scenarios with strategies to (2) reduce the number and rate of change of sex partners, (3) increase condom use, or (4) improve treatment of sexually transmitted diseases (STD); and a (5) combined-intervention scenario. The rankings were the same in both models-decreasing partner change was most effective, followed by condom use and STD treatment. Combined interventions were more effective than single interventions. They interacted to produce impacts that varied with the trajectory of the epidemic at the onset of the interventions. Their timely, targeted, and sustained implementation appears critical to slow the epidemic significantly.

Effectiveness of vasectomy using cautery

BackgroundLittle evidence supports the use of any one vas occlusion method. Data from a number of studies now suggest that there are differences in effectiveness among different occlusion methods. The main objectives of this study were to estimate the effectiveness of vasectomy by cautery and to describe the trends in sperm counts after cautery vasectomy. Other objectives were to estimate time and number of ejaculations to success and to determine the predictive value of success at 12 weeks for final status at 24 weeks.MethodsA prospective, non-comparative observational study was conducted between November 2001 and June 2002 at 4 centers in Brazil, Canada, the UK, and the US. Four hundred men who chose vasectomy were enrolled and followed for 6 months. Sites used their usual cautery vasectomy technique. Earlier and more frequent than normal semen analyses (2, 5, 8, 12, 16, 20, and 24 weeks after vasectomy) were performed. Planned outcomes included effectiveness (early failure based on semen analysis), trends in sperm counts, time and number of ejaculations to success, predictive value of success at 12 weeks for the outcome at 24 weeks, and safety evaluation.ResultsA total of 364 (91%) participants completed follow-up. The overall failure rate based on semen analysis was 0.8% (95% confidence interval 0.2, 2.3). By 12 weeks 96.4% of participants showed azoospermia or severe oligozoospermia (< 100,000 sperm/mL). The predictive value of a single severely oligozoospermia sample at 12 weeks for vasectomy success at the end of the study was 99.7%. One serious unrelated adverse event and no pregnancies were reported.ConclusionCautery is a very effective method for occluding the vas. Failure based on semen analysis is rare. In settings where semen analysis is not practical, using 12 weeks as a guideline for when men can rely on their vasectomy should lessen the risk of failure compared to using a guideline of 20 ejaculations after vasectomy.

Frequency and patterns of early recanalization after vasectomy.

BackgroundOur understanding of early post-vasectomy recanalization is limited to histopathological studies. The objective of this study was to estimate the frequency and to describe semen analysis patterns of early recanalization after vasectomy.MethodsCharts displaying serial post-vasectomy semen analyses were created using the semen analysis results from 826 and 389 men participating in a randomized trial of fascial interposition (FI) and an observational study of cautery, respectively. In the FI trial, participants were randomly allocated to vas occlusion by ligation and excision with or without FI. In the cautery study, sites used their usual cautery occlusion technique, two with and two without FI. Presumed early recanalization was based on the assessment of individual semen analysis charts by three independent reviewers. Discrepancies were resolved by consensus.ResultsPresumed early recanalization was characterized by a very low sperm concentration within two weeks after vasectomy followed by return to large numbers of sperm over the next few weeks. The overall proportion of men with presumed early recanalization was 13% (95% CI 12%–15%). The risk was highest with ligation and excision without FI (25%) and lowest for thermal cautery with FI (0%). The highest proportion of presumed early recanalization was observed among men classified as vasectomy failures.ConclusionEarly recanalization, occurring within the first weeks after vasectomy, is more common than generally recognized. Its frequency depends on the occlusion technique performed.

Randomized Controlled Trial of the Shang Ring Versus Conventional Surgical Techniques for Adult Male Circumcision: Safety and Acceptability

Objective:To compare clinical profiles of Shang Ring versus conventional circumcisions. Design:Parallel group open-label randomized controlled trial with one-to-one allocations in 2 sites. Methods:We enrolled HIV-negative men aged 18–54 years in Homa Bay, Kenya, and Lusaka, Zambia and followed them at 2, 7, 14, 21, 28, 42, and 60 days after Shang Ring versus conventional circumcision. We compared the duration of surgery, postoperative pain using a visual analog scale, adverse events rates, time to complete wound healing by clinical assessment, participant acceptability, and provider preferences between circumcision groups. Results:We randomized 200 men to each group; 197 and 201 contributed to the Shang Ring and conventional surgery analyses, respectively. Adverse event rates were similar between groups. Pain scores at most time points were similar, however, the Shang Ring group reported higher scores for worst pain during erections (3.5 ± 1.9 vs. 2.3 ± 1.7; P < 0.001). Significantly more men were satisfied with the cosmetic appearance following Shang Ring male circumcision (MC), 95.7% versus 85.9% (P = 0.02) in Kenya, and 96.8% versus 71.3% (P < 0.01) in Zambia. Although median time to complete wound healing was 43 days in both groups, conventional circumcisions healed on average 5.2 days sooner (P < 0.001). Shang Ring procedures took one-third the time of conventional MC, 7 versus 20 minutes. All circumcision providers preferred the Shang Ring. Conclusions:Safety profiles of the 2 techniques were similar, all MC providers preferred the Shang Ring technique, and study participants preferred the Shang Rings cosmetic results. The Shang Ring should be considered for adult MC as programs scale-up.

A comparison of vas occlusion techniques: cautery more effective than ligation and excision with fascial interposition

BackgroundVasectomy techniques have been the subject of relatively few rigorous studies. The objective of this analysis was to compare the effectiveness of two techniques for vas occlusion: intraluminal cautery versus ligation and excision with fascial interposition. More specifically, we aimed to compare early failure rates, sperm concentrations, and time to success between the two techniques.MethodsWe compared semen analysis data from men following vasectomy using two occlusion techniques. Data on intraluminal cautery came from a prospective observational study conducted at four sites. Data on ligation and excision with fascial interposition came from a multicenter randomized controlled trial that evaluated the efficacy of ligation and excision with versus without fascial interposition. The surgical techniques used in the fascial interposition study were standardized. The surgeons in the cautery study used their customary techniques, which varied among sites in terms of type of cautery, use of fascial interposition, excision of a short segment of the vas, and use of an open-ended technique. Men in both studies had semen analyses two weeks after vasectomy and then approximately every four weeks. The two outcome measures for the analyses presented here are (a) time to success, defined as severe oligozoospermia, or <100,000 sperm/mL in two consecutive semen analyses; and (b) early vasectomy failure, defined as >10 million sperm/mL at week 12 or later.ResultsVasectomy with cautery was associated with a significantly more rapid progression to severe oligozoospermia and with significantly fewer early failures (1% versus 5%).ConclusionThe use of cautery improves vasectomy outcomes. Limitations of this comparison include (a) the variety of surgical techniques in the cautery study and differences in methods of fascial interposition between the two studies, (b) the uncertain correlation between sperm concentrations after vasectomy and the risk of pregnancy, and (c) the use of historical controls and different study sites.