Infertility

Guideline basis: AUA 2015 and CUA 2022.

Background

Vasectomy is the 4th most commonly used method of contraception (after condoms, oral contraceptives, and tubal ligation). It is simpler, faster, safer, less expensive, and equally effective compared with tubal ligation — and is among the most cost-effective of all contraceptive methods, at roughly one-quarter the cost of tubal ligation.

In Canada there is no specific age of consent; any man with the legal capacity to provide informed consent may undergo vasectomy. Consider offering younger men more time to reflect before proceeding.

Pre-operative Assessment

Obtain a preoperative consultation in person where possible (telephone or electronic communication are acceptable alternatives). In the US there is no requirement for spousal or partner involvement, though patients should be advised that partner involvement is desirable.

History — focus on three areas:

• Reproductive history and reproductive status of the female partner — if the chance of pregnancy in the partner is already poor, the need for vasectomy may be less than the couple expects.
• Whether family planning is complete — if the partner is currently pregnant, consider delaying until after delivery to avoid regret should the pregnancy be lost unexpectedly.
• General medical history, particularly bleeding risk factors (liver disease, bleeding diathesis, anticoagulant medications).

Physical exam — examine the genitalia.

Labs — not required unless indicated by history; consider preoperative coagulation tests if bleeding risk factors are present.

Counselling Points

• Vasectomy is intended as permanent contraception, though it has a high probability of reversibility.
• Alternatives exist — permanent (tubal ligation) and non-permanent (barrier methods, oral or injectable contraception for the partner).
• Options for fertility after vasectomy (reversal, or sperm retrieval with IVF) are not always successful and may be expensive; preoperative sperm banking can be discussed for patients concerned about permanence.
• Impaired fertility from anti-sperm antibodies after vasectomy is infrequent, and serum anti-sperm antibodies should not be considered a deterrent to reversal.
• Vasectomy does not produce immediate sterility — time to azoospermia or rare non-motile sperm (RNMS) varies from weeks to months. Couples must use other contraception until success is confirmed by post-vasectomy semen analysis (PVSA).

Risk of Complications

• Symptomatic hematoma and infection: 1–2% — rates vary with surgeon experience and diagnostic criteria; epididymitis rates are generally low.
• Chronic scrotal pain: 1–2% — negatively affects quality of life; usually (not always) improved with medical or surgical therapy, and few men ultimately require surgery for it.
• Failure (failure to achieve azoospermia/RNMS, or pregnancy):
  • Early failure — motile sperm in the ejaculate at 3–6 months post-vasectomy; repeat vasectomy is needed in ≤1% when a low-failure occlusion technique is used.
  • Late failure — motile sperm after two prior PVSAs documented azoospermia; even confirmed occlusion is not 100% reliable, with pregnancy risk ≈1/2000 after a PVSA showing azoospermia or RNMS.
• Symptomatic nodule: <5% — presumed sperm granuloma (or suture granuloma if a ligature was used); acute pain usually resolves within 2–3 months; treat symptomatically with anti-inflammatories/analgesics; persistent pain is rare and may respond to excision and repeat vasectomy.
• Change in sexual function — frequency or satisfaction increases in half or more of patients and decreases in only ~5%. There is no evidence vasectomy increases erectile dysfunction, orgasmic or ejaculatory changes, reduced libido, or diminished genital sensation; no effect on hormones (testosterone, FSH, LH), lipids, or bone mineral density; and no association with prostate cancer, coronary heart disease, stroke, hypertension, dementia, or testicular cancer.

Procedure

Antibiotic Prophylaxis

Not indicated for routine vasectomy unless the patient is at high infection risk. The AUA Best Practice Policy on antimicrobial prophylaxis recommends prophylaxis for genital surgery that does not enter the urinary tract only when risk factors are present — and even ≥1 risk factor does not necessarily mandate prophylaxis. Risk factors: advanced age, anatomic anomalies of the urinary tract, poor nutritional status, diabetes, smoking, chronic corticosteroid use, immunodeficiency, distant coexistent infection, and prolonged hospitalization.

Anesthesia

Perform under local anesthesia, with or without oral sedation. IV sedation or general anesthesia is reserved for patients who decline local or when local ± oral sedation is judged inadequate. Infiltrate local anesthetic into skin and perivasal tissue using the smallest available needle (25–32G). There are insufficient data that adding buffer, epinephrine, or corticosteroids — or a topical cutaneous spray — reduces pain or postoperative inflammation, so these are not endorsed. Topical anesthetic cream may be used in addition to, but never as the sole source of, local anesthesia.

Vas Isolation

Intraoperative and early postoperative pain, bleeding, and infection relate mainly to the isolation method. Routine histologic examination of excised vas segments is not required.

Method	Recommendation	Notes
No-scalpel vasectomy (NSV)	Recommended	Minimally invasive; two special instruments (vas ring clamp and vas dissector) plus sequential specific steps — altering any step makes it a "minimally-invasive vasectomy," not NSV. Incision usually <10 mm, no skin sutures; dissection kept minimal. Significantly lower hematoma, pain, and infection than conventional.
Other minimally-invasive technique	Recommended	Acceptable alternative to NSV.
Conventional incisional	Not recommended	One midline or bilateral scalpel incisions, usually 1.5–3.0 cm; no special instruments (vas grasped with towel clip or Allis forceps); larger area of dissection.

The choice between midline and bilateral incisions is left to clinical judgment.

Vas Occlusion

Success and failure rates relate to the occlusion method.

Recommended:

• Mucosal cautery ± fascial interposition.
• Open-ended vasectomy — leave the testicular end unoccluded, apply mucosal cautery to the abdominal end, with fascial interposition. (Hypothetically reduces back-pressure pain and may aid future reversal via sperm granuloma formation; fascial interposition prevents recanalization.)
• Non-divisional extended electrocautery (Marie Stopes technique) — electrocoagulate the full-thickness anterior wall and partial-thickness posterior wall over ~2.5–3 cm without dividing the vas; the only non-divisional technique (all others divide the vas). Developed for easy dissemination, particularly in resource-limited settings.
• Division and ligation (suture or clips, ± fascial interposition, ± excising a short segment) — justified only for surgeons whose training/experience yields consistent failure rates ≤1%.

Defining terms: fascial interposition places a layer of internal spermatic fascia between the two divided ends (over either the testicular or abdominal end); it may raise complication rates and is typically combined with ligation/excision or mucosal cautery. There is no consistent evidence that excising a short segment (<4 cm) is preferable to division alone. Folding-back sutures each divided end on itself so the cut ends do not face each other.

Not recommended: folding-back; division and ligation (unless surgeon experience qualifies, as above); fascial interposition alone.

Special Scenarios

Prior or planned ipsilateral varicocelectomy — isolate the vas carefully and completely exclude the deferential artery and veins to avoid testicular injury. After varicocelectomy the deferential veins may be the sole testicular venous return (in a proper varicocelectomy all spermatic cord veins are ligated except the deferential vein), and the deferential artery may become the principal arterial supply if the testicular artery is damaged.

Post-operative Care

• Remain in clinic 15–20 minutes after the procedure; provide verbal and/or written aftercare instructions.
• Wear supportive undergarments immediately to reduce cord tension, continuing until comfortable without them.
• Mild swelling and pain for a few days are common — manage with oral analgesics.
• Keep the site clean and dry; showers (with gentle soap-and-water washing) are permitted the day after surgery, but avoid swimming or tub bathing for 3–5 days.
• Refrain from ejaculation for ~1 week; most men resume intercourse within 2 weeks.
• Hematospermia in the first month or two is benign and resolves spontaneously.
• Patients may return to non-physical work the same or next day if not limited by discomfort.

Post-vasectomy Semen Analysis

Men and partners must use other contraception until success is confirmed by PVSA.

Timing

• 2012 AUA: 2–4 months after vasectomy; exact timing is left to surgeon judgment — a longer interval improves the chance of azoospermia/RNMS but prolongs the need for interim contraception.
• 2022 CUA: 3 months after vasectomy.
• Sperm clearance is fastest with mucosal cautery + fascial interposition and slowest with ligation, so the occlusion method may inform timing.
• Collect after 2–7 days' abstinence, keep at body temperature, and submit within 30–60 minutes. Examine a fresh, uncentrifuged sample by direct microscopy within 2 hours (centrifugation may impair motility); if no sperm are seen, examine the centrifuged sample for motile and immotile sperm.

Defining Success

• 2012 AUA and 2022 CUA: a single sample showing azoospermia OR only rare non-motile sperm (≤100,000 non-motile sperm/mL).
• 2016 CUA: one azoospermic sample OR two samples showing only rare non-motile sperm.
• Counsel about late failure despite azoospermia/RNMS — usually detected first as pregnancy, then confirmed by motile sperm on semen analysis. Reappearance of (mostly immotile) sperm after two azoospermic samples occurs in up to 10% of patients and has not been associated with pregnancy.
• An FDA-approved home test detects sperm counts >250,000/mL but does not assess motility; two negative tests give a 99.9% negative predictive value. Note the 250,000/mL cutoff is higher than the ≤100,000 non-motile sperm/mL definition of success used in the guideline.

Failure & Recanalization

Causes of failure: technical/surgical error (e.g. occluding one vas twice and missing the other — persistently normal or near-normal motile counts); failure to identify vas duplication (very rare); or recanalization (suspect when motile sperm or rising concentrations appear after a PVSA had shown azoospermia/RNMS; may be transient or persistent).

AUA:

• If <6 months post-vasectomy with ANY motile sperm — continue other contraception and repeat PVSA every 4–6 weeks for up to 6 months. ~30–50% of men with recanalization eventually reach azoospermia/RNMS by 6 months (vas fibrosis occludes the recanalization), so do not judge failure on a single motile-sperm result within 6 months.
• Repeat vasectomy if motile sperm increase on serial analyses or persist >6 months.
• If >6 months with >100,000 non-motile sperm/mL persisting, use serial trends and clinical judgment (plus patient preference and risk tolerance) to decide on failure and repeat vasectomy.

2022 CUA:

• If any motile sperm or substantial immotile counts (>100,000/mL) — continue contraception and repeat the analysis.
• Persistence of any motile sperm or >100,000/mL on two samples indicates failure and is an indication for repeat vasectomy.

2016 CUA: if any motile sperm OR >100,000 non-motile sperm — continue contraception and repeat in 4–8 weeks; if repeat shows azoospermia or <100,000 non-motile sperm, contraception can be abandoned; if motile or >100,000 non-motile sperm persist at 6 months, repeat vasectomy is indicated.

If a man reports his partner is pregnant but his semen analysis is azoospermic, advise that the pregnancy could be due to transient recanalization despite the result.

Self-Test

1. What are important aspects of pre-vasectomy patient counselling? Vasectomy is permanent (though often reversible); alternatives exist (tubal ligation, barrier or hormonal methods for the partner); post-vasectomy fertility options (reversal, sperm retrieval + IVF) are not always successful and may be costly; sperm banking can be offered; anti-sperm antibodies rarely impair fertility and don't preclude reversal; sterility is not immediate; and other contraception is required until PVSA confirms success.

2. What are the potential risks of vasectomy? Hematoma and infection (1–2%); chronic scrotal pain (1–2%); failure (early or late); symptomatic nodule (<5%, sperm or suture granuloma); and changes in sexual function (mostly neutral or improved).

3. What are the methods of vas isolation, and which are recommended? Conventional incisional, no-scalpel vasectomy (NSV), and other minimally-invasive techniques. NSV and other minimally-invasive techniques are recommended; conventional incisional vasectomy is not.

4. What are the methods of vas occlusion, and which are recommended? Mucosal cautery, fascial interposition, division and ligation, folding-back, open-ended vasectomy, and non-divisional extended electrocautery (Marie Stopes). Recommended: mucosal cautery ± fascial interposition; open-ended vasectomy with mucosal cautery + fascial interposition; and the Marie Stopes non-divisional technique. Division and ligation is acceptable only for surgeons achieving ≤1% failure. Not recommended: folding-back and fascial interposition alone.

5. When should the first semen analysis be performed post-vasectomy per AUA and CUA? AUA: 2–4 months post-vasectomy (exact timing at the surgeon's discretion). CUA: 3 months post-vasectomy.

6. What is considered vasectomy success per AUA and CUA? A single sample showing azoospermia or only rare non-motile sperm (≤100,000 non-motile sperm/mL).