Procedure is best considered as permanent, but reversal is possible

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

A vasectomy is a permanent form of birth control that appeals to some men.

To understand what's important to know about this sterilization procedure, I'm talking with Dr. Timothy Byler. He's an associate professor of urology at Upstate, and one of the things he specializes in is vasectomy.

Welcome back to "The Informed Patient," Dr. Byler.

Timothy Byler, MD: Thank you for this opportunity, Amber.

Host Amber Smith: Do most of the men you see realize that a vasectomy is permanent?

Timothy Byler, MD: This is a big part of our first visit with men, is to ensure that they understand that it should be considered permanent. There's a lot of misconceptions about vasectomy and its reversibility. Lots of large studies have shown that it is reversible and has a very high rate of being successful.

However, I want to put some caution that this is in very experienced hands, and from major centers that do a lot of reversal. The majority of urologists do not perform reversal. In fact, in our department, one out out of 20 urologists does this procedure, so it's not something you can do everywhere. So we do emphasize that it should be considered to be a permanent procedure.

Host Amber Smith: If a man has a female spouse or a significant other, how often does that person have a say in whether the man has a vasectomy?

Timothy Byler, MD: We don't require a female partner or significant other to be present during the discussion, but certainly we emphasize that this is an important discussion that should be done with them.

Host Amber Smith: So this is not often offered to young men who haven't started families or haven't been in relationships.

Timothy Byler, MD: We highly encourage men, usually around age 25 or under, to wait because of the permanence. There was a large study recently performed that the average age was 36, and 4% were childless at that time. So that speaks to the volume of younger men.

Host Amber Smith: So mostly it's used for family planning.

Timothy Byler, MD: Yes, definitely.

Host Amber Smith: Well, let's talk about how a vasectomy is done. What's involved in the first appointment?

Timothy Byler, MD: The first appointment is really to gauge the patient's expectations and highlight the risks involved. Simple questions, like, why do you want a vasectomy, have you discussed this with your partner, as we've reviewed. I also take the opportunity to examine the patient and ensure that there's not going to be any difficulty in performing the procedure.

We screen for any kind of need for more than local anesthesia, and we'll get to that in just a minute, uncomfortability with the exam, anatomic changes that might influence the procedure. Some men do need additional workup prior to having a vasectomy. For example, they could be on certain medications that will increase the risk, and we screen for these kinds of issues.

We review that it is a permanent procedure and discuss the long-term risks associated with the procedure.

Host Amber Smith: You mentioned anesthesia. What are the options for that?

Timothy Byler, MD: Ninety-five percent of men do this under a local anesthesia, which means they're in the office, they're awake, and we just numb up the scrotum. There is a small subset of men that need additional anesthesia for various reasons. So we do have men that go to the operating room and have an actual anesthesiologist sedate them for it, but that's certainly the minority.

Host Amber Smith: So most of these are done as an outpatient or just in the doctor's office.

They come in like they would for an appointment, and they're able to go home soon after?

Timothy Byler, MD: Yes, the procedure takes about 20 minutes. We do recommend that you'd have a driver, but honestly, a lot of men are able to drive themselves home, because they're fully awake, and they're not sedated at all.

Host Amber Smith: Well, what does the surgery involve? What do you actually do?

Timothy Byler, MD: The patient is brought into the procedure room, and a nurse will prepare them. We use a cleaning solution on the scrotum and put sterile drapes around. We then numb up a small portion of the scrotum and make a small incision right in that area, and we grab the vas deferens (sperm duct).

This is often the hardest part for men. They can get sensations almost as if they had a hit to the scrotum. So they'll get sometimes nauseous, sometimes hot, even some stomach discomfort briefly, and that goes away as we free things up.

We then take a segment of the tube itself out, so it's in two pieces, and we put metal clips on each end and then put it back in.

That's the procedure.

Host Amber Smith: Does it leave a scar?

Timothy Byler, MD: Usually you can't find them at all. The incision is 1 centimeter (barely wider than a pencil), so it's very small, and the scrotum is very forgiving in the sense that it's folded, and the scar blends into it, so usually men cannot tell where they (the incisions) were.

Host Amber Smith: What is the recovery like? You said some men are able to just drive themselves back home, but what do they do after that? Are they supposed to take it easy?

Timothy Byler, MD: Yes. Recovery is usually one to two weeks. Some men report a little longer, and some men tell me they played basketball the next day, but generally speaking, it's somewhere between five and 15 days or so.

It's usually worse in the beginning. It's more swelling and discomfort, so we suggest, for the first few days, ice and rest. And as they feel better and better, they can ease themselves into full activity. Pain is usually very minor and on a Tylenol and ibuprofen level.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with associate professor of urology Dr. Timothy Byler about vasectomy.

Are there any physical effects on sexual drive or performance after a vasectomy?

Timothy Byler, MD: No, the vasectomy just removes the sperm from the semen. It does not affect testosterone level, sex drive or erections. There were some questions, and some men do ask me about the risk of prostate cancer or testicular cancer.

These have also been shown to not be affected by vasectomy.

Host Amber Smith: Does vasectomy have any impact or protection against sexually transmitted diseases (STDs)?

Timothy Byler, MD: Unfortunately, no. We still recommend barrier protection for STD prevention.

Host Amber Smith: What about those permanent clips you mentioned, that are left on the ends of the vas deferens?

Can a man feel those afterward? How small are they?

Timothy Byler, MD: They're also very small, but, yes, I do occasionally have men call me up maybe a year or two later and say they felt something, and they wanted me to check it out. It's usually the clip. It's small, but if you're really feeling above the testicle, you could feel a little bump where it is.

Host Amber Smith: How long after the procedure until the vasectomy takes effect?

Timothy Byler, MD: After a vasectomy, a man walks out of the procedure with a completely normal ejaculate. In other words, he could impregnate that day if he wanted. There is a lot of sperm beyond the point of the surgery that's performed. There's a high concentration in the prostate and the seminal vesicles, which are beyond that point.

So most studies show that 20 to 30 ejaculations are needed to clear that area of semen, and until that's done, they are still potent. We see men back around 12 weeks, because we assume that the first two, three weeks, let's say, they're not really sexually active, and then they'll need to do 20 to 30 ejaculations.

So we give them some time to kind of do that.

Host Amber Smith: You check after 12 weeks?

Timothy Byler, MD: Yes, and we encourage using protection in that in-between period.

Host Amber Smith: So please explain what may cause a failure of the procedure. I mean, this is supposed to be 100%, but sometimes there is a failure, right?

Timothy Byler, MD: Failure is actually very rare. It's under 1% of men with the modern methods that we use to block the tube. A lot of that stuff is historical, but yes, it still can happen.

Host Amber Smith: Is there anything that men can do to improve the chance of success for this procedure?

Timothy Byler, MD: The most important thing is to avoid ejaculation during the healing process. This allows the ends of the vas deferens to basically scar, so they don't leak sperm.

Once we have a vasectomy semen analysis at 12 weeks that is negative, the rate of something happening down the road is one in 2,000. This is pretty rare medically.

Host Amber Smith: I want to go back to, we talked about reversal and how challenging that procedure can be. If the ends of these vas deferens are separated, and they're missing a chunk in the middle, do they try to reconnect them in some way if you're trying to do a reversal? How is that done?

Timothy Byler, MD: Yes, a reversal is done by making a larger incision in the scrotum and finding the two ends and basically putting them back together, which is why it's fraught with failure. It's a very small tube. It doesn't take much to block it again, and there's parts of it missing.

Host Amber Smith: And so getting those reconnected and working is the goal, I guess, right?

Timothy Byler, MD: In a reversal, yes. we also know that over time the reversal success rates will go down. so a guy one year out versus 10 years out, the 10-year guy will have a much lower rate of patency (clear passage) of the vas deferens because of exactly what we're talking about, further scarring and issues.

Host Amber Smith: So those little clips, I know they're very small, but do they set off metal detectors, or do you have to declare them if you have an MRI (magnetic resonance imaging)?

Timothy Byler, MD: Excellent question. No, they do not set off any kind of alarms. If you have a CT scan, they may show up as artifact on it, but that shouldn't influence any major imaging.

And no, they do not set off metal detectors.

Host Amber Smith: Can you go over the risks that you like to make sure that men are aware of before they have a vasectomy?

Timothy Byler, MD: Of course. I think the most important thing is to realize that it is surgery. I think a lot of men think of it as "I'm just having a vasectomy," but it is a surgical procedure, so it does carry with it surgical risk.

Immediate concerns would be bleeding and infection and swelling. Now, fortunately, these rates are very low. But even in very experienced hands, so over a hundred vasectomies done per year, the rate of bleeding was 1.6% in a recent study. So it does happen.

Long-term risk would be post-vasectomy pain syndrome, which does affect 1% to 2% of vasectomy patients. There's a lot of reasons for this, but it's very unclear what we can do to prevent it, so we can't really pick out who's going to be affected by it. So these are things I discuss with the men.

Host Amber Smith: Do most men say later on that they're satisfied that they had this procedure? I mean, years later, maybe you don't see them, but, do you have a sense that men are satisfied with this?

Timothy Byler, MD: Yes. I usually see men back somewhere between three and four months, and at that point, most men would not know they had it. They have no symptoms anymore. They have no scars. They have no sexual side effects. And when I see men that had a vasectomy in the past, it's an afterthought.

They're not really discussing it. It's like, "Oh yeah, I had one of those."

Host Amber Smith: When they go in for other things that are totally unrelated to urology, is this something that's important to let other medical providers know that they've had?

Timothy Byler, MD: I think it's important to always mention all of your previous medical and surgical procedures, but this has very little influence on non-urologic surgery.

Host Amber Smith: So wheN the men come in for their first appointment, they might want to have an idea of a time when they can be away from work or school for a couple of weeks to recover, is that right?

Timothy Byler, MD: Yes, this is something else we discuss in the first appointment. Mainly the guys that are doing more manual jobs. And you really need to think about the first couple of days, especially, like maybe one week. Often guys that have desk jobs can go right back to work, especially if they're working from home. There's nothing that would be barring them. I've had guys work from home, day of procedure.

Host Amber Smith: Well, I appreciate you making time for this interview, Dr. Byler.

Timothy Byler, MD: Thank you.

Host Amber Smith: My guest has been Dr. Timothy Byler, an associate professor of urology at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed.

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