Feb 7, 2019

Interview Transcript

Dr. Jones: You and your partner now have three kids. And for the whole of your relationship, you've been responsible for the family planning part of family planning. And now, you and your honey decide that your family is full. You guys have all the kids you've wanted. Is it his turn? This is Dr. Kirtly Jones from Obstetrics and Gynecology at the University of Utah Health, and this is Vasectomy on "The Seven Domains of Women's Health" on The Scope.

Announcer: Covering all aspects of women's health, this is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: Women have largely had the responsibility for reversible contraception in any heterosexual relationship. Whether they took that responsibility seriously and planned all their children, or they had a number of kids by chance, what you do when you're done having kids? About 23% of American couples rely on a permanent form of contraception, such as tubal ligation or vasectomy. That's about one in four.

Now, attitudes about vasectomy vary dramatically around the world. In the U.S., 1 in 5 guys over 35 has had a vasectomy. Men who have more education, have higher income are more likely to choose a vasectomy. Men on the West Coast are more likely to use vasectomy than men on the East Coast, and both are more likely to use vasectomy than men in the South. Hispanic men and African-American men are less likely to choose vasectomy.

In countries such as Canada, in countries in Scandinavia, about 1 out of 3 men over 35 have had a vasectomy. That's a lot of guys. Other high-income countries with high vasectomy use and high gender equity, that's an important thing. Where there's gender equity, more guys have picked up a responsibility for contraception include Australia, the Czech Republic, New Zealand, Spain, South Korea, Switzerland, and the UK. In some cultures, Africa in general, vasectomy is extremely rare.

Firstly, both methods are very safe, with very few complications related to the procedure. However, tubal ligation requires either regional anesthesia, such as an epidural or spinal if a woman's having her tubal right after the baby is born, or need general anesthesia if it's done sometime after a baby when it's done by laparoscopy. A vasectomy is done under local anesthesia, which is much less risky. Women have to have their abdomen entered to have their tubes tied. For men, the vas is right under the skin of their scrotum. So it's much easier. For men, it can be done with an incision so small it doesn't even need stitches and often takes only 15 minutes. The time to recovery is faster with a vasectomy than a tubal, a couple of days for men versus a week or two for women.

Now, although men may have some pain and bruising in the scrotum after vasectomy, long-term pain occurs in less than 1 in 100 men. Contrary to many men's fears, a vasectomy doesn't lower testosterone levels, and there's no change in sexual desire. In fact, in a 2015 Stanford study, found that women whose partners had had a vasectomy were 46% more likely to have sex at least once a week compared to women whose men hadn't had the procedure. Now, that's a complicated number, and there might be a lot of interesting statistics packed in that. But at least it doesn't make you stop doing what you want to do. Both methods are very effective with pregnancy rates less than 1 in 100 couples per year. And 1 study suggested that the rate of pregnancy after vasectomy was as low as 1 in 2,000.

Now, there are some rules. You cannot count on your vasectomy for contraception until you've had an assessment of the sperm to show that there's no more sperm coming out. This may take several months and 20 ejaculations to clear all the sperm in the pipeline. Some men may have cleared the sperm in a shorter period of time. But the important thing is the ejaculate must be checked, confirmed that there are no more sperm.

Now, costs are different, but both methods are usually covered by insurance. Under the Affordable Care Act, some states have actually included vasectomy in the no-cost part of contraception. If you had to pay out of pocket, vasectomy could cost $700 to $1,200. And tubal ligation, if it isn't done at the time of delivery, could be as much as $5,000.

So far, this has been about couples in a committed, long-term relationship. But vasectomy has been increasing in young men who've never had children. It is the only method of contraception that gives men private power over their choice to have children. Increasingly, young men are requesting vasectomy as they're very sure they never want to have kids. In the past, physicians were unwilling to perform a vasectomy on a man who had not fathered children. This behavior on the part of physicians has changed in many places as the role of patient autonomy, the right of a person to make decisions about their own bodies, and healthcare has increasingly informed their attitudes about sterilization.

So what happens if you fall in love with a guy who's had a vasectomy and you always wanted kids? This is the time for an honest discussion about hopes and expectations for a long-term relationship. Perhaps the guy never wanted kids until he met you. The options for returning fertility to a man who's had a vasectomy include vas reversal, which is successful about 50% of the time, depending on the skill of the surgeon who's putting this tiny tube called the vas back together. It also depends on how long ago the vasectomy was performed and the age of the man.

For men in whom the vas reversal doesn't work to restore their fertility, in vitro fertilization to retrieve sperm from their testes can be very successful. If your guy has had a vasectomy in the past and still is quite firm in his desire to never have children, that's a more complicated discussion.

So if you and your guy have decided that he is going to have a vasectomy, where can it be done? Well, some family planning clinics have vasectomy services, and some family docs do vasectomies. It's a short office procedure. Most urologists do vasectomies. Only urologists do vasectomy reversal, and you should choose someone who has this more complicated procedure as part of their regular practice.

If for some reason your guy chooses to have a back-up, some men choose to freeze sperm in case they change their minds for whatever reason, change in circumstances such as change in partners or loss of a child. Most fertility centers that do in vitro fertilization can freeze and store sperm. And if a couple should decide that they want a kid after vasectomy, then IVF is an option. However, you and your partner make your decisions, we offer all of these services at the University of Utah Health, and your family choices are important to us.

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