Elsevier

Contraception

Volume 101, Issue 5, May 2020, Pages 342-349
Contraception

Original Research Article
Risk of vasectomy failure by ligation and excision with fascial interposition: A prospective descriptive study,☆☆

https://doi.org/10.1016/j.contraception.2020.02.001Get rights and content

Abstract

Objective

To evaluate the occlusive failure risk of ligation and excision with fascial interposition vasectomy technique. There are doubts about the effectiveness of this technique largely used in Asia and Latin America.

Study design

We conducted a prospective longitudinal observational descriptive study among men who underwent a vasectomy performed under local anesthesia in a clinic specializing in sexual and reproductive health services in Bogotá, Colombia. Three urologists used the Percutaneous No-Scalpel Vasectomy technique to isolate the vas deferens. They then ligated the vas, excised a 1 cm segment between ligations, and ligated the fascia on the prostatic end to cover the testicular end. We requested all patients to submit a semen sample three months after the vasectomy. We defined probable and confirmed vasectomy failure as 1–4.9 million sperm/ml and 5 million sperm/ml or more or any number of motile sperm observed on the last semen sample available, respectively.

Results

Among 1149 participants, 581 (51%) had at least one post-vasectomy semen analysis. The overall failure risk was 5.2% (30/581; 95% confidence interval [CI] 3.6%–7.3%) with probable and confirmed failure risk of 1.9% (11/581; 95% CI 1.1%–3.4%) and 3.3% (19/581; 95% CI 2.1%–5.1%), respectively. Older men and one urologist had statistically significant higher risk of overall failure.

Conclusion

Our study confirmed that the ligation and excision with fascial interposition vasectomy technique is associated with an unacceptable risk of failure.

Implications

Surgeons who use the ligation and excision with fascial interposition vasectomy technique and countries with large vasectomy programs in Asia and Latin America that still recommend this technique should consider adopting alternatives to reduce the failure risk to below 1% as recommended by the American Urological Association.

Introduction

Vasectomy consists of two specific surgical steps: (1) isolating and exposing the vas deferens outside of the scrotum and (2) occluding the vas. The No-Scalpel Vasectomy technique to expose the vas was developed in China by Dr. Li Shunquiang in 1974 [1] and promoted internationally by EngenderHealth since at least 1992 [2]. This minimally invasive technique to expose the vas is the most extensively studied approach to expose the vas [3]. There is high-quality evidence demonstrating that it reduces the risk of hematoma and infections [3], [4], [5].

For occluding the vas, EngenderHealth recommends putting two silk ligatures on the vas, excising about a 1-cm vas segment between the ligatures, and interposing the vas sheath (fascia) on the testicular end of the divided vas with a silk suture tied on the abdominal end (Fig. 1) [2]. However, the failure risk of this technique, based on the post-vasectomy semen analysis, seems to be greater than 1%, which is the highest acceptable failure risk recommended by experts [3]. Risks of occlusion failure of 0% [6], 2.1% [7] 2.5% [8], 2.6% [9], and 7.6% [10] have been reported for the aforementioned occlusion technique, with the most robust result from a high-quality randomized clinical trial reported at 5.9% [11].

Nevertheless, this technique is still the recommended standard in large vasectomy programs in countries with limited resources such as India, Nepal, Mexico, and Colombia [12]. The American Urology Association recommends using this technique if experienced surgeons consistently obtain satisfactory results [3]. However, due to the doubts about the effectiveness of this occlusion technique, we evaluated its failure risk in a large cohort of men vasectomized by experienced surgeons in Colombia.

Section snippets

Study design

We conducted a prospective longitudinal observational descriptive study of a cohort of adult men who voluntarily underwent a vasectomy under local anesthesia between April 7, 2017 and January 15, 2018, at a private clinic specializing in sexual and reproductive health services in Bogotá, Colombia.

Recruitment of participants

Men requesting a vasectomy at the clinic routinely have a pre-vasectomy visit with general practitioners. They provide counselling on vasectomy, perform a medical history and physical exam, and

Results

Among 2358 men who had a vasectomy at the clinic during the study period, 1149 eligible men participated in the study and 581 (51%) participants produced at least one sample for post-vasectomy semen analysis (Fig. 2). Among these, 482 (83%) were recommended to stop other contraceptive methods based on the results of the first post-vasectomy semen analysis. In the remaining 99 men, 55 (56%) provided a second semen sample. The status related to success or failure of vasectomy remained unchanged,

Discussion

We observed that vasectomy occlusion performed with ligation and excision with fascial interposition is associated with a high risk of failure based on the post-vasectomy semen analysis results. Our study confirms the results of five out of six previously published studies showing that the failure risk of this technique is unacceptable [10], [11], [12], [13], [14], [15]. The acceptable failure risk of a vasectomy occlusion technique should be under 1% [3]. Even in younger men and men

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  • Funding: This research benefited from a small grant from Universidad El Bosque, Bogota, Colombia. The Michel-Labrecque Fund for Male Reproductive Health (4476) from the Laval University Foundation supported travel to Colombia for investigator meetings. We did not receive specific grants from funding agencies in the public, commercial, or not-for-profit sectors.

    ☆☆

    Declarations of interest: none.

    1

    Present address: Profamilia, Calle 59 # 50 – 17, Barranquilla – Atlántico, Colombia.

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