The control of fertility gains its importance in modern life after that the understanding to the social and cultural values of ourselves has been advanced to accept that the man can also be sterilized to avoid unexpected pregnancies. The acceptance of our female partners to the value of the procedure and its meaning both for the male and for her has also been changed in the last decade.

In our modern cultures and advanced industrial world one let sterilization be done because of his protection from having a not planed child, or for having a psychological release during sexual activity that this will not happen. It is also performed after having children in a pair where the male wants to protect his female partner from the side effects of hormonal contraceptives or because the female suffers already under these complications. The procedure is also resorted to because it is easier to perform in comparison to the sterilization of the woman.

Sterilization is done through the division and severing of the vas deferens.
The pressure inside the vas is well regulated.

Sterilization is a simple operation but in spite of this fact it harbors some hazards with it. The first important one is infection. This may affect the epidedymis, The prostate, The testicles or the scrotal sac as a whole. The other hazard is that some nearby structures may be injured if involved in the process which is easy to happen in inexperienced hands. This is because the structures in the area are all cord like and similarly feeling. Understanding the anatomy is only a part of the procedure the second part is understanding the function of the organ (the physiology).

The severing of the vas produces a certain increase in the pressure inside the first part of the vas emerging from the tail of the epidedymis. The shorter this part is the higher the developing pressure. This experiences  back pressure on the structures producing the sperms and leads to irreversible damage onto the tissues which is easily avoided when the operation is planed on due of these facts. Another important and mostly forgotten point is the ability and skills of the surgeons performing the procedure. I perform microsurgical vasal reversal. This fact let me think of what happen if the patient will wish a reversal after some time ? That is why I plan a certain length of the structure to be left both proximally and distally to enable and facilitate the a microsurgical reconnection in the future. This is made difficult if the beginning (proximal) part is too short or too long because the access to the vas at the bone level is very difficult.

On planning to perform vasectomy, I discuss the above mentioned facts with my patient. I also ask him about his motive to let the operation done. The second very important question is about his future intentions. This is because microsurgical reversal is advisable within the first 3-5 years after sterilization. Vasectomy reduces the chance of re fertilization and the production of healthy sperms considerably after 2 years of being done. This is an important fact to be discussed seriously with patient. The female partner must be present and must sign the consent of the operation with him.

The patient should have a spermiogram before the operation done if he has no children to proof that he is fertile otherwise the operation is done for good and could have been avoided. There is no better prove of fertility than having your own children.
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Anatomy of the spermatic cord
T = testis
E = epididymis
Vd = spermatic cord
Ct = covering of the spermatic cord

Who qualifies for the Operation?

Males who wish to be sterile, males of couples who want to have no children, males who want to protect their wives from the disadvantages of the anti baby pills.

How does the operation work?

Vasectomy is done on an outpatient basis. I sometimes use a simple sedation and infiltrate the area with a local anesthetic as not more than 20 ml of xylocain 1% for both sides. The patient is lying supine. The vas is felt and rolled between   2 fingers as mentioned above. The structure is held using special shape toothed forceps. A 5 mm incision is done immediately above the structure. Which starts to protrude out of the wound as a white glistening loop. This loop is again hold as above. Bleeding is usually minute and can be easily controlled by the high frequency current forceps while the patient is protected by connecting him to the earth electrode.

The structure is examined and the distal and proximal lengths are estimated. A fine mosquito forceps is put on each limb of the loop. The segment in between is excised and sent to the pathologic examination. The resulting lumens are touched with the current forceps to seal then. The facial investment is pulled over the edge of the vase and is approximated with fine suture material. The same is repeated on the proximal limb of the vas. In this manner it is guaranteed that the two lumens will not meet together to re canalize which may happen if they are not completely isolated.

Each limb is bent on itself and secured with a stitch passing through and through the bent and then is tied. Meticulous but minimal coagulation is done to avoid the development of any hematoma. The structures are returned to the scrotum. I usually put 1 subcutaneous approximating stitch and a maximum of 2 stitches of non absorbable material to the skin and bandage that is changed by a tegaderm dressing on the first post operative visit after a day. This procedure is repeated on the other side. The operation time is about 20 minutes.

There is also the non scalpel method of vasectomy which I perform also but it does not differ much both technically and functionally from the above mentioned method.

The patient visits me 24 hours after the operation. I check his genital area clinically and examine him with the ultrasonography to exclude any sign of infection or hematoma. The bandage is changed with tegaderm. This has the advantage to let the wound be easily inspected and the patient to wash himself or take a shower without wetting the wound. Visits are repeated every other day for a week. There is no need for antibiotics but it is advisable to give a drug against swelling and some drops against pain for just in case the patient is in need of them particularly at night.

The sexual life is not allowed in particular the patient is not declared sterile before the laboratory evidence of having no sperms in his ejaculate. This is diagnosed though the spermiogram done after 6 weeks of the operation. I have the experience that earlier than that I observe some sperms which even if not motile are suspicious. The sperms that are observed earlier are those which were stored in the seminal vesicles.
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Incision

1. Is sterilization reversible?
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   Yes, it is but should be microsurgicaly reversed within 2-3 years of its performance.
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2. Does sterilization affect my potency?
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   No, it does not at all.
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3. What are the hazards of sterilization?
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   These are infection, hematoma, injury to other structures, permanent sterilization, spontaneous reversal.
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4. When can I return back to my sexual life safely?
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   After 6 weeks and only after proving that you are azoospermic that is to say there are no sperms in your ejaculate. You can return to a protected sexual life 2 weeks after the operation while you use a preservative for safe sex or your partner uses a contraceptive.
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5. Does the vasectomy affect my ejaculate or its volume?
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   No, it does not. It only devoids you from sperms.
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6. Is there any deformity left on my scrotum after vasectomy?
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   No, The vasectomy is done through minute incisions of 3-5 mm length which heal smoothly and leave an inconspicuous scar in the behind part of the neck of the scrotum. This fades away after 6 months.