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Vasectomy and vasovasostomy
Description
An in-depth report on vasectomy as a method of male birth control and reversal surgeries.
Male Contraception
As many as 40% of couples seeking vasectomy have experienced a failure with their previous method of nonpermanent birth control. Such failures can occur from misplacement of a diaphragm, an incorrectly implanted IUD, or noncompliance with an oral contraception regimen. Couples who are unsure about permanent sterility should still consider carefully all birth control options.
Withdrawal
Withdrawal before ejaculation is a form of natural contraception, but it is extremely risky and most people find it unsatisfactory. If used on a regular basis, the average risk for pregnancy is 24%.
Condoms
The only other form of male contraception currently available is the condom. However, the average rate of pregnancy for couples that rely only on condoms for protection is still 12%. In adolescents, the risk with condoms is even higher, 18%. Even for those who use a good-quality condom correctly, the annual risk for pregnancy is 3%.
The condom should be put on before intercourse when the penis is erect, long before ejaculation, since the male can discharge sufficient semen to cause pregnancy before ejaculation occurs. (Even after a vasectomy, men who are not in a monogamous relationship with an HIV-negative partner should always wear a condom during sex for protection against sexually transmitted diseases. Vasectomy is not protective.)
Condom Materials.
- Latex. Condoms made of latex rubber are the most common types. When they are contoured for better fit and contain a spermicide, they can provide fairly effective protection. Some people are allergic to latex, however, and in some cases the reaction can be very dangerous. The latex smell may also be unpleasant for some people.
- Polyurethane. Polyurethane condoms (Avanti, eZ-on) are also available. At this point, they have good acceptance by couples but have a higher breakage rate (6 - 7.2%) compared to the latex condom (1.1 - 2%). Other synthetic materials are under investigation.
- Animal Membranes. Condoms made from animal membrane can prevent pregnancy, but sexually transmitted infections can permeate them.
- Lubricants. Lubricants can be used to prevent tearing. Petroleum-based products (such as Vaseline and baby oil) and vegetable oils should not be used because they can corrode the condom.
Spermicides. Some condoms come prelubricated with sperm-killing substances called spermicides. The standard active ingredient in spermicides in the U.S. is nonoxynol-9, which attacks the surface of the sperm cell. These spermicidal-coated condoms, however, are no longer recommended for a number of reasons. Side effects include irritation of the vagina or penis, particularly if used often or in large amounts. It can also promote yeast and urinary tract infections in women. Evidence now strongly suggests that nonoxynol-9 does not provide any additional protection against sexually-transmitted diseases. In fact, research indicates that it actually increases the risk for HIV in women, possibly by causing injury in the vaginal area. Spermicides are no longer recommended for use with male condoms.
Hormonal Contraceptives for Men
Researchers are developing male hormonal contraceptives (“MHCs”) that reduce levels of sperm. Clinical trials are progressing, and a “male pill” looks like it may become a reality in the not-so-distant future. Current trials are focusing on MHCs that combine testosterone (the primary male sex hormone) with progestin, a synthetic form of progesterone (one of the primary female sex hormones).
Testosterone suppresses levels of luteinizing hormone (LH) and follicle stimulating hormone (FSH). LH and FSH are hormones that stimulate ovulation in women, and the production of testosterone in men. Low levels of these hormones interfere with sperm production, but do not completely stop it. For this reason, researchers are investigating combining testosterone with progestin. The addition of progestin further decreases LH and FSH levels, and sperm counts. Researchers are also investigating combining testosterone with gonadotropin-releasing hormone (GnRH), another type of hormone that interferes with LH and FSH secretion.
Most of the MHCs currently in late-stage clinical trials deliver the hormone through implant, injection, or both. The implant is surgically placed under the skin where it releases a steady stream of the hormone. The injection is given once every several months. Some of the investigational MHCs use a testosterone implant with progestin injections, while others use a progestin implant with testosterone injections. Oral forms are also being investigated. It generally takes around 3 - 4 months for the treatment to take effect and sperm production to be reduced. Research indicates that the MHC is easily reversible. A 2006 study in the Lancet reported men regained their full fertility within 3 - 4 months after stopping hormonal treatment.
Side effects of MHCs include weight gain, acne, and changes in mood. These side effects are typical of hormone-based therapies.
Gossypol
Gossypol, a yellow pigment extracted from the roots, seeds, and stems of the cotton plant, has been used in China, African, and Brazil as a male contraceptive. Cotton root was also used as folk medicine in the American South to treat menstrual pain and to induce abortions. The chemical destroys the lining of tubules in the testicles where sperm are produced, thereby inhibiting their formation. A 2000 Brazilian study reported that a male oral contraceptive derived from gossypol suppressed sperm production within up to 16 weeks. In men who were taking lower doses, sperm production returned in most of them within a year after they stopped taking the contraceptive. Gossypol does not appear to reduce sexual desire or frequency of intercourse. In about 20% of men, sperm production does not come back, so it should be considered as potentially permanent birth control. It also may not be effective in some men, since small numbers of sperm may survive. Researchers are investigating gossypol-derived compounds that may have less toxicity. No one should take any so-called natural gossypol product without consulting their doctors.
Reversible Vas Occlusion
Researchers are investigating procedures that block sperm flow in the vas deferens using various drugs or materials that are reversible. One promising method is called Reversible Inhibition of Sperm Under Guidance (RISUG). RISUG is a non-hormonal contraceptive that uses a polymer gel. The gel is injected into the vas deferens, where it coats the vas deferens’ inner walls and kills sperm. The gel can be injected through the skin (“percutaneously”) or by using the no-scalpel vasectomy technique of making a tiny hole in the skin. The procedure takes around 10 - 15 minutes to perform, and men can resume sexual activity within a week.
The effects of RISUG are long-lasting. Studies indicate that a single injection can provide contraceptive effect for 10 years or more. It is also easily reversible. When a man wishes to discontinue the contraceptive, the gel is removed by flushing the vas deferens with a solvent. The major side effect so far has been a temporary swelling of the scrotum following the injection.
RISUG is mostly being investigated in human trials in India. American researchers are also interested in investigating RISUG, but animal studies need to be conducted first. It will be several years before any human trials are started in the U.S.
Intra Vas Device
The intra vas device (IVD) is an investigational non-hormonal contraceptive that uses tiny silicone plugs to block sperm from traveling through the vas deferens. The plugs are surgically inserted into the vas using the no-scalpel vasectomy procedure. In 2006, the FDA granted approval to expand human trials of the IVD in several U.S. cities.
Unlike hormonal contraceptives, the IVD does not cause side effects like weight gain and acne. But researchers are still figuring out how to make this contraceptive method reversible.
- Review Date: 10/20/2006
- Reviewed By: Harvey Simon, M.D., Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital
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