Should we reconsider how we counsel young men about vasectomy?

Vasectomy is a safe and reliable means of permanent contraception that’s growing in popularity among younger Australian males (see Figure).

Some health professionals are reluctant to recommend vasectomy for young men because of its irreversible effect on fertility and the possibility that — with changes to personal circumstances over time — they may change their minds. Vasectomy reversal or testicular sperm extraction might be possible for some men to father children after a vasectomy, but these procedures are not always successful and have significant costs.

Although there are no absolute contraindications to vasectomy^[1] a man’s age, and whether he has children, are important to consider when counselling anyone about the procedure.

General practice is a common setting for discussions about contraception; albeit far more common for female patients than males^[2]. Limitations in health practitioners’ knowledge about vasectomy may contribute to underutilisation of the procedure, thereby concentrating responsibility for couples’ contraception on females^[3]. This is demonstrated by higher rates of tubal ligation in women than vasectomy in males, even though vasectomy is a simpler, shorter and safer operation.

There are important things for health professionals to know when they are helping men to decide if vasectomy is right for them:

• Vasectomy should be described as irreversible, and reversal should not be discussed as a simple option for dealing with a change of mind^[4]
• Vasectomy has a low complication rate. Haematoma and infection occur in about 1-2% of cases. After recovery, long-term scrotal pain affects 1-2% of cases^[5]
• The procedure can be performed in doctors’ rooms, under local anaesthetic, thus avoiding general anaesthesia and admission to hospital.
• Vasectomy does not result in immediate infertility, so another form of contraception must be used, for around three months, until sterility is confirmed by semen analysis
• Post-vasectomy semen analysis is essential to confirm success
• Vasectomy is not 100% effective. For men whose vasectomy is successful (confirmed by semen analysis), the possibility of causing a pregnancy is 1 in 2000^[2],[5]
• A genital examination is advisable before vasectomy, to ensure the man does not have some condition that may complicate the procedure, or suggest it may be unnecessary (e.g. testes volume <4 ml suggesting Klinefelter Syndrome)^[5]
• Vasectomy does not increase risk of disease (e.g. prostate cancer, cardiovascular disease, dementia)^[5].

None of the items in the list above apply any more or less to young men than older men.

A recent US study found that among men who were childless at the time of their vasectomies, which were conducted between 2004 and 2017, none sought reversal during the intervening period (up to 14 years)^[6]. The researchers suggest that men without children who seek vasectomy are subjected to greater scrutiny than fathers, reflecting bias on the part of the providers (likely fostered by our society’s value of procreation). The study’s senior author recognises that having a vasectomy “is an incredibly personal decision for every patient”, and “it’s not our place to ask social questions and steer [men without children] away from the procedure”.

A young man’s decision to have a vasectomy is his to make. The role of health providers is to ensure he is counselled in the same way as any other man.