How is vasectomy done without a scalpel?


Pointy Hemostat
Ring Clamp
No-scalpel vasectomy instruments, used in China since the mid-70's and introduced into the United States in 1989, are simply a very pointy hemostat, used initially to make a tiny opening into anesthetized skin of the scrotal wall, and a ring clamp, used initially to secure each vas tube in turn beneath this opening. The pointy hemostat is then used to spread all layers (the vas sheath) down to the vas tube itself and to then deliver a small loop of the vas through the opening as the ring clamp is released. In turn, the ring clamp is used to hold the vas, while the pointy hemostat spreads adherent tissue and blood vessels away from the vas under direct vision, so that the vas can then be divided with a fine surgical scissors and the upper end cauterized with a hand-held cautery unit so that it will seal closed.

Traditionally, a local anesthetic has been injected into the skin and alongside each vas tube with a very fine needle, as small as diabetics use to inject themselves with insulin. One could feel a tiny poke in the skin, then a bit of a squeeze as the anesthetic was applied to each vas tube. However, most people do not like needles of any size ... especially there!


The spray penetrates to
about 3/16", enveloping
the vas.

A MadaJet® is a spray applicator which delivers a fine stream of liquid anesthetic at a pressure great enough to penetrate the skin to a depth of about 3/16", deep enough to envelop the vas tube held snugly beneath the skin. Each vas is positioned in turn beneath the very middle of the front scrotal wall and given two or three squirts. That numbs the skin and both vas tubes adequately for 99% of men. The other 1% (usually men who have thick skin or scarring due to prior surgical procedures in the area) will require a bit more anesthetic delivered with a fine needle, usually with no pain at all because of the partial anesthesia achieved with the MadaJet.

The spray penetrates to about 3/16", enveloping the vas. For "techies," the MadaJet is a rather simple but precisely machined device. A cocking lever lifts a piston (shaft) to a locked position, compressing a strong main spring and drawing anesthetic from a fill chamber into a cylinder at the bottom of a head assembly. When a release button is pressed, the spring forces the piston down into the cylinder, ejecting the anesthetic under high pressure through a tiny orifice at the end of an extended tip. A MadaJet is demonstrated (nothing graphic) in Dr. Stein's counseling video.
Is this a "laser" vasectomy?
Certainly not. The vas tubes are most easily and safely divided under direct vision with a fine surgical scissors. But the expression "LASER" has great popular appeal, and use of laser energy in the performance of a simple vasectomy serves no purpose but to play up to this popular appeal. Lasers have proven indispensable for certain types of retinal (eye) and skin procedures, and they offer an alternative, though not necessarily better, means for destroying tissue (prostate and certain tumors) and kidney stones. But a laser (like any other form of light) cannot pass through opaque tissue without burning a hole in it, so a laser cannot be magically directed at internal organs such as the vas tubes without an access opening in the same way that sound waves can be used to destroy kidney stones without an incision. "An Update on Laser Use in Urology" in the October 2003 issue of Contemporary Urology by MJ Manyak and JW Warner from George Washington University Medical Center in Washington, DC did not even mention vasectomy as a potential laser application. The authors maintained that with the CO2 lasers used in office environments, "use is typically limited to surface applications because CO2 laser energy is absorbed by water, resulting in a shallow depth of penetration (<0.1 mm). ... Because the CO2 laser produces a plume that has the potential for vaporizing infectious viral particles, an appropriate fine mesh filtration mask must be used by all operating room personnel during all cutaneous procedures. Other drawbacks of the CO2 laser include poor coagulation of vessels with a diameter greater than 1.0 mm and development of oxidized char that impedes vaporization of underlying tissue." So lasers play no role in a procedure as simple as vasectomy and introduce an unnecessary element of risk. A recent search revealed no articles in the medical literature advocating use of a laser with vasectomy.
How are the ends prevented from rejoining?

Hemoclip
After the vas is divided, the lower end is allowed to slide back down into the sheath, while the upper end is held outside the sheath. A tiny hemoclip (the size of a grain of rice) is then used to close the empty portion of the sheath between the 2 ends. It would be like making a lengthwise opening in a wire's insulation, reaching in and dividing the wire, lifting one cut end out through the insulation, then putting a clip on the empty portion of the insulation, thereby holding one end outside and one end inside, the insulation itself serving as a barrier between the two ends. Most hemoclips are made of titanium, a non-ferromagnetic metal used for many types of implanted medical devices such as dental implants, heart valves, and joint replacement.
Some men request that we use a suture rather than a hemoclip out of an intuitive preference to avoid having any metal implanted in their bodies. No problem. A suture can take a minute more to apply than a hemoclip and may cause a little more local inflamation and scarring, but this is of little clinical significance, just an observation made at the time of vasectomy reversal, where we see virtually no scarring associated with clips because metal is so inert.
Below are artists' renditions of use of a clip and use of a suture to accomplished fascial interposition (separation of the ends). Removal of a small section of the testicular end is optional; it does not influence the effectiveness of the technique.
Could hemoclips cause a problem?
There have been no clip-related problems in the 38,000 or so men who have undergone vasectomy by Dr. Stein since he began using this method in 1990, and no reports of problems in the medical literature of which we are aware. Surgeons have used hemoclips for many years to occlude bleeding blood vessels during many operations in the abdomen and chest, sometimes over 50 clips in a single procedure. Hemoclips have been used by vasectomists for decades. In fact, during vasectomy reversal procedures, as many as 5 clips can be discovered on each side, clips of which the patient was unaware and which could not be felt by the surgeon before the reversal. Most hemoclips are made of medically inert titanium, the same metal used for dental implants, many artificial joints, and mechanical heart valves. Not ferromagnetic, titanium will not interfere with MRI studies and the small amounts used in hemoclips and dental implants do not set off metal detector alarms.
How much pain or discomfort should I expect following vasectomy?
During 104 consecutive follow-up calls on the day after vasectomy, men were asked (1) if they had taken any non-prescription pain pills (Tylenol or ibuprofen), (2) how many times they had taken pain medication, and (3) whether they had taken the medication because they were uncomfortable or just as a precaution to prevent expected discomfort. (Note: All men had received a small packet of 2 Tylenol pills in their "goody bags" following their vasectomies.) Here are the results:

45% of men took no pain medication following their vasectomies, not even the Tylenol that was provided. They had so little discomfort that they saw no need to take anything.
15% of men took pain medication (the Tylenol that was provided or home supplies of ibuprofen) one time "just in case", that is, as a precaution to prevent expected discomfort, not because they needed it.
29% of men took pain medication one time for discomfort, then did not need any additional doses.
11% of men took pain medication more than one time (two or three times), though at least 4 of these 11 men said that they had taken it more to prevent expected pain than because they were actually having discomfort.
0% of these men felt that they needed something stronger than Tylenol or ibuprofen, but we are asked for a prescription medication by about 1 in 500 men.

How often does vasectomy fail?
Prior to August, 1990, Dr. Stein used the common technique of removing a section of the vas tube (1/4 to 1/2 inch) and cauterizing the ends with a hand-held hot-wire cautery unit. Three patients (of about 1500) experienced early failure. That is, the vas tubes grew back together during the healing process, the men did not become sperm-free, and the vasectomies had to be repeated. Recognized early, the problem was corrected before an unintended pregnancy could occur. Since August 1990, Dr. Stein has used hemoclips to divert the vas ends out of alignment and only 5 anatomically normal men (of about 25,000 vasectomy cases, or one in 3000) have experienced early failure. Again, no pregnancies occurred because the men never became sperm-free and the vasectomies were successfully repeated without incident. Delayed failure, or late recanalization, is the return of live sperm to the semen at some time after the semen has been confirmed to be sperm-free by microscopic examination. It is exceedingly rare. Dr. Stein has had direct experience with this only four times: (1) a man whose vasectomy was performed in 1988 and whose semen was sperm-free three months later got his wife pregnant in 1991 and his semen at that time showed live sperm (she never got pregnant again and he returned for a vasectomy reversal in 2005 at which time he was again sperm-free), (2) another patient whose vasectomy was performed in 2000 had no sperm in his semen two months later, but his wife became pregnant nearly 4 years later and a semen check revealed a very low sperm count, (3) a man whose wife became pregnant about 16 months after a vasectomy and negative semen check (she miscarried, so it did not result in a live birth), and (4) a man whose vasectomy was performed and whose semen was sperm-free in early 2005 got a partner pregnant in late 2006; no sperm could be found in his semen even then, but DNA tests confirmed his paternity (the veritable "one got through"). From these four cases and reports in the literature, late failure resulting in pregnancy is possible but rare, odds being about one in 4000, a rate of failure much lower than with any other form of contraception.
Is it important that a vasectomy be "open-ended"?
The expression "open-end" or "open-ended" refers to a vasectomy technique in which the lower (testicular) end of the vas is not occluded with a stitch, hemoclip, or electrocautery. The internet contains many web pages that laude the benefits of the open-end technique. The theory is that if the lower end is occluded, in effect "slamming the door" on the normal egress of sperm from below, there may be a sudden increase in pressure within the epididymis and the portion of the vas tube below ("upstream") from the vasectomy site, potentially causing an increase in the level of inflammation normally required for the resorption of sperm. This exaggerated inflammatory response, so the theory goes, increases the likelihood of post-vasectomy discomfort and decreases the likelihood of reversal success, should the individual ever opt for vasectomy reversal in the future. After an open-ended vasectomy, a sperm granuloma may form at the vasectomy site with a transfer of the inflammatory sperm-resorption process to the vasectomy site, thereby sparing the upstream tubules (epididymis and vas) from this inflammation, decreasing the likelihood that they will become scarred and secondarily occluded, and enhancing the chances of reversal success.

Dr. Stein has performed open-ended vasectomies exclusively since late 1990, and while there is some merit to this technique, the web pages lauding it are probably overstating the benefits.
First, not all open-ended vasectomies result in a sperm granuloma at the vasectomy site. Dr. Stein has reversed vasectomies for a number of his own vasectomy patients and learned that many of the lower ends simply end as a sealed tube with little or no surrounding inflammation. So a natural seal of the lower vas end must occur soon after an open-end vasectomy in many patients.
Second, some open-end vasectomy patients (about one in 50) will still develop post-vasectomy discomfort and tenderness of the epididymis. The likelihood of this occurring is lower with the open-end technique: 2% of patients as opposed to 6% of patients with the closed-end technique (Contraception 46(6):521-521, 1992). This "congestive epididymitis" usually responds quickly to an anti-inflammatory drug like ibuprofen, but serves as proof that an open-end technique is not a sure way to avoid post-vasectomy epididymal inflammation.
Third, a vasectomy site granuloma can be just as tender as epididymal inflammation, though it too usually responds quickly to anti-inflammatory drugs.
Fourth, while reversal success rates may be better after open-end vasectomies, performance of this technique is no guarantee of reversal success and many men with closed-end vasectomies have undergone successful reversals.

In summary, while an open-end technique offers theoretical benefits, use of it is not a "standard of care" and the closed-end technique has worked well for years.
Are there any long-term health risks associated with vasectomy?

The February 17, 1993 issue of the Journal Of The American Medical Association contained 2 studies (by the same research group) that suggest that vasectomy was associated with a small increased risk of prostate cancer in their study groups (almost 30,000 patients in 1 study and almost 40,000 patients in the other study). Because the question was initially raised by 2 studies back in 1990, the World Health Organization convened a 1991 meeting of 23 international experts to review all research regarding vasectomy and prostate cancer. They concluded that there was no plausible biologic mechanism for a relationship between vasectomy and prostate cancer. Some medical researchers interpreted the small increased risk noted in the 1993 studies as a weak association that may be due to chance or bias. A systematic review of the medical literature in 1998 (Fertility & Sterility, 70: 191) further documented the lack of a significant relationship between vasectomy and prostate cancer. Additional convincing evidence of no relationship has been published in the Journal of Urology in June 1999 (161: 1848-1853), in the Journal of the American Medical Association in June 2002 (287:3110-3115), in the Journal of Urology in October 2002 (168: 1408-1411), and in Fertility and Sterility in November 2005 (84:1438-1443). A more recent study in 2014 raised the question once again, and once again, careful analysis of all available research data showed no association of vasectomy with prostate cancer. As recently as 2016, a study HERE shows no increased risk of prostate cancer after vasectomy. An excellent discussion about the subject is here, and the official position of the American Urological Association is here.

The question of an association between vasectomy and subsequent cardiovascular disease was raised back in 1978 and 1980 by two studies which reported an increase in atherosclerosis (hardening of the arteries) in vasectomized laboratory monkeys. The last article listed above (Cancer and cardiovascular disease after vasectomy: an epidemiological database study. Fertility and Sterility 84:1438-1443, November 2005) provides an excellent bibliography of studies showing no association in humans as well as its authors' own data comparing 24,773 vasectomized men with 159,480 non-vasectomized men as a control group. Their findings "strengthen the evidence that vasectomy is not followed by an increased risk of myocardial infarction [heart attack], coronary heart disease as a whole, or stroke. In particular, we add strong support to the evidence that there is no elevation of risk of cardiovascular disease in men after long periods after vasectomy."

My office has copies of these and other research studies, available to any patient upon request.

Are there any age restrictions?
Federal programs (Medicaid and Title10) that provide financial coverage or assistance for sterilization procedures require only that the candidate "is at least 21 years old and appears mentally competent". There are no laws forbidding vasectomy for certain age groups, though individuals under 18 require parental consent for any elective surgery. I will not provide vasectomy for a childless man less than 21 years old unless there are profound extenuating circumstances such as a hereditary disease or obvious inability to care for a child, as might be the case in someone with a cognitive disability. I have provided vasectomy for men younger than 21 who have had 2 or more children. Other vasectomy providers may follow a different or more restrictive set of guidelines, as is their prerogative.
Special Message for Young Men with Fewer than Two Children

If you are less than 30 years old and you have had fewer than 2 children, please consider the following points before having a vasectomy:
  1. You may regret it. Men who have vasectomies when they are in their 20's, especially if they have had fewer than two children, may be the ones most likely to seek vasectomy reversal at a later date, often regretting their vasectomy decisions if their reversals are not successful.
  2. You may change. Many men who think they will never want children when they are in their early 20's are delighted with fatherhood when they are in their 30's. You may be totally convinced now that you will never want children, but people change and you may have a much different outlook 10 years from now.
  3. Women change. Similarly, women who have no desire for children when they are in their early 20's may have a much stronger desire when they are in their 30's and when many of their friends are having children of their own.
  4. Relationships end. Since more than 50% of American marriages end in divorce, you may not be with the same partner ten years from now and a new partner may have a much stronger desire for children than your present partner does. So just because your present partner claims that she will never want children, her tune may change 10 years from now, or she may not even be your partner 10 years from now.
  5. The philosophy of you and your partner with respect to abortion should be considered. If you are both not philosophically opposed to abortion, you have some back-up should other forms of contraception fail, and having a vasectomy now may not seem as critical to avoid an unintended pregnancy. But keep in mind that if she gets pregnant, the choice is hers.
  6. Vasectomy should be considered a permanent and non-reversible procedure because vasectomy reversals are not always successful. So before having a vasectomy, know all of the other options ... HERE and HERE.
  7. Young men should consider Sperm Storage. The companies who provide the service will send what you need directly to your home, you can collect the semen specimens in the privacy of your home, and you can mail them back to the company in the storage container provided. Imagine meeting a prospective partner years after your vasectomy. You fall very much in love with her, but you know that she will someday want children. You can tell her, "I have had a vasectomy", or you can say, "I have had a vasectomy, BUT I banked sperm for future use." Now, which do you think will sound better to her? In her eyes, either you did a foolish thing years ago, or you made a responsible decision with good foresight. In one case, you may lose the girl; in the other case, you win her heart. So sperm storage can be a very smart thing, well worth the investment.
  8. Have you discussed your decision with your parents? If not, consider this: You're an adult, yes, but they helped you get there. How would you feel if your son came home one day and said that he had had a vasectomy? That he had done something to limit his future potential (to be a father) and to limit your own potential (to be a grandfather). How would you feel, after nurturing and guiding him for over two decades, if he did something to profoundly influence his future, but did not have the respect or courtesy to just tell you about it beforehand? As with many decisions in life, change the question from, "Should I tell my parents?" to "What can I do that I will never regret?" Would you ever regret not telling them? Possibly, especially if they are hurt as I, as a parent, would be. Would you ever regret telling them? Probably not. Having a vasectomy is still your decision, but at least you granted them the respect of letting them render an opinion. And if they succeed in discouraging you, because they know you better than any doctor does, you may one day thank them. If they don't succeed in discouraging you, they may split with you the cost of sperm storage and feel much better about your vasectomy in doing so.
All of this said, I recognize the fact that most of us know someone whose girlfriend said she could not get pregnant, or conveniently "forgot" to take her pills, or even poked pinholes in his condoms. And I recognize that our judgments can be impaired after a few drinks so that we are less inclined to cover up or pull out on time. Indeed some men perceive the risks of not getting a vasectomy to be greater than the risks of getting one. We must all be masters of our own destinies, and that is easier if we think through all of the implications, alternatives, and potential consequences of our decisions.

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