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Home , Sterilization (medicine), Vasectomy

Contraception 83 (2011) 310–315

Review article : the other (better) form of ⁎ Grace Shiha, , David K. Turokb, Willie J. Parkerc aDepartment of Family and Community , University of California San Francisco, San Francisco, CA 94110, USA bDepartment of Obstetrics and Gynecology University of Utah Health Sciences Center, Salt Lake City, UT 84112, USA cPlanned Parenthood, Metropolitan Washington, Washington DC 20036, USA Received 10 June 2010; revised 25 August 2010; accepted 25 August 2010

Abstract

Male sterilization (vasectomy) is the most effective form and only long-acting form of contraception available to men in the United States. Compared to female sterilization, it is more efficacious, more cost-effective, and has lower rates of complications. Despite these advantages, in the United States, vasectomy is utilized at less than half the rate of female sterilization. In addition, vasectomy is least utilized among black and Latino populations, groups with the highest rates of female sterilization. This review provides an overview of vasectomy use and techniques, and explores reasons for the disparity in vasectomy utilization in the United States. © 2011 Elsevier Inc. All rights reserved.

Keywords: Vasectomy; No-scalpel vasectomy; ; Sterilization; Disparities

1. Introduction sterilization, while only 6% rely on male sterilization for contraception [4]. From the 2006-2008 National Survey of Vasectomy is under-utilized despite being one of the Family Growth (NSFG) in the United States, approximately safest, simplest, most cost-effective, and most efficacious 10.3 million women used female sterilization and approxi- contraceptive methods. Worldwide, less than 3% of married mately 3.7 million men used male sterilization as their form of women of reproductive age rely on their partner's vasectomy contraception [4]. Interestingly, although the United States for contraception [1,2]. Female sterilization is approximately population of men is extremely diverse, men who select twice as common as vasectomy in the developed world, vasectomy are mostly non-Hispanic, white, well-educated, 8 times more common in Asia, and 15 times more common married, are of high economic status and have access to in Latin American and the Caribbean [3]. Vasectomy is more insurance [5]. Minority, low-income and less educated men common than female sterilization in only five countries — are a small proportion of those with a vasectomy. Bhutan, Canada, the Netherlands, New Zealand and Great Britain [1,2]. New Zealand has the highest vasectomy 2.1. Vasectomy technique prevalence among married couples of reproductive age at 20% [3]. From a surgical perspective, vasectomy has evolved to include several distinct steps: administration of anesthesia, delivering and isolating the from the 2. Vasectomy is underutilized in the United States and vasal occlusion. Currently, the standard anesthesia for a no-scalpel vasectomy (NSV) is a vasal block with 5–8mL Despite the overall increased health risk and cost, female of lidocaine without epinephrine given with a 25- or 27- sterilization is the preferred method of sterilization among gauge 1 1/2-in. needle [6]. Suggested improvements to this couples in the United States. Overall, approximately 17% of technique to minimize pain during vasectomy have included women between the ages of 15 and 44 years have had tubal using EMLA (eutectic mixture of local anesthetics) cream alone or as an adjunct to infiltration anesthesia, buffering anesthesia, spermatic cord block, the no-needle jet injector ⁎ Corresponding author. Tel.: +1 415 206 3372; fax: +1 415 206 3112. technique, and a mini-needle technique [7–15]. Overall, E-mail address: [email protected] (G. Shih). pain during vasectomy is well-controlled. On a 10-cm

0010-7824/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.contraception.2010.08.019 G. Shih et al. / Contraception 83 (2011) 310–315 311 visual analog, pain ranged from 0.1 to 2.7 cm for methods Both vasectomy and tubal ligation should be considered cited above [9,11,13–17]. permanent procedures, with comparable reversal rates. Prior to the development of the NSV in 1973 [18], successfully returns to the incisional techniques were used to isolate the vas deferens. ejaculate in 70-90% of cases and with 40–60% of couples However, compared to incisional vasectomy, NSV is reporting [34–36]. The range of pregnancy associated with lower rates of hematoma formation, less success from reversal of tubal ligation is similar with rates bleeding, fewer and shorter operative time between 42%-74% [37–39]. In both vasectomy and tubal [19–22]. A randomized trial of 1203 men comparing the ligation, pregnancy success after reversal may depend on two techniques found complications occurred less often with surgical technique, patient age and time since sterilization NSV (0.4/100 procedures) than with an incisional technique [40–42]. Approximately 6% of both men and women will (3.1/100, pb.001). In addition, operating times were shorter request reversal within 5 years after sterilization [43–45]. for NSV than incisional vasectomy [19]. Though NSV has For both methods, regret is higher among those of younger been increasing in popularity in the United States age [35,43–46]. and worldwide [18,19,23], only 48% of vasectomy providers One difference between tubal ligation and vasectomy is in the United States reported using the NSV technique in the immediate effect of tubal ligation. Vasectomy efficacy, 2002 [24]. on the other hand, is not immediate. Before relying on Various surgical approaches for vasal occlusion are used vasectomy as a method of contraception, men must complete today. Ligation and excision is the most common method post vasectomy analysis (PVSA). While PVSA used worldwide, though it is considered by many the least protocols vary, evidence supports a single sample showing effective [25]. Approximately 18% of in the after 3 months and at least 20 ejaculations is United States are performed by ligation and excision [26,27]. sufficient to determine if the vasectomy is effective [47]. Other methods to improve vasal occlusion have included Vasectomy success is considered azoospermia in the PVSA. electrical and thermal cautery of the vas lumen, vasal At 3 months, between 51–98% (median 81%) of men will irrigation, and interposition of fascial tissue between the achieve azoospermia. When sperm is persistent at 3 months, exposed vas segments known as fascial interposition (FI). a second PVSA should be obtained to determine vasectomy Though direct comparison of methods is difficult, several success. In studies that included measurement of azoosper- studies and a Cochrane review have suggested that cautery mia greater than 3 months post-vasectomy, only 1–2% of combined with FI is the most effective occlusion technique patients were found to have persistence of spermatozoa [20,28–30]. In the United States, 46% of physicians utilize (motile or nonmotile) after 6 months [48,49]. Patients with FI [24]. persistent nonmotile sperm in PVSA are typically considered infertile and are not considered vasectomy failures [50]. Vasectomy failure, defined by persistent motile spermatozoa 3. Comparison of vasectomy to tubal ligation at 6 months post-vasectomy, is approximately 0.4% [47]. As described above, when using the clinical outcome of To compare failure rates of vasectomy with other post-vasectomy pregnancy, the failure rate is 0.15% in the contraceptive methods, the rate of pregnancy post-vasec- first year. tomy is used. Other definitions of vasectomy failure such as Though both male and female sterilization are cost- persistent motile sperm will be discussed further below. effective compared to other contraceptive methods, vasec- Vasectomy has a failure rate (defined by post-procedure tomy is more cost-effective, with an average vasectomy pregnancy) of 0.15% in the first year, which is comparable costing one third as much as a tubal ligation [51,52]. A cost to failure rates of long-acting reversible contraceptives analysis of sterilization from a societal viewpoint has (LARC) available for women [31]. The US Collaborative predicted that if the number of tubal ligations and Review of Sterilization (CREST) study showed similar vasectomies were equal, potential annual savings in the cumulative probability of pregnancy for male (11.3 per United States would be $266 million in procedure cost alone 1000 procedures at Years 2, 3 and 5) and female (7.5– and $13 million additional savings in postoperative compli- 36.5 per 1000 procedures at year 10) sterilization [32,33]. cation management [53]. While the CREST study followed a group of 573 women While both male and female sterilization are extremely with vasectomized partners, it did not specifically address efficacious and cost-effective, they differ substantially in the issue of azoospermia. In contrast to vasectomy, the surgical risk. Interval tubal ligation requires failure rates of other methods are much entry into the peritoneal cavity and compared to vasectomy, higher, after 1 year of typical use, the male has a incurs higher risk due to the invasive nature of the procedure. 15% failure rate, withdrawal 27%, 29% and Compared with vasectomy, tubal ligation is 20 times more periodic abstinence 25% [31]. These high failure rates are likely to have major complications [51,53]. Though due, in part, to the absence of LARC methods for men. In procedure-related mortality is extremely rare, it is estimated fact, the only long-acting contraception available for men to be 12 times higher with tubal ligation than male is male sterilization. sterilization [53,54]. 312 G. Shih et al. / Contraception 83 (2011) 310–315 Newer methods of hysteroscopic transcervical female sterilization, it does not explain low utilization of vasectomy sterilization are similar to vasectomy in that they are not among blacks and Latino populations. immediately effective and require additional testing before Previous research has examined several hypotheses relying on them as a method of contraception [55]. One which may explain racial disparities in vasectomy utilization: advantage of hysteroscopic transcervical sterilization is that it can be office based and is less expensive than laparascopic 4.1.1. Knowledge and attitudes towards contraception tubal ligation [56–58], but may require additional equipment In one study, knowledge and attitudes around vasectomy and can be more expensive than vasectomy. In addition, were examined in Latino men compared to white men. This hysteroscopic transcervical sterilization is not readily study showed that only 54% of Latino respondents knew available for low-income populations and populations with what a vasectomy was compared with 96% of white limited access to insurance. respondents [67]. In a study of contraceptive knowledge in black and white women who had already received female sterilization, black women endorsed more myths about female sterilization than white women. Black women 4. Disparities in sterilization reported more frequently that could easily restore (58.9% vs. 39.7%, pb.001) and female While the overall underutilization of vasectomy com- sterilization would reverse itself after 5 years (55.3% vs. pared to female sterilization is notable, the pronounced 20.8%, pb.001). Black women had a lower mean correct differences in vasectomy utilization among various race/ score even after adjusting for confounders [68]. ethnic groups are particularly striking. There are patient, provider and systems level factors which may contribute to 4.1.2. History of involuntary sterilization these disparities. It is important to consider sterilization within the historical context of involuntary sterilization among minor- 4.1. Patient-level factors ities in the 1960s and 1970s [69,70]. One study found that African American men held more negative views about birth In regards to patient-level factors, studies have shown that control than African American women. Men's negative even after adjusting for reproductive history and demo- contraceptive beliefs were associated with not using birth graphic characteristics (e.g., insurance status, martial status, control [71]. In a survey of African Americans, black men and socioeconomic status), racial differences in sterilization gave both male and female sterilization significantly poorer utilization persist. In particular, black and Latino men are ratings (pb.05) than black women [72]. less likely to rely on vasectomy for contraception than white men [5,24,59–62]. While combined female and male 4.1.3. Contraceptive responsibility sterilization rates are approximately 23-24% in all racial/ The 1991 National Survey of Men identified racial ethnic groups, significant differences in distribution of the differences in male perception of contraceptive responsibil- two types of sterilization exist across racial/ethnic groups. ity [73]. Black men were more likely to view contraceptive This disparity is most marked in non-Latino black popula- decisions as a 's responsibility. Latino men were tions where 22% of women rely on female sterilization while more likely than non-Latinos to perceive men as the only 1% rely on male sterilization. In Latino populations, decision-makers regarding contraception. 20% use female sterilization, while 3% use male steriliza- tion. Though the gap between female and male sterilization 4.1.4. Union stability is smaller in the non-Latino white population, it is still Studies that have addressed union stability as contributory significant with 15% using female sterilization and 7% using to low vasectomy rates have found that even among male sterilization [63,64]. These differences in vasectomy continuously married couples, minority men are less likely rates are not explained by increased rates of female to undergo sterilization than their white counterparts [59–61]. sterilization among black and Latino women [65]. However, in one study using the 2002 NSFG, the significantly 4.1.5. Ideas of masculinity increased odds of undergoing sterilization for African Differences in ideas of masculinity have been cited as a American and Hispanic women compared to white women reason for varying use of vasectomy, however in a study of were attenuated to nonsignficance after adjustment for Latino and white men, few men from either group endorsed . This suggests that the experience of survey items that included loss of masculinity as a reason to an unintended pregnancy may contribute to a woman's avoid vasectomy [67]. decision to pursue female sterilization which is highly and 4.2. Provider-level factors immediately effective as well as independent of their partner. Since unintended pregnancy is more common among Provider-level factors, such as differential counseling, minority women, this may partially explain increased rates may also contribute to racial differences in vasectomy of female sterilization among minority women [65,66]. utilization. Studies have shown differences in patient While this may explain racial/ethnic differences in female counseling and clinical recommendations by race/ethnicity, G. Shih et al. / Contraception 83 (2011) 310–315 313 even when controlling for patient factors and access to care family physicians and 8% by general surgeons [24]. Thus, [74–81]. Differences in communication styles have also obstetrician-gynecologists who perform female sterilizations been noted when comparing physician communication with may not include vasectomy counseling with their clients African-American patients to white patients. African Amer- since they may not perform vasectomy themselves and have ican patients rate communication with their physician as a primarily female clientele. more dominant, less participatory and less patient-centered than white patients [82–84]. Few studies have examined sterilization utilization from this perspective. In a study 5. Discussion examining the relationship between race/ethnicity and receipt of sterilization counseling using 2002 NSFG data, The choice of sterilization method has important health only 2.5% of men who reported no intention for additional implications for individuals and important economic impact children received any sterilization counseling. However, this on society. Hence, it is vital that access to sterilization for low rate of counseling was not statistically different across men and women who have completed their childbearing racial/ethnic groups [85]. In contrast, another study using the becomes readily available. As providers, it 2002 NSFG data showed that minority women were more is important to understand techniques and complications and likely to receive counseling about sterilization and other birth be able to effectively compare the sterilization methods control methods, even when controlling for access to family available. Providers must also be able to identify barriers to planning services [74]. vasectomy in order to advocate for and counsel patients appropriately regarding their reproductive options. Studies 4.3. Systems barriers which further our understanding of vasectomy barriers and, in particular, the racial and ethnic disparities of sterilization Two studies have investigated barriers to vasectomy use and access are needed to allow men and women to make services. One study is an unpublished, national survey of US an informed decision about their contraceptive choices, public sector and managed care settings by Engender Health ultimately selecting methods that are most appropriate for in 2001. The survey was sent to administrators and providers their needs. selected randomly from professional organization lists. Their Vasectomy is an extremely safe and effective method of study suggests that lack of infrastructure, funding and trained contraception. It is incumbent upon the family planning staff were the most frequently cited reasons for not providing community to maximize its availability and acceptance. vasectomy services or referrals. Nearly half of both Achieving this goal will require a focused and sustained administrators and providers felt men would not use effort which will be rewarded by more men obtaining the reproductive health services even if they were available. most effective method of permanent contraception and more – In the 2007 2008 annual report of California's Family women avoiding unnecessary surgical procedures. PACT (Planning, Access, Care and Treatment), denied claims were a significant barrier to vasectomy services. Family PACT is a state-funded program that provides no- References cost family planning services (including vasectomy) to men and women with incomes less than 200% the federal [1] United Nations. World contraceptive use 2007. New York: Department level. 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