Vasectomy: AUA Guideline
Ira D. Sharlip, Arnold M. Belker, Stanton Honig, Michel Labrecque, Joel L. Marmar,
Lawrence S. Ross, Jay I. Sandlow and David C. Sokal
From the American Urological Association Education and Research, Inc., Linthicum, Maryland

Abbreviations
and Acronyms
CV ⫽ conventional vasectomy
FDA ⫽ Food and Drug
Administration
FI ⫽ fascial interposition
MC ⫽ mucosal cautery
MIV ⫽ minimally invasive
vasectomy
NSV ⫽ no-scalpel vasectomy
PVSA ⫽ post-vasectomy semen
analysisRNMS ⫽ rare non-motile sperm
This document is being printed as submission
without independent editorial or peer review by
the Editors of The Journal of Urology®

Purpose: The purpose of this guideline is to provide guidance to clinicians whooffer vasectomy services.
Materials and Methods: A systematic review of the literature using the searchdates January 1949-August 2011 was conducted to identify peer-reviewed publications relevant to vasectomy. The search identified almost 2,000 titles andabstracts. Application of inclusion/exclusion criteria yielded an evidence base of
275 articles. Evidence-based practices for vasectomy were defined when evidence
was available. When evidence was insufficient or absent, expert opinion-based
practices were defined by Panel consensus. The Panel sought to define theminimum and necessary concepts for pre-vasectomy counseling; optimum methods for anesthesia, vas isolation, vas occlusion and post-vasectomy follow up; andrates of complications of vasectomy. This guideline was peer reviewed by 55
independent experts during the guideline development process.
Results: Vas isolation should be performed using a minimally-invasive vasectomy technique such as the no-scalpel vasectomy technique. Vas occlusion
should be performed by any one of four techniques that are associated withocclusive failure rates consistently below 1%. These are mucosal cautery of
both ends of the divided vas without ligation or clips (1) with or (2) withoutfascial interposition; (3) open testicular end of the divided vas with MC ofabdominal end with FI and without ligation or clips; and (4) non-divisional
extended electrocautery. Patients may stop using other methods of contraception when one uncentrifuged fresh semen specimen shows azoospermia orⱕ100,000 non-motile sperm/mL.
Conclusions: Vasectomy should be considered for permanent contraception
much more frequently than is the current practice in the U.S. and many othernations. The full text of this guideline is available to the public at http://
www.auanet.org/content/media/vasectomy.pdf.
Key Words: vasectomy; sterilization, reproductive; vas deferens, male
contraception; guideline

INTRODUCTIONVASECTOMY is the most common nondiagnostic operation performed byurologists in the United States. Even
though an extensive body of literature
on vasectomy exists, evidence-based
standards for anesthetic, preoperative, operative and postoperative va-

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sectomy practices have not been defined. This guideline is intended to be acomprehensive evidence-based guideline on vasectomy.

BACKGROUND
The number of vasectomies performedin the U.S. has been calculated to be

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THE JOURNAL OF UROLOGY®
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© 2012 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.

AUA GUIDELINE ON VASECTOMY

175,000 to over 500,000 annually.1,2 More than 75% ofvasectomies in the U.S. are performed by urologists,1
and about 90% of urology practices in the U.S. offer
vasectomy services.1
Vasectomy is the fourth most commonly-used contraceptive method in the U.S. behind condoms, oral
contraceptives for women and tubal sterilization.3
Compared to tubal ligation, which is the other common method of permanent contraception, vasectomy
is equally effective in preventing pregnancy, butvasectomy is simpler, faster, safer and less expensive.4 Vasectomy requires less time off work, requires local rather than general anesthesia and isusually performed in a doctor’s office or clinic. The
potential surgical complications of vasectomy areless serious than those of tubal ligation.
Despite the clear advantages of vasectomy, prevalence data for 1998 –2002 show that tubal ligation
was performed about two to three times more often
than vasectomy.2 Among women ages 15 to 44 years
in the U.S., in 2002 only 5.7% relied on vasectomy
for contraception compared to 16.7% who relied on
tubal ligation.5 Worldwide, the discrepancy between
vasectomy and tubal ligation is even more marked
than in the U.S. These data and the many advantages of vasectomy compared to tubal ligation establish that vasectomy should be considered forpermanent contraception much more frequently
than is the current practice in the U.S. and manyother nations.

METHODOLOGYThe Panel employed the American Urological Association(AUA) guideline methodology. A systematic review of theliterature using the MEDLINE® and POPLINE databases with search dates January 1949-August 2011 was
conducted to identify peer-reviewed relevant publications.
The search identified almost 2,000 titles and abstracts.
Application of inclusion/exclusion criteria yielded an evidence base of 275 articles. Only a small subset of thesearticles is referenced in this summary. A complete list ofreferences and a full explanation of AUA guideline methodology can be found in the unabridged text of Vasectomy:
AUA Guideline (2012), which is available online at http://
www.auanet.org/content/media/vasectomy.pdf.

PREOPERATIVE PRACTICE
1. A preoperative interactive consultation should
be conducted, preferably in person. If an in-person consultation is not possible, then preoperative consultation by telephone or electronic
communication is an acceptable alternative. Expert Opinion
Physical examination at the time of in-person preoperative consultation is highly desirable because it
may identify genital pathology that might contrain-

2483

dicate vasectomy and may identify rare patients
who are not good candidates for local anesthesia
because of unusual scrotal sensitivity, marked anxiety or vasa that are difficult to palpate. This examination ideally should be done far enough in advanceof the vasectomy to allow the surgeon to plan for oral
or other sedation if necessary.
2. The minimum and necessary concepts
that should be discussed in a preoperative vasectomy consultation include the following:Expert Opinion
Vasectomy is intended to be a permanent form ofcontraception.
● Vasectomy does not produce immediate sterility.
● Following vasectomy, another form of contraception is required until vas occlusion is confirmed bypost- vasectomy semen analysis (PVSA).
● Even after vas occlusion is confirmed, vasectomy is
not 100% reliable in preventing pregnancy.
● The risk of pregnancy after vasectomy is approximately 1 in 2,000 for men who have post-vasectomy azoospermia or PVSA showing rare non-motile sperm (RNMS).
● Repeat vasectomy is necessary in ⱕ1% of vasectomies, provided that a technique for vas occlusion
known to have a low occlusive failure rate has
been used.
● Patients should refrain from ejaculation for approximately one week after vasectomy.
● Options for fertility after vasectomy include vasectomy reversal and sperm retrieval with in vitro
fertilization. These options are not always successful, and they may be expensive.
● The rates of surgical complications such as symptomatic hematoma and infection are 1–2%. These
rates vary with the surgeon’s experience and thecriteria used to diagnose these conditions.
● Chronic scrotal pain associated with negative impact on quality of life occurs after vasectomy inabout 1–2% of men. Few of these men require
additional surgery.
● Other permanent and non-permanent alternatives
to vasectomy are available.
●

The reproductive status of the female partner
should be considered prior to vasectomy. If thechance for pregnancy in the female partner is poor,
the need for vasectomy may be reduced. If a pregnancy exists at the time of the preoperative consultation, the couple may wish to consider delaying thedecision about permanent contraception until the
postpartum period. A sample form for providing vasectomy information to patients is available as Appendix B at http://www.auanet.org/content/media/
vasectomy.pdf.

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AUA GUIDELINE ON VASECTOMY

3. Clinicians do not need to routinely discuss
prostate cancer, coronary heart disease, stroke,
hypertension, dementia or testicular cancer in
pre-vasectomy counseling of patients because
vasectomy is not a risk factor for these conditions. Standard (Evidence Strength: Grade B)
The Vasectomy Guideline Panel performed a metaanalysis of nine cohort studies on the relationship ofvasectomy and prostate cancer.6 –14 This analysis
indicated that the risk of prostate cancer is not
greater in vasectomized versus non-vasectomizedmen (Relative risk 1.08; 95% confidence interval
0.88 to 1.32).
Three case-control studies15–17 and ten observational studies11,18 –26 examined a possible association between history of vasectomy and coronary
heart disease. Overall, the body of evidence indicates that there is no association between coronary
heart disease and vasectomy.
Several cohort studies evaluated the relationshipbetween vasectomy and stroke.19,20 There were no
significant differences in incidence or fatality rates
between vasectomized and non-vasectomized men.
One small study with a high risk of bias has reported an association between vasectomy and primary progressive aphasia, a rare type of dementia.27
A causal relationship between vasectomy and primary progressive aphasia is doubtful based on thissingle study.
4. Prophylactic antimicrobials are not indicated for routine vasectomy unless the patientpresents a high risk of infection. Recommendation (Evidence Strength: Grade C)
The AUA Best Practice Policy on Urologic Surgery Antimicrobial Prophylaxis (http://www.auanet.
org/content/media/antimicroprop08.pdf) recommends
that prophylactic antibiotics for open and laparoscopic
surgery (including genital surgery) performed without
entering the urinary tract are indicated only if infection risk factors are present. The surgeon’s clinicaljudgement should be used with regard to antimicrobial
prophylaxis.
Additional Points for Preoperative PracticePreoperative laboratory tests are not required routinely for vasectomy patients. In unusual cases, laboratory tests, such as coagulation studies, are necessary to assess the patient’s suitability for asurgical procedure. Patients may be reassured thatpsychosocial, sexual and endocrine problems are
rarely encountered following vasectomy. Prior to vasectomy, spousal consent is advisable but not legallyrequired in the U.S.
There are very rare case reports of Fournier’s
gangrene after vasectomy. In Europe, one such patient died due to this complication.

ANESTHESIA FOR VASECTOMY
5. Vasectomy should be performed with local
anesthesia with or without oral sedation. If thepatient declines local anesthesia or if the surgeon believes that local anesthesia with orwithout oral sedation will not be adequate fora particular patient, then vasectomy may be
performed with intravenous sedation or general anesthesia. Expert Opinion
The smallest available needle should be used forthe injection of local anesthesia because small gauge
needles typically produce less pain than larger
gauge needles. The optimal range of needle sizes is
25 to 32 gauge. It is not clear that intra-operative
pain is less when a pneumatic injector (jet or noneedle device) is used than when a small gauge
needle is used. Patients who are needle-phobic may
prefer a no-needle procedure.

VAS ISOLATION
6. Isolation of the vas should be performed
using a minimally-invasive vasectomy (MIV)technique such as the no-scalpel vasectomy(NSV) technique or other MIV technique. Standard (Evidence Strength: Grade B)
The risks of intraoperative and early postoperative pain, bleeding and infection are related mainly
to the method of vas isolation rather than to themethod of vas occlusion. Methods of vas isolation
include Conventional Vasectomy and MIV. Any isolation technique, including NSV, that uses the following two key surgical principles should be classified as an MIV technique:
1. Small (ⱕ10 mm) openings in the scrotal skin,either as a single midline opening or as bilateral
openings that do not need skin sutures.
2. Minimal dissection of the vas and perivasal tissues, which is facilitated by using a vas ringclamp and vas dissector or other similar special
instruments (fig. 1)

Figure 1. Instruments used for no-scalpel vasectomy and othermethods of minimally invasive vasectomy.

AUA GUIDELINE ON VASECTOMY

The available evidence indicates that a minimallyinvasive vas isolation procedure results in less discomfort during the procedure and in fewer surgicalcomplications. One large randomized controlled
trial,28 one comparative study,29 one observational
study30 and two systematic reviews31,32 concluded
that the NSV technique of vas isolation has fewer
early postoperative complications than CV.
CV technique was the most common techniqueuntil the late 1980s when MIV techniques and special vasectomy instruments were introduced. No
special instruments are used during CV, and the vas
usually is grasped with a towel clip or an Allis forceps. During CV, the scrotal incisions and the areaof scrotal dissection usually are larger than when
MIV techniques are used.
The NSV isolation technique30 was the first minimally-invasive technique for vasectomy. The term
NSV is a misnomer because the no-scalpel technique
is only a technique of vas isolation. NSV does notdescribe a technique for vas occlusion. Thus, theproper term for NSV should be no-scalpel vas isolation
technique. An excellent description of no-scalpel vas
isolation technique can be found in training materials
prepared by EngenderHealth (www.engenderhealth.
org/files/pubs/family-planning/no-scalpel.pdf).
MIV isolation techniques utilize either an open
access approach or a closed access approach. In the
open access approach, the skin opening(s) is (are)made before the vas ring clamp or similar instrument is applied to the vas. In the closed accessapproach, the vas ring clamp or similar instrument
is applied around the vas, perivasal tissue andoverlying skin before the skin opening(s) is (are)made.
CV or MIV methods are performed by making
either one midline incision or bilateral scrotal incisions using a scalpel. One large observational study(N⫽1,800) compared single incision to double incision procedures. Fewer adverse events were reported with a single incision, and the procedure
time was reduced, but no statistical testing was
performed.33 The Panel opinion is that there is noclear advantage to making one or two skin openings. The choice of one or two incisions should bebased on the surgeon’s preference.
For a midline approach, the scrotal skin opening
should be made just below the penoscrotal junction
or midway between the penoscrotal junction and the
top of the testes. For a lateral approach, many experts recommend that the scrotal skin opening
should be made at the level of the penoscrotal junction or higher. Scrotal skin openings for vasectomy
should be positioned to provide access to the straight
portion of the vas. Occlusion of the vas is moreeasily performed in the straight portion than in
the convoluted portion. Compared to occlusion in2485

the convoluted portion, occlusion in the straight
portion may facilitate anastomosis during subsequent vasovasostomy.
For a single-incision vasectomy, the surgeon should
ensure that the same vas is not isolated mistakenly
and occluded in two locations, leaving the other vas
unoccluded. A gentle tug on each vas during isolation will cause the ipsilateral testis to move.34

VAS OCCLUSION
The Panel considered the majority of the studies inthe vas occlusion literature to be Grade C evidence
because most suffer from methodological flaws that
reduce certainty regarding the relative efficacy ofvarious occlusion techniques. Examples of theseflaws are failure to identify consecutive versus selected patients, failure to obtain at least one PVSA,
lack of information about follow-up protocols, unclear criteria for vasectomy failure and wide variations and/or inadequate periods of follow-up duration for evaluation of contraceptive failure.
The Panel defined the acceptable rate of vas occlusion failure to be ⱕ1% across multiple studies
conducted by different surgeons with large numbersof patients. Failure of vas occlusion includes failure
to achieve azoospermia and failure to achieve
RNMS. The literature review produced evidence
about occlusion failure in 89 study arms reportingon 126,821 patients. The Panel found four techniques that satisfy the criterion of ⱕ1% failure rateand, therefore, recommends these four techniquesfor vas occlusion. These four techniques are detailed
below in Guideline Statement 7 and illustrated in
Figure 2.
7. The ends of the vas should be occluded by
one of three divisional methods:
1. Mucosal cautery (MC) with fascial interposition (FI) and without ligatures or clips applied on the vas;
2. MC without FI and without ligatures orclips applied on the vas;
3. Open ended vasectomy leaving the testicular end of the vas unoccluded, using MC on
the abdominal end and FI;
OR by the non-divisional method of extended
electrocautery. Recommendation (EvidenceStrength: Grade C)
MC with FI
Thirteen study arms evaluated this technique inapproximately 18,456 patients. Failure rates for thistechnique ranged from 0.0% to 0.55%, with moststudy arms reporting rates of 0.0% failure. Although
the majority of these data were from non-randomized
observational designs, one study arm was from a high-

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AUA GUIDELINE ON VASECTOMY

Figure 2. Most commonly used vas occlusion techniques and their occlusive failure rates

quality observational study35 that reported an occlusive failure rate of 0.0% with a secondary analysis of
PVSA data reporting 0% recanalizations.36
MC without FI
Six study arms evaluated this technique in approximately 13,851 patients; failure rates ranged from
0.0% to approximately 1.0%. Four of the six study
arms were from non-randomized observational designs, but two arms were from a high-quality observational study; these two arms reported an overall
failure rate of 1.0%.35

Open Ended Method Leaving the Testicular end
Unoccluded with MC of the Abdominal end and FIFour study arms evaluated approximately 4,600
men with this technique. Failure rates ranged from
0.0% to 0.50%. One study arm was from a highquality observational study and reported a failure
rate of 0.0%.35
With regard to the same technique of open ended
vasectomy with MC but without FI, only two study
arms were found. Both study arms were from thesame study,37 evaluated a total of 171 patients andAUA GUIDELINE ON VASECTOMY

2487

Characteristics of vas occlusion studies
Occlusion Technique*No. Study Arms

No. Pts

Recommended techniques
Mucosal cautery of both ends and fascial interposition
13
18456
MC of both ends
6
13851
Open testicular end, MC of abdominal end, FI
44600
Non-divisional extended electrocautery (Marie Stopes technique)†1
41814
Optional techniques for surgeons with training and/or experience that may produce acceptable failure rates
Ligation of both ends
31
24797
Ligation of both ends and FI
92782
Clips on both ends
74337
Other techniques with insufficient evidenceOpen testicular end, MC of abdominal end
2
171Open testicular end, ligation of abdominal end, FI
12150
MC and ligation of both ends and FI
11379
MC and ligation of abdominal end, testicular end left open, FI
1
61
Clips on both ends, FI
1
1073
MC and ligation of both ends
31220
MC and clips on both ends
1
324
Open testicular end, ligation of abdominal end
2758
Ligation and cautery (non-mucosal) of both ends
1
500
Ligation and cautery (non-mucosal) of both ends and FI
1
3867
Open testicular end, ligation and cautery (non-mucosal) of
1
4330
abdominal end, FIOpen testicular end, abdominal end clipped
1
262
Clips only, no excision/division2
89
Totals89

Range of Occlusive
Failure Rates
0.0%–0.55%
0.0%–1.0%
0.0%–0.50%
0.64%
0.0%–13.79%
0.0%–5.85%
0.0%–8.67%
4.35%–4.73%
0.00%
0.36%
3.28%
0.0%
2.0%–4.75%
0.62%
1.11%–2.5%
0.40%
0.08%
0.02%
0.38%
0.0%–2.56%

126,821

A complete list of references associated with this table can be found at www.auanet.org/content/media/vasectomy.pdf.
* Unless otherwise noted, FI was not performed.
† Non-divisional technique.

reported failure rates of 4.73% and 4.35% in the twoarms of the study. Therefore, the panel does not
advocate the omission of FI in performing open
ended vasectomy with MC.
Non-Divisional Vasectomy with Extended
Electrocautery (Marie Stopes International
Electrocautery Technique)
One paper reports the findings from a 10-year period
by Marie Stopes clinics during which 45,123 vasectomies were performed at more than 20 centers by
up to 30 clinicians in the United Kingdom. PVSAs
were obtained on 41,814 patients and revealed 267
early failures (a failure rate of 0.64%) defined as
patients whose PVSAs continued to show the presence of sperm and required reoperation.38
8. The divided vas may be occluded by ligatures or clips applied to the ends of the vas,with or without FI, and with or without excision of a short segment of the vas, by surgeons
whose personal training and/or experience enable them to consistently obtain satisfactory
results with such methods. Option (EvidenceStrength: Grade C)
The Panel is aware that many surgeons occlude
the vas using ligatures or clips and may add otheradjunctive techniques of vas occlusion (fig. 2). The

literature on these techniques is characterized bygreat variability in failure rates (see table), making
the balance between benefits and risks/burdens forthese techniques uncertain. Individual surgeons
who consistently obtain rates of occlusion failure of
ⱕ1% are justified in using these techniques.
9. Routine histologic examination of the excised vas segments is not required. Expert
OpinionAlthough there is no evidence for or against routine histologic examination of excised vas segments,
the AUA recommended in 1998 and reaffirmed in2003 and 2007 that histologic confirmation of thevas is not necessary because PVSA, rather thanpathologic identification of vas segments, is the determinant of vasectomy success.
Additional Points of Surgical PracticeInsufficient evidence was found to determine if folding back of the vas, irrigation of the abdominal end
or FI over the abdominal compared to the testicular
end is associated with lower occlusive failure rates.
There was insufficient evidence to determine theoptimum length of vas that should be excised, if any,
after division of the vas. The Panel believes that it is
not necessary to remove any length of vas. The decision to excise a vas segment should be left to the

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AUA GUIDELINE ON VASECTOMY

surgeon’s judgment. Although failure is very rare if
a long vas segment is excised, removal of a longsegment requires more extensive dissection andmay be associated with a higher risk of complications and more difficulty to perform a later vasectomy reversal. If the surgeon prefers to excise a vas
segment, the Panel believes that 1 cm is adequate.

POSTOPERATIVE PRACTICE
10. Men or their partners should use other contraceptive methods until vasectomy success isconfirmed by PVSA. Clinical Principle
During the first few weeks after vasectomy,
sperm that are left in the male reproductive systemon the abdominal side of the vasectomy site may
retain the ability to fertilize an ovum. Semen analysis after vasectomy is necessary to provide assurance for the patient and his partner that the risk of
future pregnancy is very low.
11. To evaluate sperm motility, a fresh uncentrifuged semen sample should be examinedwithin two hours after ejaculation. Expert
Opinion
WHO guidelines (2010) recommend that semen
analysis to assess motility should be done within 60
minutes of ejaculation when the semen sample iscollected in the laboratory facility.39 Because only
the presence or absence of motility rather than precise motion quality is important for a PVSA, thePanel believes that two hours allows time for bothdelivery of the specimen to the laboratory and subsequent processing of the specimen.
12. Patients may stop using other methods ofcontraception when examination of one wellmixed, uncentrifuged, fresh post-vasectomy
semen specimen shows azoospermia or onlyrare non-motile sperm (RNMS or < 100,000
non-motile sperm/mL). Recommendation (Evidence Strength: Grade C)
After PVSA demonstrates azoospermia, the riskof fertility is about 1 in 2,000.40 Other studies suggest that the risk of pregnancy associated with
RNMS is very low and similar to the risk when
sperm are absent.41– 45 The opinion of the Panel isthat after azoospermia or RNMS has been achieved,
the patient may rely on his vasectomy for contraception, and further PVSAs are unnecessary.
Laboratory techniques, especially centrifugation,
influence the presence or absence of azoospermia
observed in a PVSA. Recent data suggest that centrifugation leads to the identification of extremely
small, but clinically insignificant, numbers of spermin some men with uncentrifuged azoospermia, thus
possibly leading to some unnecessary repeat vasectomies. Because centrifugation may interfere with
sperm motility39 and clinically relevant numbers ofsperm can be identified without centrifugation, routine PVSA should be performed on an uncentrifugedsemen specimen.
In the U.S., CDC regulations implementing the1988 Clinical Laboratory Improvement Act distinguish provider-performed microscopy analysis (Section 493.19) from that in laboratories performing
tests of high complexity (Section 493.25). These regulations allow for semen analysis in a doctor’s office,i.e., “provider performed microscopy,” as long as thereported result is qualitative, i.e., “limited to thepresence or absence of sperm and detection of motility.” Thus, U.S. surgeons are permitted to conduct
PVSA in their offices, but they are not authorized todetermine sperm concentration unless their laboratories have “high complexity” testing certificationfrom the Clinical Laboratory Improvement Act.
13. Eight to sixteen weeks after vasectomy is
the appropriate time range for the first PVSA.
The choice of time to do the first PVSA shouldbe left to the judgment of the surgeon. Option(Evidence Strength: Grade C)
The longer the time period before the first PVSA,
the better the chance that the PVSA will reveal
sterility but the longer the time that the patientmust use another method of contraception. Spermclearance after vasectomy is time-dependent withboth large inter-individual variations as well as
variability across published reports. Because of
these variations, it is impossible to define a precise
time when the first PVSA should be performed.
Clearance of motile sperm is much more rapid andconsistent than clearance of non-motile sperm. The
majority of PVSA studies report that more than 80%
of men have no sperm or only RNMS by 12 weeks
after vasectomy. The opinion of the Panel is that8 –16 weeks is the most appropriate time range for
PVSA testing.
Rates of azoospermia and RNMS related to thenumber of post-vasectomy ejaculations are inconsistent and dependent on the patient’s age and themethod of vas occlusion. One study35 of vas occlusion
by MC showed that only 77% of men had azoospermia or RNMS after 20 ejaculations, and anotherstudy using ligation and excision showed that only
44% of men were azoospermic after 20 ejaculations.46 Thus, the number of post-vasectomy ejaculations should not be used as a guide to timing of thefirst PVSA.
14. Vasectomy should be considered a failure if any motile sperm are seen on PVSA at six
months after vasectomy, in which case repeat
vasectomy should be considered. Expert Opinion
When the vas is successfully occluded, motile
sperm disappear by a few weeks after vasectomy.36
The presence of motile sperm at 6 to 12 weeks afterAUA GUIDELINE ON VASECTOMY

vasectomy indicates that recanalization has occurred or that there was a rare technical failure ofvas occlusion. If any motile sperm are present six
months or more after vasectomy, repeat vasectomy
should be considered. There is limited evidence thatabout half of those men who have recanalization lessthan six months after vasectomy will later havespontaneous occlusion of the recanalization andachieve sterility.47
15. If >100,000 non-motile sperm/mL persist
beyond six months after vasectomy, thentrends of serial PVSAs and clinical judgment
should be used to decide whether the vasectomy is a failure and whether repeat vasectomy should be considered. Expert Opinion
If non-motile sperm are present on the first PVSA
in the surgeon’s office, one or more repeat PVSAs
should be performed in the surgeon’s office laboratory to determine if azoospermia develops over time.
If the PVSA shows persistent non-motile sperm,
then a semen specimen should be examined in aclinical laboratory that is certified for quantitative
semen analysis. If the complex lab certifies that
there are ⱕ100,000 non-motile sperm/mL, the patient may rely on his vasectomy for contraception
and stop using other methods of contraception. If the
PVSA shows ⬎100,000 non-motile sperm/mL or any
motile sperm, then further PVSA monitoring or repeat vasectomy should be considered. The decision
to consider vasectomy a failure if ⬎100,000 nonmotile sperm/mL persist for six months or more
after vasectomy should be based on clinical judgment that includes the trend of sperm counts, thepatient’s preferences and the patient’s tolerance forthe risk of pregnancy.
Additional Points of Postoperative Practice
A self-PVSA home test has been approved by the
FDA and is available for clinical use.48 This test issensitive to sperm counts ⱖ250,000/ml, but the test
does not assess for sperm motility. Furthermore, nostudies have shown that clearing men at this cut-off
without evaluating for motility is reliable enough torecommend discontinuation of contraception, and nostudies have followed patients who used the test toassess for the risk of unanticipated pregnancy. This
test may have potential value, but there still are
insufficient data for the panel to judge its clinicalutility.
In the absence of bothersome discomfort, patients
may return to non-physical work on the day of or the
day after vasectomy. Patients may resume physically demanding work or recreation when pain permits.
DNA testing has proven paternity in couples inwhom pregnancy has occurred despite demonstration of post-vasectomy azoospermia around the time2489

of pregnancy initiation.49 These rare events areprobably due to intermittent recanalization.

FUTURE RESEARCH
Gaps in knowledge about vasectomy and researchideas for filling these gaps are available online in thefull text of this guideline on the AUA website.
Conflict Of Interest Disclosures
All panel members completed COI disclosures. Relationships that have expired (more than one yearold) since the panel’s initial meeting, are listed.
Those marked with (C) indicate that compensation
was received; relationships designated by (U) indicate no compensation was received.
Consultant/Advisor: Ira D. Sharlip, Absorption Pharmaceuticals (C), Pfizer (C), Lilly(C), Bayer(C)(expired), Plethora Solutions (C)(expired); Stanton C. Honig, Endo Pharmaceuticals (C), Serono(C), Lilly/ICOS (C), Coloplast (C), AMS (C), menMD(C), Slate Pharmaceuticals (C)(expired); Michel Labrecque, Shepherd Medical (expired) (C); Joel L.
Marmar, Wellspring Urology (C); Lawrence S.
Ross, Gerson Lehrman Group (C)Investigator: Stanton C. Honig, Auxilium(C);Michel Labrecque, Contravac (C)Meeting Participant or Lecturer: Stanton C.
Honig, Sanofi (C), Novartis (C), Lilly/ICOS(C),Pfizer (C), Coloplast (C), Auxilium (C), American
Medical Systems (C), Slate Pharmaceuticals (C); Ira
D. Sharlip, Lilly (C), Pfizer (C), Bayer, (C)(expired),Johnson & Johnson(C)(expired), Shionogi Pharma(C)(expired)
Scientific Study or Trial: David Sokal, Family
Health International (C)Other-Employee, Owner, Product Development: David Sokal, Family Health International(C)Disclaimer
This document was written by the Vasectomy
Guideline Panel of the American Urological Association Education and Research, Inc., which was created in 2008. The Practice Guidelines Committee ofthe AUA selected the panel chair and co-chair. Panelmembers were selected by the chair and co-chair.
Membership of the panel included urologists, family
medicine physicians, and other clinicians with specific expertise on vasectomy techniques. The missionof the committee was to develop recommendations
that are evidence-based or consensus-based, depending on Panel processes and available data, for
optimal clinical practices in the surgical technique ofvasectomy.
Funding of the committee was provided by the
AUA; committee members received no remuneration
for their work. Each member of the committee pro-

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AUA GUIDELINE ON VASECTOMY

vides an ongoing conflict of interest disclosure to the
AUA.
While these guidelines do not necessarily establish the standard of care, AUA seeks to recommend
and to encourage compliance by practitioners withcurrent best practices related to the condition being
treated. As medical knowledge expands and technology advances, the guidelines will change. Today,these evidence-based guideline statements represent not absolute mandates but provisional proposals for treatment under the specific conditions described in each document. For all these reasons, theguidelines do not pre-empt physician judgment inindividual cases.
Treating physicians must take into account variations in resources, and patient tolerances, needs,
and preferences. Conformance with any clinicalguideline does not guarantee a successful outcome.
These guidelines are not intended to provide legal
advice about vasectomy practices.
Although guidelines are intended to encourage
best practices and potentially encompass available
technologies with sufficient data as of close of theliterature review, they are necessarily time-limited.
Guidelines cannot include evaluation of all data on
emerging technologies or management, including
those that are FDA-approved, which may immediately come to represent accepted clinical practices.
For this reason, the AUA does not regard technologies or management which are too new to be addressed by these guidelines as necessarily experimental or investigational.
The completed evidence report may be requested
through AUA.

REFERENCES
1. Barone MA, Hutchinson PL, Johnson CH et al:
Vasectomy in the United States, 2002. J Urol
2006; 176: 232.
2. Eisenberg ML and Lipshultz LI: Estimating thenumber of vasectomies performed annually in the
United States: data from the National Survey of
Family Growth. J Urol 2010; 184: 2068.
3. Martinez GM, Chandra A, Amba JC et al: Fertility,
contraception, and fatherhood: data on men andwomen from cycle 6 (2002) of the 2002 National
Survey of Family Growth. Vital Health Stat 2006;
23: 1.
4. Trussell J, Lalla AM, Doan QV et al: Cost effectiveness of contraceptives in the United States.
Contraception 2009; 79: 5.
5. Chandra A, Martinez GM, Mosher WD et al:
Fertility, family planning, and reproduction healthof U.S. women: data from the 2002 National
Survey of Family Growth. Vital Health Stat 2005;
23: 1.
6. Giovannucci E, Ascherio A, Rimm EB et al: Aprospective cohort study of vasectomy and prostate cancer in US men. JAMA 1993; 269: 873.
7. Giavannucci E, Tosteson TD, Speizer FE et al: A
retrospective cohort study of vasectomy andprostate cancer in US men. JAMA 1993; 269:
878.
8. Hiatt RA, Armstrong MA, Klatsky AL et al: Alcohol consumption, smoking, and other risk factors
and prostate cancer in a large health plan cohort
in California (United States). Cancer Cause Control 1994; 5: 66.
9. Lynge E: Prostate cancer is not increased in men
with vasectomy in denmark. J Urol 2002; 168:488.
10. Moller H, Knudsen LB and Lynge E: Risk of testicular cancer after vasectomy: cohort study over
73 000 men. BMJ 1994; 309: 295.

11. Nienhuis H, Goldacre M, Seagroatt V et al: Incidence of disease after vasectomy: a record linkage retrospective cohort study. BMJ 1992; 304:
743.
12. Rohrmann S, Paltoo DN, Platz EA et al: Association of vasectomy and prostate cancer among
men in a Maryland cohort. Cancer Cause Control
2005; 16: 1189.
13. Sidney S: Vasectomy and the risk of prostatic
cancer and benign prostatic hypertrophy. J Urol
1987; 138: 795.
14. Sidney S, Quesenberry CP Jr, Sadler MC et al:
Vasectomy and the risk of prostate cancer in acohort of multiphasic health-checkup examinees:
second report. Cancer Cause Control 1991; 2:
113.
15. Beaglehole R, Scragg R, Jackson R et al: Risk
factors for coronary heart disease: a case-control
study. New Zeal Med J 1985; 98: 131.
16. Chi IC, Ko UR, Wilkens LR et al: Vasectomy andnon-fatal acute myocardial infarction: a hospitalbased case-control study in Seoul, Korea. Int J
Epidemiol 1990; 19: 32.
17. Rosenberg L, Schwingl PJ, Kaufman DW et al:
The risk of myocardial infarction 10 or more years
after vasectomy in men under 55 years of age.
Am J Epidemiol 1986; 123: 1049.
18. Coady SA, Sharrett AR, Zheng ZJ et al: Vasectomy, inflammation, atherosclerosis and longterm followup for cardiovascular diseases: no
associations in the atherosclerosis risk in communities study. J Urol 2002; 167: 204.
19. Goldacre MJ, Wotton CJ, Seagroatt V et al:
Cancer and cardiovascular disease after vasectomy: an epidemiological database study. Fertil
Steril 2005; 84: 1438.

20. Manson JE, Ridker PM, Spelsberg A et al: Vasectomy and subsequent cardiovascular disease
in US physicians. Contraception 1999; 59: 181.
21. Massey FJ Jr., Bernstein GS, O’Fallon WM et al:
Vasectomy and health. JAMA 1984; 252: 1023.
22. Mullooly JP, Wiest WM, Alexander NJ et al:
Vasectomy, serum assays, and coronary heartdisease symptoms and risk factors. J Clin Epidemiol 1993; 46: 101.
23. Perrin EB, Woods JS, Namekata T et al: Longterm effect of vasectomy on coronary heart disease. Am J Public Health 1984; 74: 128.
24. Petitti DB, Klein R, Kipp H et al: A survey of
personal habits, symptoms of illness, and histories of disease in man with and without vasectomies. Am J Public Health 1982; 72: 476.
25. Tang GH, Zhong YH, Ma YM et al: Vasectomy andhealth: cardiovascular and other diseases following vasectomy in Sichuan Province, People’s Republic of China. Int J Epidemiol 1988; 17: 608.
26. Walker AM, Jick H, Hunter JR et al: Hospitalization rates in vasectomized men. JAMA 1981; 245:
2315.
27. Weintraub S, Fahey C, Johnson N et al: Vasectomy in men with primary progressive aphasia.
Cogn Behav Neurol 2006; 19: 190.
28. Sokal D, McMullen S, Gates D et al: A study ofthe no scalpel and standard incision approaches
to vasectomy in 5 countries. The Male Sterilization Investigator Team. J Urol 1999; 162: 1621.
29. Nirapathpongporn A, Huber DH and Krieger JN:
No-scalpel vasectomy at the King’s birthday vasectomy festival. Lancet 1990; 335: 894.
30. Li SQ, Goldstein M, Zhu J et al: The no-scalpel
vasectomy. J Urol 1991; 145: 341.

31. Labrecque M, Dufresne C, Barone MA et al:
Vasectomy surgical techniques: a systematic review. BMC Med 2004; 2: 21.
32. Cook LA, Pun A, van Vliet H et al: Scalpel versus
no-scalpel incision for vasectomy. Cochrane Database Syst Rev 2007: CD004112.
33. Castillo Jimeno JM, Santiago Gonzalez A, Rodriguez
Perez MJ et al: Unique incision vasectomy: review
of 1,800 cases. Arch Esp Urol. 1992; 45: 63.
34. Kumar V and Kaza RM: A combination of checktug and fascial interposition with no-scalpel vasectomy. J Fam Plann Reprod Health Care 2001;
27: 100.

AUA GUIDELINE ON VASECTOMY

2491

38. Black T and Francome C: The evolution of theMarie Stopes electrocautery no-scalpel vasectomy procedure. J Fam Plann Reprod Health Care
2002; 28: 137.

44. Lewis EL, Brazil CK and Overstreet JW: Human
sperm function in the ejaculate following vasectomy. Fertil Steril 1984; 42: 895.

39. World Health Organization: WHO laboratory manual for the examination and processing of humansemen: 5th Edition. World Health Organization
2010.
40. Philp T, Guillebaud J and Budd D: Late failure ofvasectomy after two documented analyses showing azoospermic semen. Br Med J (Clin Res Ed)
1984; 289: 77.

45. Richardson DW, Aitken RJ and Loudon NB: Thefunctional competence of human spermatozoa
recovered after vasectomy. J Reprod Fertil 1984;
70: 575.
46. Barone MA, Nazerali H, Cortes M et al: A prospective study of time and number of ejaculations
to azoospermia after vasectomy by ligation andexcision. J Urol 2003; 170: 892.

41. Edwards IS: Earlier testing after vasectomy,
based on the absence of motile sperm. Fertil
Steril 1993; 59: 431.

47. Labrecque M, St-Hilaire K and Turcot L: Delayed
vasectomy success in men with a first postvasectomy semen analysis showing motile sperm. Fertil Steril 2005; 83: 1435.

36. Labrecque M, Hays M, Chen-Mok M et al: Frequency and patterns of early recanalization after
vasectomy. BMC Urol 2006; 6: 25.

42. Korthorst RA, Consten D and Van Roijen HJ:
Clearance after vasectomy with a single semen
sample containing ⬍ than 100 000 immotile
sperm/mL: analysis of 1073 patients. BJU Int
2010; 105: 1572.

48. Klotz KL, Coppola MA, Labrecque M et al: Clinicaland consumer trial performance of a sensitive
immunodiagnostic home test that qualitatively
detects low concentrations of sperm following
vasectomy. J Urol 2008; 180: 2569.

37. Shapiro EI and Silber SJ: Open-ended vasectomy,
sperm granuloma, and postvasectomy orchialgia.
Fertil Steril 1979; 32: 546.

43. Jouannet P and David G: Evolution of the properties of semen immediately following vasectomy. Fertil Steril 1978; 29: 435.

49. Smith JC, Cranston D, O’Brien T et al: Fatherhood
without apparent spermatozoa after vasectomy.
Lancet 1994; 344: 30.

35. Barone MA, Irsula B, Chen-Mok M et al: Effectiveness of vasectomy using cautery. BMC Urol
2004; 4: 10.