Contraception 83 (2011) 310 – 315
Review article
Vasectomy: the other (better) form of sterilization
Grace Shiha,⁎, David K. Turokb , Willie J. Parkerc
a
Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA 94110, USA
b
Department of Obstetrics and Gynecology University of Utah Health Sciences Center, Salt Lake City, UT 84112, USA
c
Planned 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; Tubal ligation; Sterilization; Disparities
1. Introduction
Vasectomy is under-utilized despite being one of the
safest, simplest, most cost-effective, and most efficacious
contraceptive methods. Worldwide, less than 3% of married
women of reproductive age rely on their partner's vasectomy
for contraception [1,2]. Female sterilization is approximately
twice as common as vasectomy in the developed world,
8 times more common in Asia, and 15 times more common
in Latin American and the Caribbean [3]. Vasectomy is more
common than female sterilization in only five countries —
Bhutan, Canada, the Netherlands, New Zealand and Great
Britain [1,2]. New Zealand has the highest vasectomy
prevalence among married couples of reproductive age at
20% [3].
2. Vasectomy is underutilized in the United States
Despite the overall increased health risk and cost, female
sterilization is the preferred method of sterilization among
couples in the United States. Overall, approximately 17% of
women between the ages of 15 and 44 years have had tubal
⁎ Corresponding author. Tel.: +1 415 206 3372; fax: +1 415 206 3112.
E-mail address: shihg@fcm.ucsf.edu (G. Shih).
0010-7824/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.contraception.2010.08.019
sterilization, while only 6% rely on male sterilization for
contraception [4]. From the 2006-2008 National Survey of
Family Growth (NSFG) in the United States, approximately
10.3 million women used female sterilization and approximately 3.7 million men used male sterilization as their form of
contraception [4]. Interestingly, although the United States
population of men is extremely diverse, men who select
vasectomy are mostly non-Hispanic, white, well-educated,
married, are of high economic status and have access to
insurance [5]. Minority, low-income and less educated men
are a small proportion of those with a vasectomy.
2.1. Vasectomy technique
From a surgical perspective, vasectomy has evolved to
include several distinct steps: administration of anesthesia,
delivering and isolating the vas deferens from the scrotum
and vasal occlusion. Currently, the standard anesthesia for a
no-scalpel vasectomy (NSV) is a vasal block with 5–8 mL
of lidocaine without epinephrine given with a 25- or 27gauge 1 1/2-in. needle [6]. Suggested improvements to this
technique to minimize pain during vasectomy have included
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
technique, and a mini-needle technique [7–15]. Overall,
pain during vasectomy is well-controlled. On a 10-cm
G. Shih et al. / Contraception 83 (2011) 310–315
visual analog, pain ranged from 0.1 to 2.7 cm for methods
cited above [9,11,13–17].
Prior to the development of the NSV in 1973 [18],
incisional techniques were used to isolate the vas deferens.
However, compared to incisional vasectomy, NSV is
associated with lower rates of hematoma formation, less
bleeding, fewer infections and shorter operative time
[19–22]. A randomized trial of 1203 men comparing the
two techniques found complications occurred less often with
NSV (0.4/100 procedures) than with an incisional technique
(3.1/100, pb.001). In addition, operating times were shorter
for NSV than incisional vasectomy [19]. Though NSV has
been increasing in popularity in the United States
and worldwide [18,19,23], only 48% of vasectomy providers
in the United States reported using the NSV technique in
2002 [24].
Various surgical approaches for vasal occlusion are used
today. Ligation and excision is the most common method
used worldwide, though it is considered by many the least
effective [25]. Approximately 18% of vasectomies in the
United States are performed by ligation and excision [26,27].
Other methods to improve vasal occlusion have included
electrical and thermal cautery of the vas lumen, vasal
irrigation, and interposition of fascial tissue between the
exposed vas segments known as fascial interposition (FI).
Though direct comparison of methods is difficult, several
studies and a Cochrane review have suggested that cautery
combined with FI is the most effective occlusion technique
[20,28–30]. In the United States, 46% of physicians utilize
FI [24].
3. Comparison of vasectomy to tubal ligation
To compare failure rates of vasectomy with other
contraceptive methods, the rate of pregnancy post-vasectomy is used. Other definitions of vasectomy failure such as
persistent motile sperm will be discussed further below.
Vasectomy has a failure rate (defined by post-procedure
pregnancy) of 0.15% in the first year, which is comparable
to failure rates of long-acting reversible contraceptives
(LARC) available for women [31]. The US Collaborative
Review of Sterilization (CREST) study showed similar
cumulative probability of pregnancy for male (11.3 per
1000 procedures at Years 2, 3 and 5) and female (7.5–
36.5 per 1000 procedures at year 10) sterilization [32,33].
While the CREST study followed a group of 573 women
with vasectomized partners, it did not specifically address
the issue of azoospermia. In contrast to vasectomy, the
failure rates of other male contraceptive methods are much
higher, after 1 year of typical use, the male condom has a
15% failure rate, withdrawal 27%, spermicides 29% and
periodic abstinence 25% [31]. These high failure rates are
due, in part, to the absence of LARC methods for men. In
fact, the only long-acting contraception available for men
is male sterilization.
311
Both vasectomy and tubal ligation should be considered
permanent procedures, with comparable reversal rates.
Vasectomy reversal successfully returns sperm to the
ejaculate in 70-90% of cases and with 40–60% of couples
reporting pregnancy [34–36]. The range of pregnancy
success from reversal of tubal ligation is similar with rates
between 42%-74% [37–39]. In both vasectomy and tubal
ligation, pregnancy success after reversal may depend on
surgical technique, patient age and time since sterilization
[40–42]. Approximately 6% of both men and women will
request reversal within 5 years after sterilization [43–45].
For both methods, regret is higher among those of younger
age [35,43–46].
One difference between tubal ligation and vasectomy is
the immediate effect of tubal ligation. Vasectomy efficacy,
on the other hand, is not immediate. Before relying on
vasectomy as a method of contraception, men must complete
post vasectomy semen analysis (PVSA). While PVSA
protocols vary, evidence supports a single sample showing
azoospermia after 3 months and at least 20 ejaculations is
sufficient to determine if the vasectomy is effective [47].
Vasectomy success is considered azoospermia in the PVSA.
At 3 months, between 51–98% (median 81%) of men will
achieve azoospermia. When sperm is persistent at 3 months,
a second PVSA should be obtained to determine vasectomy
success. In studies that included measurement of azoospermia greater than 3 months post-vasectomy, only 1–2% of
patients were found to have persistence of spermatozoa
(motile or nonmotile) after 6 months [48,49]. Patients with
persistent nonmotile sperm in PVSA are typically considered
infertile and are not considered vasectomy failures [50].
Vasectomy failure, defined by persistent motile spermatozoa
at 6 months post-vasectomy, is approximately 0.4% [47].
As described above, when using the clinical outcome of
post-vasectomy pregnancy, the failure rate is 0.15% in the
first year.
Though both male and female sterilization are costeffective compared to other contraceptive methods, vasectomy is more cost-effective, with an average vasectomy
costing one third as much as a tubal ligation [51,52]. A cost
analysis of sterilization from a societal viewpoint has
predicted that if the number of tubal ligations and
vasectomies were equal, potential annual savings in the
United States would be $266 million in procedure cost alone
and $13 million additional savings in postoperative complication management [53].
While both male and female sterilization are extremely
efficacious and cost-effective, they differ substantially in
surgical risk. Interval laparoscopy tubal ligation requires
entry into the peritoneal cavity and compared to vasectomy,
incurs higher risk due to the invasive nature of the procedure.
Compared with vasectomy, tubal ligation is 20 times more
likely to have major complications [51,53]. Though
procedure-related mortality is extremely rare, it is estimated
to be 12 times higher with tubal ligation than male
sterilization [53,54].
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G. Shih et al. / Contraception 83 (2011) 310–315
Newer methods of hysteroscopic transcervical female
sterilization are similar to vasectomy in that they are not
immediately effective and require additional testing before
relying on them as a method of contraception [55]. One
advantage of hysteroscopic transcervical sterilization is that
it can be office based and is less expensive than laparascopic
tubal ligation [56–58], but may require additional equipment
and can be more expensive than vasectomy. In addition,
hysteroscopic transcervical sterilization is not readily
available for low-income populations and populations with
limited access to insurance.
4. Disparities in sterilization
While the overall underutilization of vasectomy compared to female sterilization is notable, the pronounced
differences in vasectomy utilization among various race/
ethnic groups are particularly striking. There are patient,
provider and systems level factors which may contribute to
these disparities.
4.1. Patient-level factors
In regards to patient-level factors, studies have shown that
even after adjusting for reproductive history and demographic characteristics (e.g., insurance status, martial status,
and socioeconomic status), racial differences in sterilization
utilization persist. In particular, black and Latino men are
less likely to rely on vasectomy for contraception than
white men [5,24,59–62]. While combined female and male
sterilization rates are approximately 23-24% in all racial/
ethnic groups, significant differences in distribution of the
two types of sterilization exist across racial/ethnic groups.
This disparity is most marked in non-Latino black populations where 22% of women rely on female sterilization while
only 1% rely on male sterilization. In Latino populations,
20% use female sterilization, while 3% use male sterilization. Though the gap between female and male sterilization
is smaller in the non-Latino white population, it is still
significant with 15% using female sterilization and 7% using
male sterilization [63,64]. These differences in vasectomy
rates are not explained by increased rates of female
sterilization among black and Latino women [65]. However,
in one study using the 2002 NSFG, the significantly
increased odds of undergoing sterilization for African
American and Hispanic women compared to white women
were attenuated to nonsignficance after adjustment for
unintended pregnancy. This suggests that the experience of
an unintended pregnancy may contribute to a woman's
decision to pursue female sterilization which is highly and
immediately effective as well as independent of their partner.
Since unintended pregnancy is more common among
minority women, this may partially explain increased rates
of female sterilization among minority women [65,66].
While this may explain racial/ethnic differences in female
sterilization, it does not explain low utilization of vasectomy
among blacks and Latino populations.
Previous research has examined several hypotheses
which may explain racial disparities in vasectomy utilization:
4.1.1. Knowledge and attitudes towards contraception
In one study, knowledge and attitudes around vasectomy
were examined in Latino men compared to white men. This
study showed that only 54% of Latino respondents knew
what a vasectomy was compared with 96% of white
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
reported more frequently that tubal reversal could easily
restore fertility (58.9% vs. 39.7%, pb.001) and female
sterilization would reverse itself after 5 years (55.3% vs.
20.8%, pb.001). Black women had a lower mean correct
score even after adjusting for confounders [68].
4.1.2. History of involuntary sterilization
It is important to consider sterilization within the
historical context of involuntary sterilization among minorities in the 1960s and 1970s [69,70]. One study found that
African American men held more negative views about birth
control than African American women. Men's negative
contraceptive beliefs were associated with not using birth
control [71]. In a survey of African Americans, black men
gave both male and female sterilization significantly poorer
ratings (pb.05) than black women [72].
4.1.3. Contraceptive responsibility
The 1991 National Survey of Men identified racial
differences in male perception of contraceptive responsibility [73]. Black men were more likely to view contraceptive
decisions as a woman's responsibility. Latino men were
more likely than non-Latinos to perceive men as the
decision-makers regarding contraception.
4.1.4. Union stability
Studies that have addressed union stability as contributory
to low vasectomy rates have found that even among
continuously married couples, minority men are less likely
to undergo sterilization than their white counterparts [59–61].
4.1.5. Ideas of masculinity
Differences in ideas of masculinity have been cited as a
reason for varying use of vasectomy, however in a study of
Latino and white men, few men from either group endorsed
survey items that included loss of masculinity as a reason to
avoid vasectomy [67].
4.2. Provider-level factors
Provider-level factors, such as differential counseling,
may also contribute to racial differences in vasectomy
utilization. Studies have shown differences in patient
counseling and clinical recommendations by race/ethnicity,
G. Shih et al. / Contraception 83 (2011) 310–315
even when controlling for patient factors and access to care
[74–81]. Differences in communication styles have also
been noted when comparing physician communication with
African-American patients to white patients. African American patients rate communication with their physician as
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
examining the relationship between race/ethnicity and
receipt of sterilization counseling using 2002 NSFG data,
only 2.5% of men who reported no intention for additional
children received any sterilization counseling. However, this
low rate of counseling was not statistically different across
racial/ethnic groups [85]. In contrast, another study using the
2002 NSFG data showed that minority women were more
likely to receive counseling about sterilization and other birth
control methods, even when controlling for access to family
planning services [74].
4.3. Systems barriers
Two studies have investigated barriers to vasectomy
services. One study is an unpublished, national survey of US
public sector and managed care settings by Engender Health
in 2001. The survey was sent to administrators and providers
selected randomly from professional organization lists. Their
study suggests that lack of infrastructure, funding and trained
staff were the most frequently cited reasons for not providing
vasectomy services or referrals. Nearly half of both
administrators and providers felt men would not use
reproductive health services even if they were available.
In the 2007–2008 annual report of California's Family
PACT (Planning, Access, Care and Treatment), denied
claims were a significant barrier to vasectomy services.
Family PACT is a state-funded program that provides nocost family planning services (including vasectomy) to men
and women with incomes less than 200% the federal
poverty level. Though there is no cost to the clients for
sterilization, claim denials have caused some clinics to
discontinue services. In their 2007–2008 report, 28% of
clients that had vasectomy services had their claims denied.
This was slightly improved from a 33% denial in 06/07.
Some claim denials were attributed to incomplete completion of the consent form (PM 330) imposed by the Federal
government. Incorrect completion of the forms led to claim
denials and sterilization services could not be reimbursed
by Family PACT.
Our system of contraceptive counseling, which is often
geared towards women, may also contribute to underutilization of vasectomy. In the Engender Health survey cited
above, providers commonly reported the lack of male clients
in their practice as a reason not to regularly discuss male
sterilization as a contraceptive option. Additionally, providers were focused on methods they were able to provide
themselves. In the United States, 79% of vasectomies are
performed by urologists, followed by 13% performed by
313
family physicians and 8% by general surgeons [24]. Thus,
obstetrician-gynecologists who perform female sterilizations
may not include vasectomy counseling with their clients
since they may not perform vasectomy themselves and have
a primarily female clientele.
5. Discussion
The choice of sterilization method has important health
implications for individuals and important economic impact
on society. Hence, it is vital that access to sterilization for
men and women who have completed their childbearing
becomes readily available. As family planning providers, it
is important to understand techniques and complications and
be able to effectively compare the sterilization methods
available. Providers must also be able to identify barriers to
vasectomy in order to advocate for and counsel patients
appropriately regarding their reproductive options. Studies
which further our understanding of vasectomy barriers and,
in particular, the racial and ethnic disparities of sterilization
use and access are needed to allow men and women to make
an informed decision about their contraceptive choices,
ultimately selecting methods that are most appropriate for
their needs.
Vasectomy is an extremely safe and effective method of
contraception. It is incumbent upon the family planning
community to maximize its availability and acceptance.
Achieving this goal will require a focused and sustained
effort which will be rewarded by more men obtaining the
most effective method of permanent contraception and more
women avoiding unnecessary surgical procedures.
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