Comparing vasectomy techniques, recovery and complications: tips and tricks

Vasectomies are an affordable [1], safe [2], and highly effective [3] method of contraception with low complication rates [3,4,5]. These sterilization procedures involve cutting, sealing, or blocking the vas deferens which prevent sperm from traveling to the ejaculatory duct, making it a reliable birth control option for individuals and families interested in long-term contraception [6, 7]. In 2015, around 527,476 vasectomies were done in the U.S. [8], making it the most common contraception option after condoms, oral contraceptives, and tubal ligations [9]. Worldwide, the highest rates of vasectomies are in Oceania, North America, parts of Asia, and Northern Europe [10]. Despite vasectomies being a reliable and well-tolerated contraceptive method, the global rate has decreased by nearly 61% in the past two decades [11], with similar trends noted in the U.S. across all age groups [8]. However, in the U.S, since Roe vs. Wade was overturned with the Dobbs decision, national interest in the U.S. has grown in vasectomies. From 2021–2022 in the U.S., there was a 35% increase in vasectomy consultation requests, correlating with an increased in completed procedures [12].

Most vasectomies are performed by urologists, with a small percentage of family medicine doctors and general surgeons also performing these procedures. There are two main types of vasectomies that can be performed: the conventional vasectomy with a larger incision or minimally invasive, including the popular no-scalpel vasectomy (NSV) [7, 13]. Failure rates for these methods depend on the vasal occlusion technique, but are consistently below 1% [3, 7], with very low complication rates, around 1–2% [3,4,5]. All types of vasectomies are generally well-tolerated, with the majority of patients resuming normal activity within 1 week of the procedure [2]. Furthermore, vasectomies generally have no absolute contraindications [7].

Given the increasing interest in vasectomies as a contraceptive method in recent years, the purpose of this review is to highlight different vasal occlusion techniques, review the safety profile of vasectomies, and provide framework for preventing or managing complications.

2012 American Urological Association (AUA) guidelines state that vasectomies are designed to be a permanent form of contraception and patients should be counseled as such, though reversal and testicular sperm retrieval are possible options for patients looking for future fertility [7]. With regard to who qualifies for vasectomies, these guidelines do not have strict contraindications for vasectomies [7]. However, it should be noted that the European guidelines do cite young age ( < 30 years), severe illness, single relationship status, and scrotal pain as general contraindications [14, 15]. Pre-procedure consultations should aim to review vasectomy efficacy, possible complications, and pre- and post-operation recommendations for recovery and confirming success [7].

With regard to pre-procedure evaluation, it has been historically advised that pre-vasectomy counseling be done in person to allow for physical exams. However, given the rise of telehealth and its equivalency for urologic care, virtual consultations are an acceptable modality for initial vasectomy consultations [7]. It is well-documented that both in-person and telehealth consultations result in comparable rates of vasectomy, highlighting that telehealth is an effective form of preoperative evaluation and that preoperative physical exams may not always be necessary [16,17,18]. Moreover, given that many telehealth visits are insured services following the COVID-19 pandemic, patients may actually prefer having a pre-vasectomy consultation by telephone [19]. Therefore, despite the lack of physical exam, telehealth is a great alternative for patients as a pre-vasectomy evaluation. However, it should be noted that there is a 1% risk of same-day cancellation if unique anatomy or prior patient history reveals contraindications to the procedure [18]. Ultimately, it is up to the physician’s clinical judgement to determine whether an in-person visit is warranted.

For patients on long-term aspirin therapy, it has traditionally been recommended that they discontinue aspirin 7–10 days prior to the procedure [20, 21]. However, expert opinion suggests that discontinuation 5 days prior may be sufficient for any non-cardiac procedure [22]. Therefore, in practice, the general consensus among urologists for aspirin cessation has been around 5–7 days prior to the procedure.

The current approach to vas isolation has evolved in recent decades to favor minimally invasive no-scalpel approaches over traditional approaches. The NSV offers a minimally invasive option involving a puncture wound compared to the conventional incisional method, which involves a scalpel to create a large incision in the scrotum [7]. In both procedures, the vas deferens is accessed and occluded through mucosal cautery (MC), ligation, excision, or some combination of these techniques. Additionally, vasectomies can involve a fascial interposition (FI), which involves placing a layer of tissue between severed ends of the vas deferens to further ensure the success of the procedure [7]. Each vas isolation technique differs with regard to invasiveness, recovery, and complication rates.

As mentioned, the traditional vasectomy approach involves using a scalpel to create either one or two 1- to 3-cm incisions in the scrotum to access and isolate the vas deferens [7]. The NSV involves a small ( < 10 mm) puncture for access and involves less dissection of the vas and peri vasal tissues [23,24,25]. Since the introduction of the NSV in 1974, conventional vasectomies have decreased in popularity worldwide given their more invasive approach, longer recovery times [13, 26], and higher complication rates [13, 26].

While vasectomy efficacy rates are similar in both the conventional vasectomy and minimally-invasive vasectomy (MIV) [27], NSVs have become the mainstay approach given shorter procedure times and lower risks for perioperative bleeding, surgical pain, scrotal pain, hematomas, and incisional infection [13, 26, 27]. Additionally, patients who undergo NSVs report quicker resumption of sexual activity, likely due to decreased pain [13, 27]. While the NSV has the most publications and therefore presumably more widely-used, any technique where a skin opening is 10 mm or less in size achieves a similar post-operative complication to puncturing the skin with a vas dissector, which is specific to NSV [7].

With regard to postoperative pain between the two approaches, one meta-analysis by Auyeung et al. in 2020 demonstrated that there was a three-fold higher rate of postoperative pain in the conventional approach compared to NSV [28]. Therefore, less-invasive methods such as the NSV should be the preferred method for vas access and isolation, consistent with the AUA, European, French, and Canadian guidelines on vasectomies [7, 14, 15, 29] (Table 1).

The key component of a vasectomy is occlusion of the vas deferens. This can be achieved through blocking or sealing the vas deferens, either through MC, ligation, excision, or a combination of multiple techniques [7]. Additionally, FI may be performed alongside the aforementioned approaches to ensure success in sterilization [7]. While the AUA, European, French, and Canadian guidelines differ slightly with regard to overall recommendations, all favor MC and FI as techniques for vas occlusion [7, 14, 15, 29] (Table 1). Vasectomies involving MC with or without FI have similarly high rates of success (Table 2).

Mucosal cauterization with or without facial interposition

MC, which involves either thermal or electrical heat, is a common choice for physicians performing vas occlusion during vasectomies given its efficacy [30], feasibility, and safety [31]. MC involves applying heat to the lumen of the vas deferens which seals the segment and prevents passage of sperm. One multinational study demonstrated that MC, both thermal and electrical, had an efficacy of 99.7% in achieving severe oligozoospermia and azoospermia, highlighting its efficacy in vasectomy success [30].

MC may be combined with FI. FI involves playing a layer of the vas sheath between the cut ends of the vas deferens to prevent them from recanalizing. One systematic review showed that MC in combination with FI may be more effective in preventing early recanalization compared to other vasal occlusion techniques [32]. However, one study demonstrated that MC alone may be more effective in achieving azoospermia than ligation and excision (LE) with FI [31]. This study found that there was a five-fold higher risk of failure (4.9%) in the LE and FI group compared to the MC alone group (1.0%) [31], Therefore, a combinatorial approach with MC and FI may be most effective, consistent with various vasectomy guidelines (Table 1).

Ligation, excision, fascial interposition, and a combinatorial approach

Ligation involves occluding the vas with ligatures and dividing or excising a segment, with or without FI. AUA guidelines state that the length of the excised segment is commonly 1 cm but may vary between 0 and 5 cm [7]. While research is limited on whether the length of the excised vasal segment affects recanalization rate, one study from 2003 reported that there was no association between the two [33].

Similarly to MC, LE may be achieved either alone or in combination with FI. LE with FI has been shown to be extremely effective and is associated with a higher rate of achieving oligozoospermia and azoospermia more quickly than LE alone, with reduced risks of vasectomy failure [34]. One study showed that in men who underwent FI, the median times to success were four weeks for oligozoospermia and 10 weeks for azoospermia, compared to six weeks and 14 weeks, respectively, for the non-FI group [34].

Worldwide, LE without FI has also proven effective as a vasal occlusion technique. One study in India found that across 3392 patients who received a vasectomy with LE alone, only 1 patient (0.03%) had vasectomy failure [35]. However, other studies suggest there may be a higher failure rate of up to 5.7% in LE alone than compared to LE with FI [34, 36]. Therefore, the general recommendation and census for LE is to combine it with FI for reduced risk of failure, given that FI is an effective and well-tolerated approach to achieve sterilization success.

Cautery vs. ligation

Regarding long term success of a vasal occlusion, both ligation and cautery have demonstrated similar efficacy. In one study done by Altok et al. in 2015, semen analyses were done on patients three months after receiving either ligation or bipolar cautery for vasal occlusion, which demonstrated no significant differences in success or complications between the two groups [37]. However, another study by Sokal et al. suggested that cautery may actually achieve severe oligozoospermia more quickly compared to LE with FI, with significantly fewer early failures, defined as >10 million sperm/mL at week 12 or later, although this study is outdated and had various limitations [31]. Therefore, while bipolar cautery may be preferred for its feasibility in NSVs, this review supports the idea that ligation may have similar long-term efficacy to bipolar cautery.

LigaSure™ (LSVS)

LigaSure™ (LSVS; Valleylab, Boulder, CO, USA) is a novel vessel sealing device that combines physical compression with radiofrequency energy to denature collagen and elastin, different from conventional electrocautery devices. A 2018 experimental study on 125 fresh vas deferens samples showed that when compared to standard ligation methods, LSVS resulted in better total occlusion rates [38]. Although promising, the research only explored LSVS in histologic samples and therefore, more research and large-scale validation in patients is necessitated to explore this device as a potential approach to vas occlusion.

Epithelial curettage

In 2010, a pilot study explored the safety and efficacy of epithelial curettage as a novel approach for vasectomy in 12 patients. This study demonstrated that overall, epithelial curettage was effective in achieving short-term azoospermia. However, 25% of the men profiled demonstrated vasal recanalization in the long term and had to undergo repeat vasectomies [39]. Evidence remains extremely limited on epithelial curettage as a vasectomy technique, and further research must be done to explore its efficacy in achieving successful sterilization.

Following a vasectomy, patients commonly experience minor surgical site pain or pressure that can be managed with supportive care such as non-steroidal anti-inflammatory (NSAIDs) medications, ice, and supportive undergarments. Opioid medications should have little role in the post-procedure recovery except for rare clinical cases where an allergy or contraindication limits NSAID use [40]. Patients may also experience minor sanguineous discharge and erythema around the surgical site which generally improves after a few days, especially given than with NSV techniques the incision is <10 mm and sutures are not usually needed for closure [7]. The current recommendation for patients is to limit physical and sexual activity for 3–5 days and to avoid incision submergence with bathing or swimming for 5–7 days [41]. Generally, most patients resume normal activity within 1 week of the procedure [2].

Given that viable sperm may remain within the semen for up to three months [42], it is recommended to advise patients to use other methods of contraception until a post-vasectomy semen analysis (PVSA) has demonstrated rare, non-motile sperm (≤100,000 non-motile sperm/mL) or azoospermia [7]. All patients who undergo a vasectomy should undergo a PVSA 8–16 weeks after the procedure to monitor sperm count and motility, as per AUA guidelines [7]. In patients with persistent motile sperm on serial PVSAs, a repeat vasectomy may be considered after a 6-month evaluation period.

Timing of motile and non-motile sperm clearance varies and therefore, clinicians should establish a PVSA protocol that is simple to follow and allows for confirmation of occlusion effectiveness. When establishing PVSA protocol, physicians should note that research demonstrates no difference in compliance between “drop in” visits and scheduled appointments [43]. Additionally, given the emergence of home-based PVSA testing kits, research shows that remote tests may be a reliable alternative to traditional in-office testing. One study in 2020 showed that compliance rates and detection of vasectomy failure between the two were comparable. Therefore, urologists should optimize adherence to PVSA protocols by tailoring approaches that align with patient-specific needs and preferences [44].

While many patients commonly report surgical site discomfort and pressure, vasectomies are safe [2] and well-tolerated with low risk of complications [3, 5]. Complications may include sperm granulomas, hematoma formation, infection, postoperative pain, vasectomy failure, and recanalization [2, 45]. Rarer long-term complications may include fistula formation, with vasocutaneous fistulas being the most prevalent, although much of the literature on post-vasectomy fistulas is described in case studies [46].

Sperm granulomas

Sperm granulomas may be a possible complication following a vasectomy and may occur a few weeks post-vasectomy at the surgical site. Oftentimes, they are asymptomatic, although a subset may be associated with pain. While research is outdated and extremely limited, sperm granulomas have been reported to appear in up to 40% of patients [47]. The incidence of sperm granulomas in current vas isolation and occlusion approaches is not currently known. Additionally, sperm granulomas are thought to play a role in recanalization and vasectomy failure in a subset of patients, although the risk remains low [48]. Notably, presence of sperm granulomas at time of vasectomy reversal may confer higher success rates [49, 50].

Hematoma formation and infection

One of the most commonly reported complications following a vasectomy is hematoma formation, which is thought to occur due to intraoperative damage to venous structures. While NSVs have a low risk for hematoma formation compared to traditional vasectomies, AUA guidelines acknowledge a 1–2% risk for hematoma formation [7]. AUA guidelines and some studies imply that the incidence of hematoma formation correlates with the physician’s experience, with those having done a greater number of cases having less hematoma complications [7, 51].

Infections that may arise post-vasectomy are usually mild and limited to the surgical site. One retrospective, multinational review found the estimated risk for infection with NSVs to be between 0.8 and 2.1% [52], although this may be overestimated given that many cases reported infection uncertainty. Rarer infectious complications such as Fournier’s gangrene and endocarditis have been reported in the literature as case studies [53, 54].

Postoperative pain: acute and chronic

While pain and discomfort are expected side effects that usually last a few days, a small subset of patients experience persistent postoperative pain. Research shows that continued post-vasectomy pain may occur in up to 1–6% of patients [55, 56], however, one meta-analysis done in 2020 reports that the average rate of pain may be as high as 15% [28]. Additionally, it has been shown that the incidence of post-vasectomy pain is likely significantly higher in the traditional scalpel approach versus NSV [28].

Post-vasectomy pain syndrome (PVPS), defined as post-vasectomy pain that has a severely negative impact on quality of life, may occur in up to 1–2% of patients of patients experiencing persistent pain [7]. Patients with PVPS usually have persistent orchialgia for more than three months after surgery but it should be noted that some patients experience pain with ejaculation, intercourse, or erection [57]. PVPS is considered a diagnosis of exclusion and requires a multidisciplinary approach and medical evaluation involving a thorough history and physical examination after three months [57]. Both conventional vasectomies and NSVs have similar complication rates of PVPS [28]. While the etiology of PVPS remains unclear, the current consensus is that it may be related to direct damage or compression of spermatic cord structures, back pressure from epididymal congestion, or perineural fibrosis [57].

For patients with PVPS, vasectomy reversal relieves symptoms in up to 79% of cases [58], though this may not be an option for patients and couples seeking continued sterility. Other options like epididymectomy or spermatic cord denervation are effective alternatives. When compared to vasectomy reversal efficacy in alleviating PVPS, epididymectomy show similar rates in pain reduction [59]. Similarly, microdenervation of the spermatic cord for PVPS has proven effective in relieving pain, with success among 71–81% of patients with PVPS [60]. Therefore, when discussing treatment options for PVPS, urologists should collaborate with patients to understand their long-term goals and provide education on the various therapies and their effectiveness, enabling informed decision-making.

Vasectomy failure and recanalization

Vasectomy failure is defined as the presence of motile sperm or pregnancy post-procedure. Although risk factors for vasectomy failure include early resumption of sexual activity, sperm granulomas, and recanalization, vasectomy failure rates remain very low, especially when recommended guidelines for vas isolation and occlusion are properly followed [7, 29]. Early recanalization, the return of large sperm following a vasectomy, depends on occlusion technique and can range anywhere from 0% with MC and FI to 13% with LE without FI [61], although overall is low around 0.5% [62]. While early recanalization can be frustrating for both patient and provider, it underscores the importance of a well-defined PVSA protocol and proper post-procedure counseling.

In the U.S., the expansion of telehealth in specialty care and the growing restrictions on reproductive care have led to an increase in vasectomy consultations and procedures [12]. With this rise in vasectomy consultations, a notable new trend is being seen – younger men, including those without partners or children, are pursuing vasectomy consultations at higher rates than before [63]. With this evolving interest, it will be important for physicians to monitor whether this will have long-term consequences on the uptake of vasectomy reversals, testicular sperm retrievals for IVF, or cryopreservation prior to vasectomies.

A 2013 survey of men aged 15–45 years found that approximately 2.0% of vasectomized men reported having a vasectomy reversal, while up to 19.6% of vasectomized men expressed a desire for future children [64]. Another study found that 6.1% of women expressed regret within 5 years after their husband’s vasectomy [65]. Some of the documented factors that influence the decision to undergo a vasectomy reversal include age at time of initial vasectomy, parental status, death of a child, relationship status, and financial status [66, 67]. For families seeking fertility after a vasectomy, there are options apart from a reversal. Sperm retrieval is a suitable option for families and has shown comparable pregnancy rates to vasectomy reversals [68]. However, the most important consideration for post-vasectomy fertility options is generally cost given that in the U.S., these procedures are often out of pocket. These procedures can cost patients anywhere from $5000–$15,000 for vasectomy reversals and $1000–$10,000 for sperm retrievals [69, 70]. These costs do not include the additional costs of in-vitro fertilization (IVF), which can range anywhere from $12,000–$30,000 per cycle if there is no insurance coverage [71,72,73]. Anecdotally, more patients are presenting with questions regarding cryopreservation. Sperm cryopreservation usually includes an initial freezing free ranging from $250–$775 along with an annual storage fee ranging from $100–250 [74]. At-home cryopreservation kits have also become more accessible, and while limited to patients with a known intimate partner, the costs may be lower and more affordable. Since there are established methods to regain fertility after a vasectomy, it is important to prioritize shared decision-making and patient autonomy to address individual reproductive health needs.

Just as in the U.S., other countries have also experienced an increase in vasectomy use. In France, the number of vasectomies performed jumped from 3743 in 2015 to 29,890 in 2022, showing a 698% increase in the number of vasectomies performed [75]. Additionally, in Canada, 20% of all men are choosing to undergo a vasectomy, which surpasses the prevalence of tubal ligations [76, 77]. Interestingly, European urologists have differing views on the role of cryopreservation before vasectomy [78]. Notably, French urologists see failing to discuss cryopreservation as medical oversight and are more in favor of cryopreservation before vasectomy, unlike their counterparts in other countries [78]. This underscores the influence of sociocultural context on vasectomy consultations and emphasizes the need for future efforts to establish international best practices for discussing fertility options among reproductive urologists and andrologists worldwide.

With regard to global uptake, vasectomy utilization has decreased to almost 31% of what it was two decades ago [11]. Particularly within low- and middle-income countries (LMICs), almost all report zero to negligible vasectomy prevalence, likely due to a combination of cultural differences, family demands, and lack of accessible up-to-date information [11]. Global vasectomy prevalence data is limited, and further research is needed to determine how a post-COVID-19 world and restricted abortion access may affect male contraception uptake.

The growing interest in social media platforms and artificial intelligence (AI) tools has also shaped perspectives and the spread of information regarding vasectomies. One study in 2024 found that the topic of vasectomy received very high engagement on TikTok, with 61% of videos being positive toward the vasectomy process, though 23% contained inaccurate medical information [79]. Another study revealed that various AI chatbots provided “somewhat accurate” responses when it came to vasectomy-related questions, although readability and comprehension by the general public were limited [80]. With the growing role of social media and AI in medical information sharing, urologists should leverage these platforms to educate patients and the public.

Vasectomies have been historically intended to be a permanent form of contraception, but advances in procedure approach, reversible agents, and novel vasal occlusion techniques have started changing the landscape. In recent decades, there has been a notable increase in interest regarding reversible male contraception, but there remains no single approved reversible method. Many of these novel vasal occlusion techniques and reversible agents, such as injectable polymers, hydrogels, and implantable devices, are still being explored in animal models or are in the early stages of human trials with limited data [81]. Continued development and exploration of these reversible male contraceptives will undoubtedly impact the delivery of fertility care in the future, and it will be critical to understand how their success rates compare to the gold-standard vasectomy.

Vasectomies are safe, well-tolerated, and have a success of up to 99.7% in achieving sterilization. With increasing interest in vasectomies as a contraceptive option, patients should be educated on the various vasectomy techniques, recovery profiles, risks, and complications to best inform their decision. This comprehensive review explores various vasectomy techniques, their efficacy, and associated complications, highlighting that NSVs are associated with fewer complications, shorter recovery times, and lower rates of postoperative pain. Additionally, this review examines various vasal occlusion techniques, noting that NSV combined with MC or FI may be the most effective in achieving success, although simple ligation and excision may be an effective option in resource-limited settings. As global vasectomy trends change, the impact of fertility procedures such as vasectomy reversals and sperm extraction procedures remains to be seen. In conclusion, careful vasectomy technique selection, postoperative monitoring, and proper patient education are crucial for optimizing outcomes.