Vasectomy is usually performed under local anesthesia. The basic technique is to palpate the vas through the scrotum, grasp it with fingers or atraumatic forceps, make a small incision over the vas, and pull a loop of the vas into the incision. A small segment is removed, and then a needle electrode is used to coagulate the lumen of both ends. Improved techniques include the no-scalpel vasectomy, in which the pointed end of the forceps is used to puncture the skin over the vas. This small variation reduces the chance of bleeding and avoids the need to suture the incision. Another variation is the open-ended vasectomy, in which only the abdominal end of the severed vas is coagulated while the testicular end is left open. This is believed to prevent congestive epididymitis (305). Fascial interposition can be used with any of the above techniques and is widely believed to reduce recanalization. This technique involves securing the thin layer of tissue that surrounds the vas over one of the cut ends (306).
Reversibility Vasectomy must be regarded as a permanent means of sterilization; however, with micro-surgical techniques, vasovasostomy will result in pregnancy about half of the time. The longer the interval since vasectomy, the poorer is the chance of reversal.
Safety Operative complications include scrotal hematomas, wound infection, and epididymitis, but serious sequelae are rare. There were no reports of deaths from vasectomy in the United States in many years, and the death rate in a large third world series was only 0.5 per 100,000. Studies of vasectomized monkeys showed accelerated atherosclerosis, but several large-scale human studies found no connection between vasectomy and vascular disease (307). There is no evidence of cardiovascular risk even 20 years after the operation (308). Concerns about long-term safety recurred with the report of a possible association between prostate cancer and vasectomy (309). Recent large studies present the very clear conclusion that vasectomy is not associated with prostate cancer (310–312).
It is extremely likely that normal couples will experience at least one unwanted pregnancy at some time during their reproductive years. In third world countries, desired family size is larger, but access to effective contraception is limited. As a result, abortion is common. While there was a decline in the overall number of abortions worldwide from 46 million in 1995 to 42 million in 2003, this decline was greater in developed than in developing countries. About half of induced abortions are illegal and considered “unsafe” by the World Health Organization definition: procedures carried out either by an unskilled person or in unsafe conditions or both (313,314).
As shown in Table 10.9 total abortion rates are quite similar over much of the world. What differs is the rate of safe abortions compared with unsafe abortions. In the developed countries, unsafe abortions are rare. In the developing countries they are very common. The highest rates of unsafe abortion are in Latin America and Africa, where abortion is generally illegal. North America, where abortion is legal and contraceptive use is high, has a lower abortion rate, 21 per 1000 women of reproductive age. Abortion rates are even lower in Western Europe, 12 per 1000 (314). Where abortion is legal, it is generally safe; where it is illegal, complications are common. Seventy thousand women die every year from complications of unsafe abortion. Societies cannot prevent abortion, but they can determine whether it will be illegal and dangerous or legal and safe. Death from illegal abortion was once common in the United States. In the 1940s, more than 1,000 women died each year of complications from abortion
Table 10.9 Estimated Numbers and Rates of Safe and Unsafe Abortion Worldwide, by Region and Subregion, 2003