Developing male contraceptive methods is crucial because up to 40% of women encounter difficulties with family planning methods, leading to about 80 million unintended pregnancies each year. Currently, the available male contraceptive methods are primarily condoms, periodic abstinence, and withdrawal, which have been in use for centuries. However, these methods have relatively high failure rates in the first year: withdrawal has a failure rate of 19%, periodic abstinence 20%, and condoms range from 3% to 14%. These rates are much higher compared to modern female contraceptive methods, which have significantly lower failure rates (0.1-3%).
For men, it is essential to have contraceptive methods that are acceptable, affordable, reversible, and effective. Hormonal male contraception, which works by suppressing gonadotropins and replacing testosterone, is currently the closest method to meeting these requirements. This approach helps maintain sexual function, bone health, and muscle mass. Various regimens have been tested, including testosterone monotherapy and combinations of androgens and progestins. Although there are differences in the response to androgens across ethnic groups, a combination of testosterone and progestin proves to be very effective and comparable to female hormonal methods.

Vasectomy

Vasectomy is a safe, permanent surgical method of male sterilization. It is important for couples to be fully informed about the benefits and risks of this procedure. An Australian survey showed that 9.2% of individuals regretted having a vasectomy.

Surgical Techniques

There are several techniques for vasectomy, with the least invasive being the no-scalpel vasectomy, which also has a low complication rate. The most effective technique involves cauterizing the vas deferens and interposing the deferential fascia. Most of these techniques can be performed safely with local anesthesia and on an outpatient basis.

Complications

Vasectomy does not significantly affect sperm production or Leydig cell function, and the volume of ejaculate remains unchanged. There is no evidence that vasectomy increases the risk of systemic diseases such as atherosclerosis or prostate cancer. However, local complications such as hematoma, wound infection, and epididymitis can occur in up to 5% of cases. It is important to discuss potential long-term complications, such as chronic testicular pain, with the patient before proceeding.

Vasectomy Failure

With an effective technique, the risk of vasectomy failure is less than 1%. However, although rare, recanalization can occur in the long term. No motile sperm should be detected three months after the vasectomy. If motile sperm are present, the procedure may need to be repeated.

Counseling

Before undergoing a vasectomy, it is important to consider:

1. Vasectomy is considered irreversible.
2. Although the risk of complications is low, it is essential to be informed about all risks before giving consent.
3. Vasectomy can fail, although this is unlikely.
4. Other contraceptive methods should continue to be used until sperm clearance is confirmed.
5. There are no serious long-term side effects associated with vasectomy.
6. The cauterization and fascia interposition technique appears to be the most effective in preventing early recurrences.

Reversibility of Vasectomy

The success of vasectomy reversal varies but can be up to 90%, depending on the time elapsed since the vasectomy and the technique used. Success rates are higher if reversal is performed within three years of the vasectomy.

Tubulovasostomy

After ten years post-vasectomy, 25% of men may have an epididymal blockage, requiring tubulovasostomy to reverse the vasectomy.

Vasectomy Reversal vs. Sperm Retrieval and ICSI

Vasectomy reversal is generally less expensive and more effective compared to sperm retrieval and subsequent ICSI. To achieve similar success rates to vasectomy reversal, sperm retrieval with ICSI would need to provide an 81% pregnancy rate per cycle.