Introduction

In the United States up to 500,000 men elect vasectomy each year. The desire for more children is the most common reason for dissatisfaction after the procedure. ¹ Up to 20% of men who have undergone vasectomy express a desire for more children, raising concern about the need for more comprehensive preoperative counseling. ²

Vasectomy reversal success ranges from 63% to 98%, and even in the hands of an experienced microsurgeon its success is far from guaranteed. ³ There is little literature evaluating whether men who have not fathered children are at greater risk for post-vasectomy desire for children.

Materials and Methods

We performed an analysis of the 2002 to 2017 waves of the National Survey for Family Growth (NSFG), a nationally representative survey of family planning in the United States. The study was performed by in-person structured interviews with a sample of people designed to provide nationally representative data.

We compared demographic information and family planning attitudes among men who had undergone vasectomy and compared characteristics of those with vs without children. In addition to demographic characteristics, we evaluated their responses to the questions, “Do you want (more) children?” and “Have you ever had a vasectomy reversal?”

Results

Out of 29,192 men who participated in the NSFG, 1,043 (3.6%) reported undergoing vasectomy. Applying the NSFG sampling weights, this population of sterilized men represents 5.7% of the national population of 63,313,791 men age 15 to 44 in the nation. Of the 1,043 men who participated in the NSFG and reported having a vasectomy, 61 (5.8%) reported having no children. This rate would be equivalent to a national population of 4.4% of the men with vasectomy.

There were significant demographic differences between the vasectomized men with and without children (table 1). Men in both groups underwent vasectomy at similar ages. Men with no children had a significantly higher annual household income at 413% of the poverty line compared to men with children at 347% (p=0.011). Men with no children were significantly more likely to have never been married (18.7% vs 0.7%, p <0.001). Men with no children were also more likely to be agnostic or atheist (61.4% vs 18.8%, p <0.001).

Employing multivariate logistic analysis we found that higher income, religion and marital status remained significantly associated with undergoing vasectomy without having fathered children (table 1). Compared to men who were married, men who were never married were 94.5 times more likely to have never fathered a child before undergoing vasectomy. Compared to men who identified as Protestant, men who did not identify with a religion were 15.2 times as likely to have never fathered a child before undergoing vasectomy.

We also evaluated family planning outcomes among the men who underwent vasectomy. For this analysis men were categorized as having no children or 1 child or at least 2 children. There were no differences among the 3 groups in regard to wanting children or undergoing vasectomy reversal (table 2). Of note, none of the men who underwent vasectomy without children underwent vasectomy reversal.

Discussion

This is the first population based characterization comparing men who underwent vasectomy with vs without having fathered children. Men who elect surgical sterilization with no children have distinct demographic differences from men who do so after having children. Compared to men with children, men without children are more likely to not be married, report no religious affiliations and have a higher household income.

Almost a fifth of men who underwent vasectomy without children had never been married. Less than 1% of vasectomized men with children were never married. The decision to undergo vasectomy with no children may reflect that these men are less likely to identify with a traditional nuclear family structure.

Household income was significantly higher in the population of sterilized men with no children compared to men with children. The negative correlation between number of children and income is well documented in the United States population and is likely the result of the interplay between educational attainment on both earning potential and timing of children. ⁴

None of the men without children reported undergoing vasectomy reversal. They also did not express the desire for more children at a higher rate. Thus, over the followup period (an average of 6.4 years post-vasectomy), men without children may not have experienced post-procedure regret.

Few studies have evaluated the risk of regret after vasectomy. Bryk et al reviewed 1,656 men who had vasectomies at a single institution, of whom 68 (4.1%) did not have children. ⁵ During a followup of 6.3 years the 54 men without children whom they were able to reach had not sought vasectomy reversal. They concluded that men without children should not be counseled differently than men with children, which our findings also support.

The 2015 AUA guidelines on vasectomy state that surgeons should take into account patient age and number of children when exercising clinical judgment to determine the appropriateness of performing a vasectomy. The 2012 European Association of Urology guidelines state that relative contraindications to vasectomy include the absence of children, age less than 30 years, severe illness, no current relationship and scrotal pain. While some of these recommendations are supported by the literature, absence of children is not.

Only 4.4% of the men who reported undergoing vasectomy in the NSFG did so without having children. However, urologists who perform a high volume of the procedure will likely encounter this situation. When counseling these men, these data are reassuring that the absence of children does not portend future regret. To further ameliorate risk of regret, sperm banking allows for the future option of assisted reproductive technology.

Conclusions

Men who undergo vasectomy without having children constitute a small but distinct population. Compared to men with children, men without children are more likely to not be married, report no religious affiliations and have a higher household income. Men without children did not report vasectomy reversal over 7-year followup. The data suggest that men without children should be counseled carefully, but not discouraged from vasectomy.