Introduction

The current male choices for reversible and temporary contraception include abstinence, withdrawal, condom, and now the question is whether vasectomy should be considered temporary. There has been no new reversible male contraception in hundreds of years, and even the condom has been considered and used in different forms over that time. Latex was the only reason that condoms not only became more effective, but also led to prevention of sexually transmitted infections (STIs).

In the spectrum of a male’s reproductive life, the need for and different types of contraception change. When the male is young, free, and single, the main concern is preventing STIs and pregnancy, with the ability to have the opportunity for children later as they wish. Similarly, later in life when a man has completed his family or not having children, the need for permanent status may be more valid over STI prevention. However, if the man is not in a stable relationship, he may continue STI prevention. Equally, the situation is similar for the female contraceptive and reproductive life.

For any medication, especially a contraceptive being used in a healthy population, the contraceptive needs to be 100% safe, 100% effective, 100% reversible, with no short or long-term side effects, and ideally affordable for all groups of patients. This sets a very high bar for drug development. There are ongoing studies and drug development in reversible male contraceptives both by the National Institutes of Health in the US and others around the world, ranging from hormonal to nonhormonal, as well as mechanical plugs and now maybe even vasectomy! Some of these trials are just in vitro and others are in phase 2b trials.

The argument of whether a vasectomy is considered permanent or temporary can be viewed either as a logical argument or an illogical argument. By definition, and thereby logically, vasectomy is reversible, so how can it be permanent? Doesn’t that make it temporary? Alternatively, if males currently go into the procedure as being permanent, ie, short- and long-term, even though it is reversible, isn’t that considered more a conversation about permanent status, with sperm freezing and all reversal and/or in vitro fertilization only being an extreme backup in case of a change? That could be divorce, death of a child, or, of course, change in fertility status of a couple in the same relationship.

So why is vasectomy even being considered now as a more deliberate form of temporary contraception? Arguably, this is a US-centric problem that has been highlighted as of June 2022, when Roe v Wade was overturned by the Dobbs decision in the US Supreme Court and the reproductive rights of women turned back to the state level when previously protected by federal mandate. Several states have now banned or limited female reproductive rights, especially abortion. As a result of this, men have had to step up to the plate and take charge of their own reproductive rights as well as potentially for the couple. This has led to a massive increase in vasectomy consults and procedures being requested. The earliest paper that was published, Patel et al, showed that there was an increased relative search volume in states that had prohibited or limited female reproductive rights compared with states that maintained their rights.¹ This relative search volume has been translated into actual increase in vasectomy consults and procedures since June 2022.^2,3 The true question is, why has this occurred? Is it because males of legal age who clearly procrastinated prior to the Dobbs decision may well be scared and want to get it done, so there is no further concern, especially in states where the female partner has lost her reproductive rights? The second possible reason could be that males want to take control of their reproductive rights more responsibly and completely, as should have been the case for centuries! Finally, new patients and generations of males may be investigating vasectomy as a possible form of temporary contraception despite the gold standard/dogma/ethical standing on what vasectomy represents. The cross fire panel will discuss both sides of this argument.

—Ajay K. Nangia, MBBS, FACS

Vasectomy Should Not Be Considered Temporary Contraception

In urology, we often have fun and focused debates. Debatable strategies abound: to perc or laser a 1.5-cm stone; active surveillance or treatment for a small renal mass or low risk prostate cancer. What is not debatable? The status of vasectomy as a form of permanent contraception. Guidelines from Europe, Canada, and the AUA explicitly state vasectomy is permanent.^4-6 It has a long-term failure rate of just 0.002%, beaten only by orchiectomy or hysterectomy, neither true options!

Yes, about 5% of men will regret their decision for vasectomy.⁷ Yes, urologists have become very competent at vasectomy reversal, with 90% patency and pregnancy rates of 70%.⁸ Yes, in vitro fertilization with sperm retrieval is a good and successful option. But this is no guarantee of future fertility. We are very good with these techniques, but not good enough to promise men we can restore their fertility. And unfortunately the world still lacks a highly effective temporary male contraceptive option.

So if we promise men control over their reproductive futures with the surety that vasectomy provides, how can we also promise reversibility? These are not compatible.

—Christopher M. Deibert, MD

Vasectomy Should Be Considered Temporary Contraception

There is a need for reversible contraceptive options. This need has increased with the overturn of Roe v Wade, which has limited access to reproductive care for some patients. For the reasons below, vasectomy should be offered as reversible contraception.

All available reversible contraceptives have limitations, are executed by females, and have concerning failure rates. One study found within 3 months of starting a reversible contraceptive, 4.2% of women experienced a failure, at 6 months 7.3% had a failure, and by 12 months 12.4% had a failure.⁹ The most common reversible contraceptive used is the oral contraceptive pill, with a 7% typical use failure rate.¹⁰ All contraceptives also have risks. For pill users, there is a 1.2- to 2.2-fold relative risk of thrombotic stroke and a 2.2- to 5-fold relative risk of myocardial infarction.¹¹ Additionally, some women have medical contraindications,¹² or cannot take these medications due to side effects.

Vasectomies are low risk, efficacious, and have a quick functional recovery. The same can be said for reversals, when done by a skilled microsurgeon within a reasonable obstructive interval. The Vasovasostomy Study Group showed that if men underwent reversal within 3 years of vasectomy, there was a 97% patency and 76% pregnancy rate. At 3 to 8 years postvasectomy, there was an 88% patency and 53% pregnancy rate.¹³ These data clearly show that vasectomy reversals work.

Finally, prohibiting vasectomy as a reversible contraception is paternalistic. If men are well informed about the risks of vasectomy and reversal, and patency/pregnancy rates after reversal, it is ultimately the couple’s decision to determine the optimal contraception for them. Our role as physicians is to provide patients with information and allow them to make the best decision for their individual circumstances. For all these reasons, vasectomy should be offered for reversible contraception.

Overall, and in closing on this topic, how we interpret the dilemma requires personal reflection based on many of the points brought up in this discussion. It requires a personal decision about the definition of permanent vs patient-informed consent. There are many surgeries we do that are generally quantity-of-life decisions vs quality-of-life decisions. What threshold any clinician decides is adequate to proceed must be based on many factors.

—Mary K. Samplaski, MD