Male Reproductive Clinic, PA

Russel H. Williams, M.D.
Board Certified in Urology

9190 Katy Frwy., Ste 101
Houston, Texas 77055
11302 Fallbrook, Ste 106
Houston, Texas 77076

Telephone 832.358.8600
Facsimile 832.358.0376

Vasectomy Consent Form (Part 2)

(Part 2 - for patient chart) See also Part 1 - patient copy/ instructions.

CONSENT TO STERILIZATION OPERATION
(SURGICAL VASECTOMY)

I have been given and understand the following information:

Explanation of Sterilization Procedure:

Vasectomy is a minor surgical procedure that is performed in the doctor's office under local anesthetic. The surgery takes approximately 30 minutes and involves making one or two small incisions or punctures (no-scalpel technique) in the scrotum. Each sperm duct (vas deferens) is brought out of the scrotum, one at a time, and sealed with surgical clips. To reduce the possibility that the cut tubes may rejoin, a 1/2 to 1 inch piece of vas deferens is removed and the sealed ends of the vas are replaced into the scrotum. The skin incisions/punctures are very small and stitches may not be used. If stitches are necessary, they will dissolve on there own.

Description of the Attendant Discomfort and Risks:

A small amount of oozing blood (enough to stain the dressing), some discomfort and mild swelling in the area of the incision are not unusual and should subside within 72 hours. Occasionally the skin of the scrotum and base of the penis turn black and blue. This is not painful. It lasts only a few days and disappears without treatment.

Very rarely, a small blood vessel may escape into the scrotum and continue to bleed to form a clot or hematoma. A small clot will be reabsorbed over time. However, a large clot which develops after a vasectomy may cause more swelling and pain in the scrotum and may require a surgical exploration and drainage of the scrotum. This would require hospitalization and general anesthesia to evacuate the hematoma.

Most men will have a small amount of discomfort in the scrotum/testicle region for a few days to a week following their vasectomy. There are some men who develop a more chronic pain in the genital region (post-vasectomy syndrome). This may last for a prolonged period, but usually responds to warm tubs and anti-inflammatory medications.

Infections are a rare complication following a vasectomy. Antibiotics are not routinely used, but any incision on the body can potentially get infected. There may be some irritation and inflammation at the site of a suture that usually resolves as it dissolves. Superficial infections that may occur usually respond to oral antibiotics and conservative measures. Infections of the epididymis and testicles can also occur after a vasectomy and will respond to antibiotics. Lastly, testicular atrophy and sperm granulomas rarely occur after a vasectomy.

For 72 hours following the vasectomy, sex should be eliminated. Strenuous exercise (for example: climbing ladders, riding bicycles, yardwork, playing tennis, etc.) should likewise be avoided for three days and nothing that weighs over a few pounds should be lifted. The reason for this is that engaging in these activities sometimes results in complications.

The surgical procedure is not always 100 percent effective in preventing pregnancy, because on rare occasions the cut ends of the cord may rejoin. This only occurs at a rate of approximately one to three in every 1000 vasectomies. Furthermore, sperm can survive from the point where the cords were cut for months. ANOTHER FORM OF CONTRACEPTIVE MUST THEREFORE BE USED UNTIL STERILITY IS ASSURED. To ensure sterility, a specimen of seminal fluid should be brought in for microscopic examination. The specimen must contain no sperm before unprotected intercourse is allowed. We recommend waiting at least 2 months and approximately 20 to 25 ejaculations prior to bringing your first sample to the lab. We require 2 negative samples for sperm, at least 2 weeks apart prior to clearing you for unprotected intercourse. Occasionally; it may take up to six months or longer to flush out all of the sperm.

Benefits to be Expected:

Vasectomy is a simple safe method for preventing unwanted pregnancies. Recovery is usually quick and often the patient can return to work in as little as two days, with recovery over a weekend, for example.

Sexual activity, penile sensitivity and the production of male hormones are not adversely affected. In fact, the freedom from fear of producing unwanted pregnancies may greatly improve the mutual enjoyment of your sexual relations. You may find that your desire for sexual expression becomes more spontaneous and more frequent.

Counseling Concerning Alternate Methods:

If your objective is merely to space out pregnancies, or if you have even the slightest reason to believe that you might want to have children in the future, then a vasectomy will not suit your purpose and should not be considered. Other methods of birth control that may be used include:

  • Oral contraceptive
  • Intrauterine device (IUD)
  • Diaphragm
  • Condom
  • Aerosol contraceptive foam
  • Rhythm method
  • Contraceptive cream/jelly
  • Tubal ligation of female partner
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Effect and Impact of Sterilization:

The purpose of a vasectomy is to prevent sperm from entering the seminal fluid so that the female egg cannot be fertilized subsequent to intercourse. Sperm cells continue to be produced in the testes but disintegrate and are reabsorbed. However, the amount of the fluid discharged during intercourse does not decrease more than 5 to 10 percent after vasectomy. Vasectomy is to be considered a permanent birth control procedure, even though these operations can be reversed if absolutely necessary with a subsequent pregnancy rate of approximately 60 percent. Although a vasectomy must be thought of as producing permanent sterility, the procedure is not always 100 percent effective.

A vasectomy should have no adverse effect on your sex life. Any problems that develop in relation to having sexual intercourse may result from psychological, rather than physical causes. After a vasectomy, a man's hormones remain normal and there is no noticeable difference in his ejaculate since sperm make up only a tiny part of semen (5 to 10%). Because the sperm cannot come out after the cord is cut, like other dead body cells, the sperm disintegrate and are reabsorbed by the body. Some men, even knowing these facts, are still anxious about what a vasectomy will do to their sexual performance. These men should not have vasectomies. Worrying about sexual performance is likely to impair a man's ability to have an erection or ejaculate, even though the production of sperm and male hormones continues.

A vasectomy is not the answer to a problem of sexual maladjustment or failing sexual powers. Therefore, if you are getting a vasectomy in hopes of improving your wife's attitude toward sex or to increase your sexual powers, you are likely to be disappointed. On the other hand, freedom from fear of producing unwanted children may improve greatly the mutual enjoyment in your sexual relations.

Inquires:

Any inquiries or questions I had about the sterilization procedures described in this document were fully answered and I fully understand the explanation of the sterilization procedure that I have been given.

PLEASE SIGN BELOW:

DATE:


SIGNATURE OF PATIENT:


WITNESS:


SIGNATURE OF PHYSICIAN/
PERSON OBTAINING CONSENT: