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You Asked: I've Never Had an Orgasm

DearSugar — Mon, 18 Aug 2008 17:00:00 -0700

Dear Sugar,

I've never had an orgasm. Not with another person or on my own. All the advice I find just tells me to relax and spend some time alone getting to know myself. And I've been trying that all these years with no luck. I am frustrated beyond belief! I get so stressed out about it that I often end up in tears. I know stress can be a factor, but knowing that doesn't help. I've discussed it with my various boyfriends over the years, and they have felt bad about it, but have no better ideas than me. I've read that some women go their entire lives without ever experiencing one. I don't want to be one of those women. Please help!

- Feeling Awful About Orgasms Alice

To see DearSugar's answer, read more.

Dear Feeling Awful About Orgasms Alice,

Alice, there is absolutely nothing wrong with you. Sexuality, especially that of females, is incredibly complicated. Everyone is made and develops differently. While it's true some women out there are unable to experience an orgasm, just because you haven't yet, it doesn't mean that you never will. Orgasms are nearly impossible when you're distracted, and there's nothing as distracting as the pressure of trying to climax.

As much as I know you want this, you have to stop making an orgasm the be all end all of your sexual encounters. Let your body remember what it's like to enjoy sex without the stress of something that may or may not happen. Instead of trying various positions and movements to see if they'll elicit the response you're looking for, focus on the sensation that you're actually feeling. If you can learn to enjoy the moment, it will help relieve all the stress and disappointment you're coping with.

Though it sounds like you're already doing it, don't stop communicating with your partners about what you like and don't like. And be sure to use lubrication, which can turn a dismal sexual experience to an extremely sensual and arousing one. Give yourself a break for a while and just let your body do what it naturally does. Sometimes the moment you let go is the moment things turn out, but in any case, you'll be ultimately more satisfied if you can find the pleasure in sex without an orgasm.

Source

I've Never Had an Orgasm!

DearSugar — Mon, 14 May 2007 13:00:00 -0700

Dear Sugar--

For almost a year now I have been involved with a man, and it was great for a while, I still feel there is a lot of chemistry between us inside and outside the bedroom, the thing is I never have orgasms when we have sex, I don't know why, maybe it's the fact that he's married and I feel like crap for being in a relationship of this nature but truth be told...I've never had an orgasm during sex, I'm 29 years old and I'm scared something is wrong with me, I need some advice.

--Unsatisfied Samantha

To see DEARSUGAR's answer read more

Dear Unsatisfied Samantha--

I really doubt that something is wrong with you - many women don't have orgasms during sex, or ever at all, which is a sad truth. It may be a good idea to spend some time alone with yourself to figure out what you like and what gets you excited. Then when you're with a guy, you can tell him (or show him) how to push your buttons. While you're at it, you can also tell him to slow down - it's like a 50-meter dash with some guys - they make it to the finish line before you've even laced up your sneakers.

Another thing - foreplay is HUGE. And I'm not talking about 10 minutes of kissing your neck. I'm talking about ALL DAY foreplay. It starts in the morning, when he wakes up, rolls over to give you a 5-minute hug, and then makes you breakfast. Then later on in the day he calls you and tells you he misses you, and asks you to go to dinner. Maybe you find a sweet note he left in your car, and later before dinner, he tells you how soft your hair is, or how cute you look in your new jeans. Then after dinner he says, "Maybe we should plan a weekend away, just the two of us."

That's right - when it comes to being sexually aroused, we need to be warmed up emotionally too. Women are all about their feelings, so when we feel loved, wanted, desired, and appreciated, sex is bound to be amazing.

Also, an orgasm's not going to be happening if you have your mind on something, or the orgasm itself, which brings up the fact that you're sleeping with a married man. I know you don't need me to tell you to stop seeing him, but since you seem to know it's wrong, that could be your major buzz kill right there. Find yourself a single guy, so he can give you all his love and attention. You shouldn't be sharing your man with anyone else. Good luck!

Source

Hump Day: I Have Little Desire to Have Sex Anymore

TresSugar — Wed, 04 Nov 2009 04:00:00 -0800

Welcome to Hump Day, TrèsSugar's sex advice column. Are you confused about sex? Do you have trouble having an orgasm? Is there something you'd like to try but you're worried it's too weird? Send your questions to TrèsSugar, and our friend Dr. Charlie Glickman from Good Vibrations will offer his sound advice!

Today's Question:

“When my husband and I first got married, I was so in love with him that we had sex what (for me) seemed like a lot (a few times a week). But now, three years into it, I feel like my baseline libido, which never was much in the first place, has flatlined. I simply have no interest in sex mentally or physically. My husband keeps asking me if there’s someone else, but in reality, I don’t want sex at all - with anyone. I’m worried he’s going to leave me, this is causing so many problems between us. Any advice?”

To see the answer, read more

It’s pretty common for sexual frequency for couples to lessen after a couple of years. It’s not always just the stereotypical “things are becoming routine” situation. Shifts in hormones can occur as time goes by and those shifts can affect sexual desire. Lots of people have a low interest in sex for any of a number of reasons. It’s not necessarily a sign of any kind of problem and if that has been your pattern for a long time; that may be simply how your sexuality is.

Do you consider your lack of interest in sex a problem? If you do, you might want to see if there are any medical issues causing it. You could have low testosterone for example. While we generally only think of it as a male hormone, women also have some testosterone in their systems and it’s often related to interest in sex. Sexual desire is quite complex and sometimes, the answers aren’t as easy as that, but it could be worth exploring.

Whether you think that your low desire is a problem or not, it sounds like your concerns center on how you and your husband talk about it and what his and your expectations are. Differences in desire can be one of the more tricky relationship challenges and almost all couples face it at some point or another. When you consider how much we (as a culture) equate sexual desire with relationship health, it’s no wonder that many of us feel a lot of pressure around it.

While I would NEVER suggest to anyone that they engage in sex that they don’t want, the two of you might want to explore other ways to connect physically. After all, it doesn’t have to be sex or intercourse. For example, would it work if you gave him backrubs? What if he masturbated while you help him or ran your hands across him? And are there ways that you would like to receive physical contact? As another possibility, are there ways in which the two of you could make room for him to get his sexual needs met, such as giving him solo time at home for some self-pleasure?

Whether you find your low desire a problem or not, you could also find a sex-positive therapist. One of the most helpful things that a therapist can offer is tools for talking about tricky topics and a safe space to do it in. Plus, sometimes an outside perspective can be really helpful. There are plenty of great people who know about sexuality issues and lots of them can be found on the website for the American Association of Sexuality Educators, Counselors and Therapists. Anyone in their directory has passed a rigorous certification process, which gives them the foundation to be as helpful with sexuality topics as possible.

Ultimately, the best advice I can offer you is to be honest with each other about what’s going on for you and how you each feel about it. With that as the foundation, the two of you can start looking for new ways to be together that work for both of you.

Slow-Sex Movement Guru: On Orgasms and Sex Positivity

TresSugar — Fri, 21 Aug 2009 11:00:00 -0700

"I’ve never actually met a woman who wasn’t orgasmic. I’ve met women who’ve put themselves against a cultural idea, but we orgasm differently from the model that we’re told orgasm is."

This is the last post in a four-part series of interviews I had with Nicole Daedone, who is emerging as the leader of the slow-sex movement, and who founded the OneTaste urban retreat center in San Francisco. OneTaste invites men and women to learn about mindful sexuality by participating in workshops, yoga, and (for residents only) controversial "OMing" sessions in which men stroke women to orgasm during daily morning sessions. To read the fourth part of the interview with Nicole, read more.

TrèsSugar: Do you think that so-called “sex positivity” has helped women? There are a lot of women who have grown up around the idea that sexual desire isn’t something shameful, but rather something to explore and have fun with. Has it brought its own problems?
Nicole Daedone: I think that it’s like yoga; you’re constantly making microadjustments. I think that we went too far this way, into heedlessness, and that’s not any fun either. We’ve opened a field of sexuality and so the next question is, “What do we do with it?” Just open is a mess, but open and directed is power.

TS: You have a book coming out, but what’s your fantasy about where all this is going?
ND: My vision of how it’s going to go is that there will be a slow-sex movement and it will be women who carry it. It will be twofold: top down with a lot of information coming in from the media, but it will also be grassroots where the message will be transmitted from one person to the next.

TS: What do you think about the fact that there are many women who still - alone or with a partner - have never had an orgasm?
ND: It’s heartbreaking. It shows how far away from our own bodies we have to be to feel that way. I’ve met a lot of women who say they’ve never had an orgasm.
TS: Or they fake it! I think that some women feel that there’s a right way to have an orgasm: it’s supposed to look like this, sound like that, feel exactly like this …
ND: But - I’ve never actually met a woman who wasn’t orgasmic. I’ve met women who’ve put themselves against a cultural idea, but we orgasm differently from the model that we’re told orgasm is. So yeah, you know what? I don’t do "that" either.

Thanks, Nicole! (To see all of TrèsSugar's coverage of the slow-sex movement and Nicole Daedone's interviews, click here.)

Hump Day: I'm Curious but Nervous About Back Door Action

TresSugar — Wed, 09 Sep 2009 07:00:00 -0700

Today's Question:

“I’m curious about having anal sex with my boyfriend, but I’ve had unpleasant experiences in the past. Any tips?” To hear what Dr. Glickman has to say, read more

I’ve noticed an increase in questions about anal play over the last few years, and while I think it’s great that more people are discovering new ways to experience pleasure, anal play isn’t everyone’s cup of tea. Many people don’t enjoy it at all and unfortunately, some guys have a tendency to pressure their partners into doing it. Quite a few women report that their boyfriends have seen so much anal in porn that they’re convinced that every woman wants it. But sex in porn is like a car chase in an action movie. There’s a lot that happens behind the scenes that you don’t see in order to create the illusion that shows up on the screen; in the case of anal sex - lots of lube and warming up.

For some women, anal play (note: not just anal sex) heightens their orgasms. First, the anus is very sensitive and packed with nerve endings. Second, its muscles are connected to the rest of the pelvic muscles and contract along with the vagina during orgasm. Third, there are people who enjoy the experience of doing something naughty or taboo.

So now that we have that taken care of, there are three ingredients to hot anal play: relaxation, lubrication, and communication. Let’s take them one at a time.

Relaxation: the anus is made up of two rings of muscles and they’re under both voluntary and involuntary control. With practice, you can learn to increase how much control you have over your ability to relax. And ironically, if you’re nervous about anal play hurting or not being fun, it can make the anus get tighter, which makes it more likely to be unpleasant.

The best way to get started is to go slowly and start small. Try a little external pleasure with a finger or a slim vibrator. If you’re concerned about keeping things clean, slip on a glove. Experiment with tightening the anus and bearing down - you’ll be able to feel it contract and relax.

If you want to try penetration, go slowly and use lots of lube (either water-based or silicone-based, which doesn't dry out as easily but is harder to clean off). You’ll probably enjoy it more if you’re also doing something that you enjoy such as using a vibrator. Lots of women report that anal play on its own isn’t nearly as much fun as when it’s an add-on.

Communication: the anus is a delicate part of the body and it’s easy to get too rough with it. It’s super-important to be able to tell your partner when things are uncomfortable, if you need more lube, or if you want to try something else. For that matter, it’s important to be able to say something if you’re not enjoying it, or if you’re experiencing any pain. And if your partner is pressuring you to do something that you don’t want to do, that’s a big red flag!

Important safety tips: any toys that you use for anal play need to be smooth, have a base, and ideally made of easy-to-clean silicone. Since the anus is so much more delicate than the vagina, it’s easy for toys with bumps and ridges to cause discomfort. (If you have a porous rubber toy or you’re not sure if it's made of silicone, cover it with a condom.) And NEVER put anything that has been used anally inside the vagina - that’s a great way to give yourself an unpleasant infection. Lastly, if your toy doesn’t have a base, there’s a chance that it could go all the way in and not come back out. That can mean a trip to the emergency room.

If you’re looking for more info, here are some great places to start. For books, I'd recommend Anal Pleasure & Health and The Ultimate Guide To Anal Sex For Women. For DVDs, Tristan Taormino's Expert Guide to Anal Sex and Anal Massage For Lovers are great.

I hope that helps! Email the folks at TrèsSugar if you have more sex questions. I’d love to hear from you.

Slow Sex Movement Guru: Women and the Power of Sexuality

TresSugar — Mon, 17 Aug 2009 07:00:00 -0700

"There’s a way that we actually have men take all the responsibility for sexuality, and then we get upset that they’re holding it."

This is the second in a four-part series of interviews I had with Nicole Daedone, who is emerging as the leader of the slow-sex movement and who founded the OneTaste urban retreat center in San Francisco. OneTaste invites men and women to learn about mindful sexuality by participating in workshops, yoga, and (for residents only) controversial "OMing" sessions in which men stroke women to orgasm during daily morning sessions. To read the second part of the interview with Nicole, read more.

TrèsSugar: What is the primary reason women come to OneTaste?
Nicole Daedone: I think it's to connect with power - not what we’ve made power into, something that you lord over people - but to connect with that personal sense of power. I think that’s one of the biggest challenges for women in our age: we don’t have access to our own power, and we don’t have access to our power because the raw source of it is our sexuality and most women have never been trained how to hold that much power in our bodies. So there’s a way that we actually have men take all the responsibility for sexuality, and then we get upset that they’re holding it. Or they have this sort of power within them, and then we get upset that we don’t have that kind of power.

TS: I don't know if you've read Ariel Levy's book Female Chauvinist Pigs, but she talks about how a lot of young women feel that having power in sexuality means attracting men, but it's not about owning it or their own pleasure. And then they wonder why they don’t have good sex.
ND: Well, I think that’s what power in its nascent stages looks like and I think that one of the reasons that we haven’t come to hold our power is that it's embarrassing. I remember when my orgasm was just starting to get turned on and I went from kind of, I was basically attractive, but I went to like “Wow!” I got really power drunk; power drunk doesn’t feel good. And I had to actually feel that something deeper was available.

TS: Do you think women are afraid of that power when they they feel it?
ND: It’s terrifying. As a woman, there isn’t a lot of information about how to do it well. In terms of how to be sexual, there’s no map for it so I’m really having to feel my way around in the dark and make mistakes and that’s scary. By the same token, I think that one of the things that’s happening in this time is that we’re sensing something deeper in ourselves that’s saying we have to listen to our bodies, we have to listen to these sexual impulses and if we have to respond to them, we have to learn how to do it well and do it in a really healthy way.

Have You Ever Faked an Orgasm?

TresSugar — Mon, 24 Aug 2009 04:00:00 -0700

I remember talking to a friend of mine years ago who told me that she'd never had an orgasm with a man - but that she almost always faked it.

It really surprised me because she seemed otherwise like a take-charge kind of woman - confident, beautiful, and certainly not shy. I didn't understand why she'd feel the pressure! (She was an actress, though, so I guess that kind of makes sense.)

Most of us are not actresses, or not good ones anyway, and it doesn't make a lot of sense to me to pretend your significant other is doing something right if he's not. Isn't faking something you'd just have to keep doing? And then if you stopped, he'd wonder why whatever he was doing before no longer worked?

Orgasmic dysfunction

admin — Thu, 04 Sep 2008 18:49:53 -0700

Illustrations

Male and female reproductive systems

HEALTH GUIDE REFERENCE FROM A.D.A.M

Alternative Names

Inhibited sexual excitement; Sex - orgasmic dysfunction; Anorgasmia

Information

Orgasmic dysfunction is when a woman either can't reach orgasm, or has difficulty reaching orgasm when she is sexually excited.

CAUSES, INCIDENCE, AND RISK FACTORS

The condition is called primary orgasmic dysfunction when a woman has never had an orgasm. This is the case in 10 - 15% of women. It is called secondary orgasmic dysfunction when a woman has had at least one orgasm in the past, but is currently uanble to have one. Surveys suggest that 33 - 50% of women are dissatisfied with how often they reach orgasm.

Many factors can contribute to orgasmic dysfunction. They include:

A history of sexual abuse or rape
Boredom and monotony in sexual activity
Certain prescription drugs, including fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft)
Hormonal disorders and chronic illnesses that affect general health and sexual interest
Medical conditions that affect the nerve supply to the pelvis (such as multiple sclerosis, diabetic neuropathy, and spinal cord injury)
Negative attitudes toward sex (usually learned in childhood or adolescence)
Shyness or embarrassment about asking for whatever type of stimulation works best
Strife or lack of emotional closeness within the relationship

PREVENTION

A healthy attitude toward sex, and education about sexual stimulation and response will minimize problems.

Couples who clearly communicate their sexual needs and desires, verbally or nonverbally, will experience orgasmic dysfunction less frequently.

It is also important to realize that sexual response is a complex coordination of the mind and the body, and both need to be functioning well for orgasms to happen.

SYMPTOMS

The symptom of orgasmic dysfunction is being unable to reach orgasm, taking longer than you want to reach orgasm, or having only unsatisfying orgasms.

SIGNS AND TESTS

A complete medical history and physical examination needs to be done, but results are almost always normal. If the problem began after starting a medication, this should be discussed with the doctor who prescribed the drug. A qualified specialist in sex therapy may be helpful.

TREATMENT

Treatment can involve education, cognitive behavioral therapy, teaching orgasm by focusing on pleasurable stimulation, and directed masturbation.

Most women require clitoral stimulation to reach an orgasm. Incorporating this into sexual activity may be all that is necessary. If this doesn't solve the problem, then teaching the woman to masturbate may help her understand what she needs to become sexually excited.

A series of couple exercises to practice communication, more effective stimulation, and playfulness can help. If relationship difficulties play a role, treatment may include communication training and relationship enhancement work.

Medical problems, new medications, or untreated depression may need evaluation and treatment in order for orgasmic dysfunction to improve. The role of hormone supplementation in treating orgasmic dysfunction is very controversial and the long-term risks remain unclear.

If other sexual dysfunctions (such as lack of interest and pain during intercourse) are happening at the same time, these need to be addressed as part of the treatment plan.

EXPECTATIONS (PROGNOSIS)

Women tend to have better results with treatment if their orgasmic dysfunction is due to another condition. Women with orgasmic dysfunction that is not due to another condition often do better when treatment involves learning sexual techniques or a method called desensitization, which gradually stops the response that causes lack of orgasms. Desensitization is helpful for women with significant sexual anxiety.

Improved orgasmic function is usually associated with being emotionally healthy and having a loving, affectionate relationship with a partner.

COMPLICATIONS

When sex is not enjoyable, it can become a chore rather than a mutually satisfying, intimate experience. When orgasmic dysfunction continues to happen, sexual desire usually declines, and eventually sex occurs less often. This can create resentment and conflict in the relationship.

References

Goldwin I. Urologic Management of Women with Sexual Health Concerns. In: Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, PA: Sauders Elsevier; 2007: chap 28.

Katz VL, Lentz GM, Lobo RA, Gershenson DM eds. Comprehensive Gynecology. 5th ed. Philadelphia, PA: Mosby Elsevier; 2007: chap 101.

Kronenberg HM, Melmed S, Polonsky KS, Larsen PR, eds. Williams Textbook of Endocrinology. 11th ed. Philadelphia, PA: Saunders Elsevier; 2008: chap 19.

Review Date: 5/19/2008

Reviewed By: Linda Vorvick, MD, Seattle Site Coordinator, Lecturer, Pathophysiology, MEDEX Northwest Division of Physician Assistant Studies, University of Washington School of Medicine; Timothy A. Rogge, MD, private practice in Psychiatry, Kilkland, WA. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

A.D.A.M. Copyright

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997-2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

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Hump Day: Is My Cold Sore Contagious?

TresSugar — Wed, 12 Aug 2009 06:00:00 -0700

Welcome to Hump Day, TrèsSugar's sex advice column! Are you confused about sex? Do you have trouble having an orgasm? Is there something you'd like to try but you're worried it's too weird? Send your questions to TrèsSugar, and our friend Dr. Charlie Glickman from Good Vibrations will offer his sound advice!

Today's Question:

“I know that cold sores are the same virus as herpes. Is it a bad idea to go down on my boy when I have one? Is it transmissible that way?” To hear what Dr. Glickman has to say, read more.

Dr. Glickman's Answer:

YES!!!

There are two types of herpes virus: HSV-1 and HSV-2. Oral herpes is usually HSV-1 and it’s estimated that 80 percent of the population has been exposed to it. Genital herpes is usually HSV-2 and it’s estimated that 25 percent of women and 12 percent of men have it. However, genital herpes can be caused by either version of the virus, so going down on someone when you have a cold sore (another name for a herpes outbreak) can spread it. To make things a bit more complicated, only about 1/3 of the people who have genital herpes are aware of it - either they’ve never had an outbreak or the outbreak was very mild. (See herpes.com for more info.)

Part of what makes herpes tricky is that it can be transmitted even when you don’t have a visible outbreak. The virus lives in your nervous system and every so often, it’ll come to the surface. It’s especially likely to happen when you’re sick or have been stressed for a while. There’s evidence that the virus starts shedding from the skin (and is therefore potentially contagious) before any visible symptoms. It’s a low risk, but it’s a possibility. To make matters worse, if the site of the shedding isn’t covered by a condom, it can be spread even when you’re practicing safer sex.

While herpes can be uncomfortable, it doesn’t represent nearly as much risk as other sexually transmissible infections (STIs) such as chlamydia, gonorrhea, syphilis, human papilloma virus (HPV), or HIV. Having said that, there’s evidence that HSV-2 makes HIV transmission more likely. See this article for more information about how that works.

It’s also worth mentioning that I’ve seen a lot of people get really upset about STIs when they don’t get nearly as upset about any other health issue. I’ve also seen a lot of people who have all sorts of judgment about STIs but think nothing of going to work and sharing their flu germs (or worse)! STIs can be unpleasant, annoying, or life-threatening, but they don’t mean anything about the person who has them any more than chicken pox or measles do. Negative attitudes about STIs are a holdover from before we invented antibiotics and when diseases such as syphilis were seen as the wages of sin. But now we know that they’re just germs and we don’t need to shame people for having them. (Not that I’m saying that you’re doing that, but I wanted to mention it.)

The best thing that we can all do is to get tested for STIs regularly, even if you’ve never had a symptom. Lots of people have STIs and don’t know it. Check your local Planned Parenthood or other agency for information, although I recommend going with anonymous testing in order to ensure your privacy.

And safer sex is always a good choice. It’s easy to do, with a little practice. Using a lubricant can make safer sex more enjoyable since latex tends to have a bit more friction than skin. Try a silicone-based brand if you’re prone to yeast infections. Water-based brands are a bit easier to clean up since they rinse away.

If you or your partner don’t like the way condoms feel, try a different brand. The Japanese-process condoms such as Maxx and Skinless Skin are more sheer than other types. Or you could give Skyn a whirl. It’s made from polyisoprene, rather than latex, so it’s very sheer and both people will get more sensation.

Given that you have oral herpes, you might want to talk with your boyfriend about using condoms for oral sex. If you go that route, change the condom before having intercourse. That will make sure that you don’t spread the herpes virus to your vulva or vagina. It’ll also reduce the risk of your condom breaking; teeth can cause small abrasions that weaken the condom.

For an excellent, sex-positive read on safer sex, check out The Hot Guide to Safer Sex . It’s full of helpful advice and great tips.

Vasectomy and vasovasostomy

FitSugar — Wed, 08 Oct 2008 17:35:49 -0700

In This Report

Highlights
Introduction
Considerations
Male Contraception
Surgery
Complications
Unexpected Pregnancy
Long-Term Complications
Reversal Surgery
Assisted Reproductive Techn...
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Search Continues for the "Male Pill"

Research is progressing on a male contraceptive, but there have also been setbacks. The drug miglustat (Zavesca), which is used to treat a rare condition called Gaucher's disease, had shown success in animal studies but failed to work in a clinical trial, according to results published in 2007 in Human Reproduction. Researchers are now investigating an experimental drug, Adjudin (AF-2364), which disrupts sperm production.

Reversible Inhibition of Sperm Under Guidance

Reversible inhibition of sperm under guidance (RISUG) is one of the investigational male contraceptives furthest along in clinical trials. It is currently in phase III trials in India, but it is not yet known when or if clinical trials will be conducted in the United States. RISUG is a non-hormonal contraceptive method that uses an injectable polymer gel to stop sperm flow within the vas deferens.

No-Scalpel Vasectomy

The no-scalpel vasectomy is gaining in popularity as an alternative to standard vasectomy, but it requires a well-trained doctor to perform it. Performed correctly by an experienced doctor, no-scalpel vasectomy can result in shorter surgical time and less bleeding, infection, pain, and postoperative complications, according to a 2007 review published in the Cochrane Database. If you are considering a no-scalpel vasectomy, make sure that your doctor has performed at least 15 - 20 of these procedures.

Vasectomy Reversal

Vasectomy reversal may work better than assisted reproductive technologies (such as sperm retrieval) for men who have had a vasectomy but later decide to have children, according to research presented at the 2007 annual meeting of the American Urological Association.

Introduction

In the United States, vasectomy emerged as a popular method of permanent contraception during the 1960s. Within a decade, 750,000 men were undergoing vasectomies each year. Vasectomy rates markedly declined in the 1990s and have now plateaued at about 500,000 a year. Worldwide, an estimated 42 million couples use vasectomy as a method of birth control.

The procedure works by surgically interrupting the route that the sperm take from the testicles (where they are produced) to the penis. After vasectomy, the testicles still continue to generate sperm, but their movement is blocked at the site of the vasectomy. Eventually the sperm die, and the patient's body absorbs them. During sex, semen is produced in the same amount as before vasectomy, but this fluid does not contain sperm.

The testes are where sperm are manufactured in the scrotum. The epididymis is a tortuously coiled structure topping the testis, and it receives immature sperm from the testis and stores it several days. When ejaculation occurs, sperm is forcefully expelled from the tail of the epididymis into the deferent duct. Sperm then travels through the deferent duct through up the spermatic cord into the pelvic cavity, over the ureter to the prostate behind the bladder. Here, the vas deferens joins with the seminal vesicle to form the ejaculatory duct, which passes through the prostate and empties into the urethra. When ejaculation occurs, rhythmic muscle movements propel the sperm forward.

Click the icon to see an animation about vasectomy.

Vasectomy should not be confused with castration. It has no noticeable impact on a man's ability to perform sexually, or on his sensation of orgasm and pleasure. It does not affect the balance of male hormones, male sex characteristics, or sex drive. Testosterone continues to be produced in the testes and delivered into the bloodstream. Sperm form a very small portion of semen, so patients notice no difference in the amount of semen produced during orgasm.

The male reproductive tract performs three functions:

It enables a man to produce offspring.
It provides him with a supply of male hormones.
It enables him to experience sexual pleasure.

The Traveling Sperm. The sperm's journey through the male body -- from the testes (the testicles) to the final stage (the orgasm) -- is long and complex:

Sperm are produced in the testes at a rate of 50,000 an hour within tiny ducts called seminiferous tubules.
Sperm do not mature in the testes. They must first pass into the epididymis, a C-shaped storage chamber adjoining the testes composed of a 20-foot coiled tube. The sperms' journey through the epididymis takes about 2 - 3 weeks. They are held here until sexual activity forces them to move on.
When a man experiences sexual excitement, nerves stimulate the muscles in the epididymis to contract. This forces the sperm to pass into one of two rigid and wire-like muscular channels, called the vasa deferentia. (A single channel is called a vas deferens. It is the vas deferens that is cut during vasectomy.)
Muscle contractions in the vas deferens from sexual activity propel the sperm along past the seminal vesicles, which are clusters of tissue that contribute fluid, called seminal fluid, to the sperm. The vas deferens also collects fluid from the nearby prostate gland. This mixture of various fluids and sperm is the semen.
Each vas deferens then joins together to form the ejaculatory duct. This duct, which now contains the sperm-containing semen, passes down through the urethra. (The urethra is the same channel in the penis through which a man urinates. During orgasm, however, the prostate closes off the bladder so urine cannot enter the urethra.)
The semen is forced through the urethra during ejaculation, the final stage of orgasm when the sperm is literally thrown out of the penis.

Click the icon to see an image of sperm.

Considerations

Having a vasectomy is a serious decision. The surgery is intended to be permanent. The great majority of men who seek a vasectomy have been married for 10 years or more. Not all are good candidates, however. It is important that both the woman and the man completely agree that they no longer want to have children. They should also agree that permanent birth control is the right decision for them. Ideally, the couple should view the operation as a mutual commitment to an already successful marriage or relationship. Vasectomy generally is not a good idea if the couple's relationship is under great stress. It is not a cure for emotional or sexual problems between a man and woman.

After deciding that permanent birth control is the best solution, a couple still has the option of either vasectomy for the male or tubal ligation for the female.

Studies indicate that 5 -11% of men who have vasectomies regret the decision. In one study, 56% of men seeking treatment for fertility were hoping to reverse their vasectomies. Thirty years ago, this percentage was only 5%.

A reversal procedure called vasovasostomy is available, but it is a major operation that provides no guarantee of restored fertility. In a study of procedures performed between 1980 - 1996, vasectomy rates had leveled off but vasovasostomy rates had increased in men by nearly 70% in the most recent 5-year period compared to the earliest 5-year period.

Vasectomies may be right for:

Men in relationships in which both partners agree they have all the children they want and both do not want to use or are unable to use other methods of contraception
Men in relationships whose partners have health problems that make pregnancy unsafe
Men in relationships in which one or both have genetic disorders that they do not want to transmit

Vasectomies may not be right for:

Men in relationships in which one partner is unsure about his or her desire to have children in the future. (Couples in which the woman is working when they make the decision are at particular risk for regretting the decision later on.)
Men whose current relationships are unstable, going through a stressful phase, or are marked by substantial conflict
Men who are considering the operation just to please their partners
Men who are counting on having children later by storing sperm or by surgical reversal of the vasectomy
Young men, who still have many life changes ahead
Men who are single (including those divorced or separated) at the time of vasectomy
Men who are having the operation primarily for the sake of their partners and not wholly for their own reasons
Men or couples whose only motive is freedom from distraction imposed by other contraceptive methods during sexual activity

Vasectomy should not be undertaken in response to temporary stressful situations that might block the desire for children. Such conditions may include illness, temporary financial crisis, death in the family, or birth of a child. Couples should wait through such short-term stresses or seek counseling or psychotherapy to be sure that they are not making a decision they will later regret.

All Future Scenarios. Before deciding on a vasectomy, the couple should consider all future scenarios for their life together, such as the following examples:

If a couple already has children, how would they feel about a vasectomy if one of their children died?
If financial stress is triggering the decision for a vasectomy, would improved affluence increase their desire for children?
How would the man consider the vasectomy if his current relationship ended, either by divorce or the woman's death?

The word "sterilization" has a deep emotional connotation for many people. Even though a couple may rationally accept the idea of a vasectomy, it is extremely important for each partner to be as open as possible about any negative feelings they might associate with the procedure. Such feelings on the part of either partner can have devastating consequences on a relationship if they surface only after the procedure has been performed. Openness with each other is essential in order to make a decision that is clear of any hidden apprehensions. Neither partner should be too embarrassed to request counseling if the emotional aspects involved in making the decision are too difficult to solve between themselves.

What the man may be feeling:

A man may have a poor self image, including concerns for his own physical health or sexual ability. Such men are likely to have a difficult time adjusting psychologically to vasectomy.
A man may not actually really want the procedure but may not want to confront a partner he loves who wants him to have it.

What the woman may be feeling:

A woman might believe, incorrectly, that a vasectomy is emasculating, but she might not want to express this idea to her partner.
On the other hand, some women fear that vasectomy may make their partner more attractive and encourage outside affairs. (Research from the 1970s indicates that married men who have a vasectomy are no more likely to indulge in extramarital sex than fertile men.)

Storing frozen sperm in a sperm bank before vasectomy might enable men to have children later. Before the vasectomy, the man collects sperm, which are frozen and stored until he wants to have a child. In one study, 1.5% of men who had stored sperm later used it for conception and most were successful. Other studies have shown a lower success rate, however, and it is a very expensive process. Experts believe that a man who wants to bank sperm should probably reconsider his decision to have a vasectomy because such a concern may indicate doubts about giving up his ability to father a child.

Male Contraception

As many as 40% of couples seeking vasectomy have experienced a failure with their previous method of nonpermanent birth control. Such failures can occur from misplacement of a diaphragm, an incorrectly implanted intrauterine device (IUD), or noncompliance with an oral contraception regimen. Couples who are unsure about permanent sterility should still consider carefully all birth control options.

Withdrawal before ejaculation is a form of natural contraception, but it is extremely risky and most people find it unsatisfactory. If used on a regular basis, the average risk for pregnancy is 24%.

The only other form of male contraception currently available is the condom. However, the average rate of pregnancy for couples that rely only on condoms for protection is still 12%. In adolescents, the risk with condoms is even higher, 18%. Even for those who use a good-quality condom correctly, the annual risk for pregnancy is 3%.

The condom should be put on before intercourse when the penis is erect, long before ejaculation, since the male can discharge sufficient semen to cause pregnancy before ejaculation occurs. (Even after a vasectomy, men who are not in a monogamous relationship with an HIV-negative partner should always wear a condom during sex for protection against sexually transmitted diseases. Vasectomy is not protective.)

Click the icon to see an illustrated series detailing how to apply a condom.

Condom Materials.

Latex. Condoms made of latex rubber are the most common types. When they are contoured for better fit and contain a spermicide, they can provide fairly effective protection. Some people are allergic to latex, however, and in some cases the reaction can be very dangerous. The latex smell may also be unpleasant for some people.
Polyurethane. Polyurethane condoms (Avanti, eZ-on) are also available. At this point, they have good acceptance by couples but have a higher breakage rate (6 - 7.2%) compared to the latex condom (1.1 - 2%). Other synthetic materials are under investigation.
Animal Membranes. Condoms made from animal membrane can prevent pregnancy, but sexually transmitted infections can permeate them.
Lubricants. Lubricants can be used to prevent tearing. Petroleum-based products (such as Vaseline and baby oil) and vegetable oils should not be used because they can corrode the condom.

Spermicides. Some condoms come prelubricated with sperm-killing substances called spermicides. The standard active ingredient in spermicides in the U.S. is nonoxynol-9, which attacks the surface of the sperm cell. These spermicidal-coated condoms, however, are no longer recommended for a number of reasons. Side effects include irritation of the vagina or penis, particularly if used often or in large amounts. It can also promote yeast and urinary tract infections in women. Evidence now strongly suggests that nonoxynol-9 does not provide any additional protection against sexually-transmitted diseases. In fact, research indicates that it actually increases the risk for HIV in women, possibly by causing injury in the vaginal area. Spermicides are no longer recommended for use with male condoms.

Researchers are developing male hormonal contraceptives that reduce levels of sperm. Animal studies and clinical trials are progressing, and a "male pill" may become a reality in the not-so-distant future. Current trials are focusing on male hormonal contraceptives that combine testosterone (the primary male sex hormone) with progestin, a synthetic form of progesterone (one of the primary female sex hormones).

Testosterone suppresses levels of luteinizing hormone (LH) and follicle stimulating hormone (FSH). LH and FSH are hormones that stimulate ovulation in women and production of testosterone in men. Low levels of these hormones interfere with sperm production, but they do not completely stop it. For this reason, researchers are investigating combining testosterone with progestin. The addition of progestin further decreases LH and FSH levels, along with sperm counts. Researchers are also investigating combining testosterone with gonadotropin-releasing hormone (GnRH), another type of hormone that interferes with LH and FSH secretion.

Most of the male contraceptives currently in late-stage clinical trials deliver hormones through implant, injection, or both. The implant is surgically placed under the skin where it releases a steady stream of the hormone. The injection is given once every several months. Some of the investigational male hormonal contraceptives use a testosterone implant with progestin injections, while others use a progestin implant with testosterone injections. Forms taken by mouth are also being investigated. It generally takes around 3 - 4 months for the treatment to take effect, and for sperm production to be reduced. Research indicates that the male hormonal contraceptives are easily reversible. A 2006 study in the Lancet reported men regained their full fertility within 3 - 4 months after stopping hormonal treatment.

Side effects of male hormonal contraceptives include weight gain, acne, and changes in mood. These side effects are typical of hormone-based therapies.

Because of hormonal side effects, researchers are also investigating non-hormonal male contraceptives. Several initially promising drugs (such as miglustat) have performed well in animal studies, but have failed in human studies. Some non-hormonal research is now focusing on an experimental drug called Adjudin, which appears to work by disrupting sperm maturation in the testes. A 2006 animal study showed positive results, but it is still unknown if this drug will work in humans.

Researchers are investigating procedures that block sperm flow in the vas deferens using various drugs or materials that are reversible. One promising method is called Reversible Inhibition of Sperm Under Guidance (RISUG). RISUG is a non-hormonal contraceptive that uses a polymer gel. The gel is injected into the vas deferens, where it coats the vas deferens' inner walls and kills sperm. The gel can be injected through the skin through a needle or by using the no-scalpel vasectomy technique of making a tiny hole in the skin. The procedure takes around 10 - 15 minutes to perform, and men can resume sexual activity within a week.

The effects of RISUG are long-lasting. Studies indicate that a single injection can provide contraceptive effect for 10 years or more. It is also easily reversible. When a man wishes to discontinue the contraceptive, the gel is removed by flushing the vas deferens with a solvent. The major side effect so far has been a temporary swelling of the scrotum following the injection.

RISUG is mostly being investigated in human trials in India. American researchers are also interested in investigating RISUG, but animal studies need to be conducted first. It will be several years before any human trials are started in the U.S.

The intra vas device (IVD) is an investigational non-hormonal contraceptive that uses tiny silicone plugs to block sperm from traveling through the vas deferens. The plugs are surgically inserted into the vas using the no-scalpel vasectomy procedure. In 2006, the Food and Drug Administration granted approval to expand human trials of the IVD in several U.S. cities.

Unlike hormonal contraceptives, the IVD does not cause side effects like weight gain and acne. But researchers are still figuring out how to make this contraceptive method reversible.

Gossypol, a yellow pigment extracted from the roots, seeds, and stems of the cotton plant, has been used in China, Africa, and Brazil as a male contraceptive. Cotton root was also used as folk medicine in the American South to treat menstrual pain and to induce abortions. The chemical destroys the lining of tubules in the testicles where sperm are produced, thereby inhibiting their formation.

Gossypol does not appear to reduce sexual desire or frequency of intercourse. In about 20% of men, sperm production does not come back, so it should be considered as potentially permanent birth control. It also may not be effective in some men, since small numbers of sperm may survive. Researchers are investigating gossypol-derived compounds that may have less toxicity. No one should take any so-called natural gossypol product without consulting their doctors.

Surgery

Vasectomy is a minor operation that takes about 30 minutes and is usually performed in a doctor's office or a family planning clinic. If the operation is performed under local anesthesia, the cost ranges from about $500 - $1,000. Most insurance policies will cover vasectomies performed as a minor outpatient procedure, but will not cover vasectomies performed as major surgery in an operating room. If a Vasclip procedure is performed, there may be an additional cost of $400 - $500 for this device.

The Procedure.

To prevent increased risk of bleeding, patients should avoid taking aspirin or NSAIDs (Advil, Motrin) for 10 days prior to the procedure.
Before the operation, the patient's scrotum is shaved and cleaned.
A local anesthetic is injected into the scrotum. Patients should ask their doctor about applying an anesthetic cream (EMLA) before the injection to reduce its pain.
The surgeon makes a tiny incision on one side of the scrotum and locates one vas deferens. The vas deferens is isolated, drawn through the incision, and clamped at two sites close to each other.
The segment between the clamps (which should be more than 15 mm, or a little over 1/2 inch) is then removed.
The surgeon then seals off (ligates) the tube with surgical clips, sutures, or cauterization with an electric needle. Fascial interposition is an additional technique that may be used in combination with these methods to improve closure. With fascial interposition, the surgeon pulls the fibrous layer covering the vas (the fascia) over the cut end of the vas and sews it closed. This increases the barrier and further reduces residual sperm. Recent research suggests that fascial interposition combined with cauterization or ligation/excision is the best method for sealing off the vas.
The surgeon may choose to close off either one end of the vas (called an open-ended procedure) or both ends (closed-ended technique). In the open-ended procedure, the vas section connected to the testis is left open, and the one leading to the prostate is sealed. In the closed-ended approach, both are sealed. Many surgeons now prefer the open-ended version because it has lower complication and failure rates than the closed-ended method, and it results in fewer cases of chronic pain.
After closing off the tube, the vas deferens is gently placed back into the scrotum.
The procedure is then repeated on the other side.
After a short rest, usually about half an hour, the patient can leave the doctor's office or clinic. Arrangements should be made ahead of time for someone else to drive the patient home.

Click the icon to see an illustrated series detailing a vasectomy.

A method of vasectomy called no-scalpel vasectomy (NSV) that does not require the use of a scalpel was developed in China in 1974. NSV is now used in at least one-third of vasectomies.

The technique takes about 10 minutes and is performed in a doctor's office or a family planning clinic. The no-scalpel vasectomy differs from a conventional vasectomy in the method of accessing the vasa deferentia:

In NSV, the doctor feels for the vas deferens under the skin and holds them in place with a small ring clamp.
Instead of making two incisions, the doctor employs a sharp hemostat, a special instrument that makes one tiny puncture and then is used to gently stretch the opening until the vas deferens can be pulled through it. (The surgeon must rotate his wrist to pull the vas out -- called a supination maneuver -- which may be difficult to perform.)
The vas is then sealed off using the same methods (clips, sutures, cauterization using an electric needle, or some combination) as conventional vasectomy. As with standard vasectomy, the closures can be open- or closed-ended.
There is very little bleeding with the no-scalpel vasectomy. No stitches are needed to close the tiny opening, which heals quickly and leaves no scar.

When performed correctly, NSV works just as well as conventional vasectomy, takes less time, and (according to a 2007 review) causes less bleeding, infection, and pain. Current research indicates that NSV is the safest type of vasectomy procedure. NSV is difficult to perform, however, and most surgeons must do about 15 - 20 procedures in order to be proficient. NSV is becoming a popular alternative to standard vasectomy, but it is important to select a doctor who is experienced with this procedure.

A simpler method of NSV, called percutaneous vasectomy, is now being used. Recent research suggests that it works as well as standard NSV and is easier to perform. Percutaneous vasectomy uses the same instruments as no-scalpel vasectomy, but with a different surgical technique. The hemostat is used to first puncture the skin (instead of spearing the vas and lifting it out). The ringed clamp is then passed through the incision and used to enclose the section of the vas that is then pulled out for closure. This avoids the need for the difficult wrist maneuver in NSV.

Vasclip. The Vasclip is a recent alternative to standard vasectomy. This very small rice-sized plastic clip locks around the vas deferens and stops the flow of sperm. Some studies have reported fewer post-surgical complications than with standard vasectomy, including infection and swelling. It may be more easily reversible than a standard vasectomy.

Complications

Vasectomy is a low-risk procedure, and the complications, which occur in about 10% of patients, are usually easy to control. One study of no-scalpel vasectomy, for example, reported only 7 complications out of 4,255 procedures and they were mostly minor. Pain or soreness typically lingers for a few days after the procedure, but this is normal and usually does not require a return visit to the doctor. No deaths resulting from vasectomy have been reported in the United States.

Nearly all men recover completely in a few days. The following are some guidelines after the operation to help recovery:

The local anesthetic wears off about 1 - 2 hours after the procedure, and most patients then experience a dull ache in the testicles and groin. The doctor may prescribe a painkiller for the first few days, continuing with mild over-the-counter pain relievers if discomfort persists. Acetaminophen (Tylenol) with or without codeine is the primary choice for postoperative pain. Aspirin, ibuprofen (Advil, Medipren, Motrin, Nuprin), naproxen (Aleve), or other non-steroidal anti-inflammatory drugs (NSAIDs) can cause bleeding and should be avoided.
The patient should stay in bed on his back for at least one day and apply ice packs for 8 hours. The doctor may suggest that the patient wear an athletic supporter.
Some oozing of blood onto the gauze pads is normal during the first 2 days after the operation.
The patient should not perform any heavy physical labor for at least 2 days. Sports and heavy lifting may be resumed 2 - 3 weeks after surgery.
A semen analysis is done about 6 - 12 weeks after surgery to ensure that no live sperm remain in the semen. Many urologists recommend delaying a semen analysis until 2 months after a vasectomy or 12 ejaculations (whichever comes first). The semen is usually collected at home in a small jar and delivered to the doctor's office, where it is examined under a microscope. A second semen analysis is sometimes performed again about 4 months after the vasectomy, although many experts now believe that a second sample is unnecessary unless sperm found the first time were motile (still able to move). According to a 2006 study, 25% of men never bother to return for follow-up sperm testing. Without a follow-up test, men do not know whether the vasectomy was successful. Until test results verify that there are no sperm in the semen, men are at risk of fathering unwanted pregnancies.

All men experience some pain in the scrotum (the sac that contains the testes) after the operation. This pain generally disappears within two days, although the patient may feel sore for a few more days. In rare cases, pain can be persistent, which is known as post-vasectomy pain syndrome. The cause of this is unclear.

A few men may have an allergic reaction to the local anesthesia and develop itching and hives.

Frequently, blood may seep under the skin, so that the scrotum and penis appear to be bruised. If there is no dangerous swelling, this painless problem usually disappears without treatment within 1 - 2 weeks. If the patient bleeds excessively in the days after the operation and requires more than two or three gauze changes per day, he should call his doctor.

In 2 - 5% of cases, bleeding inside the scrotum can cause a painful swelling known as a hematoma. In these cases, the scrotum swells up shortly after vasectomy. The doctor should be called immediately.

Infections occur in 4 - 9% of men after vasectomy. The incision site may become infected, causing redness and swelling around the incision. Antibiotics, antimicrobial creams or ointments, or both, along with hot baths several times a day will usually clear the infection in a few days. There have been a few cases of infections in the lining of the heart (endocarditis) and severe gangrene of the scrotum, but they are extremely rare.

Unexpected Pregnancy

Pregnancy rates after a vasectomy are estimated to be very low, about 1 in 1,000. There are two main reasons for an unexpected pregnancy:

Residual sperm were still alive when the partners had unprotected sex. This is the most common reason for an unexpected pregnancy after a vasectomy. Men should make sure they have follow-up sperm analysis testing. They should also continue to use birth control until their doctor notifies them that the test results confirm sterility.
Failure of the procedure and recanalization. Failure in some cases is due to a technical error, but most often it is due to recanalization -- when the cut ends of the vas spontaneously reconnect. Success rates are best when an experienced surgeon performs the vasectomy.

Once the patient feels comfortable, he can resume sexual activity, usually in about a week. During ejaculation, the patient may experience some discomfort in the groin and testicles at first due to the contraction of the vas deferens. This almost always diminishes as the tissues heal.

However, after the operation there are always some active sperm left in the semen for several months so the risk for pregnancy persists. It is essential that the patient and his partner continue to use other methods of birth control until his sperm count is zero. The patient is considered sterile only when there are no live or moving (motile) sperm in his semen. It takes, on average, around 3 months or 20 ejaculations to clear the viable sperm from the reproductive system, but it may take some men as long as 6 months to become sterile.

About a third of men experience a recurrence or persistence of sperm that have no ability to move (immotile) 12 weeks after surgery and, in one study, about 7% had persistently immotile sperm. Immotile sperm, however, cannot swim up the vaginal canal and pose no danger for fertility. In rare cases, vasectomies have to be repeated because live sperm persisted in the semen. The risk for sperm surviving indefinitely is, however, very low.

The primary reason for vasectomy failure itself is recanalization-- when the cut ends of the vas deferens spontaneously reconnect. Recanalization in some cases may be due to sperm granulomas. These are tiny balls of debris that form from sperm, scar tissue, and white blood cells at the incision site. Cells lining the inside of the vas deferens grow through the scar tissue and form a new channel through which the sperm can now move. In general, surgeons can reduce the risk for recanalization by leaving a gap between the two cut ends.

This natural vasectomy reversal can occur after any vasectomy surgical procedure, but it is uncommon, with most studies reporting it occurring in less than 1% of cases. When recanalization does occur, sperm counts are almost always very low and pregnancies are still rare. Most cases of recanalization develop within several months after the operation. In very rare cases (about 0.6%), sperm have reappeared a year or even longer after vasectomy.

Long-Term Complications

Sperm Granulomas. After vasectomy, sperm often leak from the vasectomy site or from a rupture in the epididymis, the tightly coiled, thin tube that connects the testicle to the vas deferens. Sperm elicit a very strong response from the immune system, which views them as foreign substances and attacks them. Sperm leakage therefore provokes an inflammatory reaction. The body forms pockets to trap the sperm in scar tissue and inflammatory cells. Firm balls of tissue about 1/2 inch in diameter then form; these are known as sperm granulomas. They occur in about 60% of vasectomy patients.

Although they rarely cause serious problems, one study reported that sperm granulomas were troublesome in 15% of patients. In about 3 - 5% of cases, sperm granulomas obstruct the already blocked ends of the vas deferens and generate pressure build-up in the epididymis. This can cause a rupture from the pressure of the fluid. In such cases, the testicles may become enlarged and painful. A damaged epididymis can be repaired, but if the patient later wishes a reversal of the vasectomy, disruption of this tiny tube makes success much less likely.

Epididymitis. Epididymitis occurs when an inflammation at the site of the vasectomy causes swelling of the epididymis. This condition may occur within the first year and can be treated with heat and anti-inflammatory medications. It usually clears up within a week.

The male reproductive structures include the penis, the scrotum, the seminal vesicles and the prostate.

Positive Effects. Surveys indicate that about 90% of men are satisfied with vasectomy and that the feeling persists. One study reported even higher satisfaction in the partners, with more than 95% of wives reporting satisfaction with the procedure. Younger and older couples, with or without children, were all equally likely to have favorable reactions to vasectomies. Most men who have vasectomies feel relieved that the worry about pregnancy is over, and most couples respond well to their new-found contraceptive freedom.

Negative Effects. Some men go through a brief period of self-consciousness, wondering whether others notice some difference in their masculinity. About half of vasectomy patients keep their operations a secret. They may believe that vasectomy is tainted by the stigma of emasculation and that knowledge of it would degrade them in the eyes of their friends and family. For most men, this tentativeness passes quickly.

In a few men, however, problems of poor self-image persist and require counseling. Some may experience depressed and angry emotions. They may actually require a mourning period over the loss of their reproductive ability (similar to what some women go through during menopause). These negative feelings usually resolve over time as the patient moves on to the next stage of his life.

A small percentage of couples experience serious difficulties with the adjustment. Their emotional distress most often manifests itself in sexual dysfunction, such as impotence, premature ejaculation, or painful intercourse. In such cases, however, the vasectomy is probably the catalyst but not the cause of such extreme reactions. Studies have indicated that men who experience erectile dysfunction after vasectomy are more likely to have female partners who are unable to accept the operation.

Research indicates that up to a third of men have some pain in or around the testes that lasts longer than 3 months. In a study of 700,000 patients with vasectomies, up to 10% reported long-term chronic pain around the testicles. In one survey, 19% of subjects reported chronic pain that was simply a nuisance, and 12% reported more severe pain. Another study that followed men for an average of 19 months reported that 27% had some pain in the testicles, although, in the great majority, the pain was brief.

Causes of Chronic Pain. In many cases the source of the pain after vasectomy is not known, although some of the following conditions may be a source of pain:

Scarring from the surgery
Obstruction of part of the epididymis that causes swelling in another section
Pinched nerves
In about 1% of all vasectomies, the epididymis becomes so congested with dead sperm and fluid that the patient feels a dull ache in his testicles. This condition, called chronic orchialgia, usually disappears within 6 months.
Some doctors believe that granulomas may cause more chronic pain than generally believed. Others point out, however, that open-ended procedures, which increase the risk for granuloma production, result in less pain than closed-ended techniques that produce fewer granulomas.

Treatments for Chronic Pain. Surgery may be required if time or more conservative measures fail to relieve pain. Procedures may include:

Removal of the epididymis and surrounding tissue tends to be effective if the pain is in the scrotum (the sac that contains the testes) and if abnormalities in the epididymis can be observed using ultrasound.
A surgical procedure that blocks nerves in the sperm cord can bring relief in severe cases.
Surgery to reverse vasectomy (vasovasostomy) may relieve chronic pain. In one study, nearly 70% of men became pain free, although researchers were unable to discover any biologic differences after the procedure that might explain such relief.

Prostate Cancer. Prostate cancer is the second most common cause of cancer death among American men. About 30% of all American men will develop at least localized prostate cancer at some time in their lives. Long-term high-normal levels of testosterone may be associated with an increased risk for prostate cancer. Because testosterone levels remain higher for a longer period in men who had vasectomy, experts have been concerned that such men have a greater chance for developing the cancer.

Click the icon to see an image of prostate cancer.

A 2002 review indicated a 10% increase in risk for every 10 years after the procedure. The authors of the study reported, however, that such increased risk may not be caused by vasectomy since the association was small and could be due to bias. Most recent studies report no higher danger. A rigorous 2002 study from New Zealand, which has the highest vasectomy rates in the world, found no increased risk of prostate cancer from the procedure, even 25 years after the operation. Another 2002 study, in fact, reported a lower risk for prostate cancer in men who had had vasectomies.

It is possible that the higher rates reported in the early studies may simply be due to earlier prostate screening in men who have had vasectomies. One study reported that about 25% of doctors screened men with vasectomies earlier for prostate cancer than those without the operation.

An expert panel has recommended that vasectomy reversal is not warranted to prevent prostate cancer and that screening criteria for prostate cancer should be the same for men with and without vasectomies. Men with a family history of prostate cancer can discuss the risks and benefits of vasectomy with their doctors, although the weight of evidence to date indicates there is no link between vasectomy and prostate cancer.

Testicular Cancer. There have also been some concerns that vasectomy could increase the risk of testicular cancer. However, studies show there is no association between the two.

Vasectomy is known to provoke immune system changes.

Anti-sperm Antibodies. Sperm continue to be produced after vasectomy but are disposed of in the body. In some men the immune system mistakes these sperm as foreign proteins (antigens) and produces anti-sperm antibodies that are designed to target and interfere with sperm's motility (ability to move). Up to two thirds of vasectomized men develop such anti-sperm antibodies. Infections in the genital tract, such as orchitis or sexually transmitted diseases, increase the risk for anti-sperm antibodies. The anti-sperm response itself appears to be a problem only if a man wishes to reverse the vasectomy.

Heart Disease and Other Changes. Some researchers are concerned that changes in the immune system might cause damage in other parts of the body, including contributing to heart disease. However, a large 2002 follow-up study of men who had vasectomies found no increase in risk for heart disease, stroke, or peripheral artery disease, even after more than 20 years. Nor did researchers find any evidence of greater risk for hardening of the arteries (atherosclerosis) or inflammation, which play a role in cardiovascular disease.

Click the icon to see an image of atherosclerosis.

Some experts have voiced concern that vasectomy may increase the risk for the bone-thinning condition known as osteoporosis. However, evidence to date does not support an association.

Studies suggest that men younger than their mid-40s who have vasectomies have twice the risk for kidney stones as their peers who have not had vasectomies. The increased risk persists for up to 14 years after the operation. Kidney stones are not life threatening, but they can be extremely painful. Drinking plenty of fluids is the best way to prevent kidney stones.

Click the icon to see an image of kidney stones.

Reversal Surgery

Although men should consider vasectomy a permanent decision, vasovasostomy is a reversal procedure that may restore fertility in men who change their minds. Vasovasostomies are also effective in relieving chronic pain from vasectomies in the rare case that this occurs.

One Australian study suggested that although the rate of vasectomies has not changed over the past few decades, the desire for reversal surgery increased by over 70% in the late 1990s compared to the early 1980s. Men who had vasectomies in their 20s are more likely to seek reversal later on than older men. The main reasons for requesting a reversal are remarriage, the death of a child, or an improvement in finances. Reversal may also be performed to relieve post-vasectomy pain, which occurs in a small percentage of men. However, fewer than 10% of patients who request reversals do so because of physical or psychological problems following vasectomy.

Standard Procedure. Vasovasostomy reconnects the severed ends of the vas deferens to reestablish the flow of sperm. The procedure is difficult:

It involves sewing together the two tiny ends of both tubes, each with pinhead-sized openings.
If the vas deferens is blocked, the surgeon may try to connect the epididymis to an area in the vas deferens that bypasses the blockage.

Vasovasostomy can usually be done on an outpatient basis, and patients can usually return to work within 1 - 2 weeks. It is far more difficult and expensive than vasectomy itself, however, and is even costlier if the procedure involves connecting the vas to the epididymis, which takes about 3 hours. It should be noted that reversal surgery is usually not reimbursed by insurance companies, and that the results may not be known for some time.

Microscopic versus Magnification Techniques. The surgeon may view the surgical site using either magnification instruments (called macroscopic vasovasostomy) or microscopic techniques. Advanced microscopic techniques are proving to increase the chances of a reversal's success. Although macroscopic vasovasostomy has a slightly lower success rate, pregnancy rates can still be over 50%, and it is less expensive and has a shorter operating time than microscopic procedures. Still, a 2003 study suggested the microscopic approach is preferable for repeat vasovasostomies when the initial procedure failed.

Laser Techniques. Laser surgery is being investigated and may prove to require less surgical expertise, reduce operating time, and result in fewer complications. At this time, however, results vary widely.

An Australian study reported that the pregnancy rates in the late 1990s after reversal surgery were nearly four times higher than they were in the early 1980s. Pregnancy rates of over 50% are now being reported after vasovasostomy. One study indicated that when successful conception occurs, it does so at an average of 1 year after the surgery.

A successful reversal is more likely if the following conditions are present:

The section removed during vasectomy was not long.
The original procedure was performed on straight sections of the vas deferens.
The pieces joined during the vasovasostomy are of equal size.

The closer in time the vasovasostomy is to the original vasectomy, the better. In one large study, the pregnancy rates were 76% for those who had vasectomy less than 3 years before reversal surgery, but decreased to 30% for those men who had a vasectomy more than 15 years earlier. The decrease in rates as time goes by is probably due to an increase in the chance for obstruction of the epididymis and the development of anti-sperm antibodies. Success rates, according to some studies, are slightly better if the male partner does not change female partners after the procedure. Other studies suggest that it makes no difference if the man has a new female partner. The age of the woman is an important factor, and the chances of achieving pregnancy are best for women younger than age 35. Some research suggests that men who have a vasectomy reversal may have a greater rate of sperm chromosomal abnormalities than normal fertile men.

Even though tubes are re-opened and sperm is restored in as many as 85% of men who undergo vasovasostomy, pregnancy is not guaranteed. Several factors may play a role in the failure of reversal surgery.

Epididymis Obstruction. If the sperm count does not recover within a reasonable period after vasovasostomy, it is often due to blockage from scarring that has occurred in the epididymis. This sometimes can be corrected with a second procedure. The doctor may be able to detect obstruction before the vasovasostomy by pressing and manipulating (palpating) the epididymis. If any part seems swollen or larger than other parts, an obstruction is very likely to be present and the patient is likely to need a vasoepididymostomy, which creates a bypass around the obstruction.

Antisperm Antibodies. In many cases in which vasovasostomy fails, the reversal procedure reopens the tubes but fertility is impaired because of a process called autoimmunity. With this condition, important immune factors called antibodies attack the body's own cells, mistaking them for antigens (any foreign microinvader that the immune system perceives as a threat).

In the case of vasectomy, the autoantibodies attack the sperm, and so are called antisperm antibodies. Such antibodies develop when sperm continue to be produced after vasectomy, but, instead of being confined to the reproductive passages, they leak out into the body. Once out of their natural habitat, the immune system perceives them as foreign invaders and develops antibodies to attack them.

Antigens are large molecules (usually proteins) on the surface of cells, viruses, fungi, bacteria, and some non-living substances such as toxins, chemicals, drugs, and foreign particles. The immune system recognizes antigens and produces antibodies that destroy substances containing antigens.

The antisperm antibodies bind to specific parts of the sperm (the head or tail) and cause problems depending on the site of attachment. Sperm may stick together (agglutinate), fail to interact with the woman's cervix, or fail to penetrate the egg. Even after vasovasostomy, such antibodies often persist.

Oxidation. The immune factors that trigger the autoimmune process may have other harmful effects as well. In a process called oxidation, they can trigger the release of particles called free radicals, highly reactive oxygen molecules that, in excess, can do considerable damage to cells and genetic material. When high levels of free radicals persist after a vasectomy, they may, in theory at least, injure sperm DNA, contributing to infertility.

Repeat Vasovasostomy. If pregnancy fails, in some cases a repeat vasovasostomy may be effective. Success rates depend on several factors:

The doctor's skill
Complications from the original operation
Effects of anti-sperm antibodies
Time elapsed since vasectomy (the shorter the better)
History of previous children. In one study, conception rates after reoperations were highest (80%) in couples who had had previous children. The pregnancy rate was only 17% when men had remarried.

A 2003 study indicated that the microscopic approach may be preferable for many repeat vasovasostomies.

Vasoepididymostomy. Vasoepididymostomy is a microsurgical technique that is useful when a vasovasostomy has failed because of damage to the epididymis. This procedure creates a bypass around the obstruction. It may be done on one or both sides of the testes.

To appreciate the difficulty of this operation, one should realize that the epididymis is 1/300th of an inch wide with a wall thickness of 1/1000th of an inch. Microscopic techniques are critical for the success of this procedure and require a surgeon who specializes in them. Refinements in vasoepididymostomy techniques are showing promising results, opening tubes in 77 - 85% of cases.

Success rates are higher for repairing obstructions closer to the testicles, because the epididymis is wider in this area. In general, pregnancy rates are around 25%, but higher rates have been reported. In one study of men who had vasectomy reversal more than 15 years after the original procedure, 62% required vasoepididymostomy, and the overall pregnancy rate was 43%. Pregnancy rates ranged from 49% in those who had had their vasectomy 15 - 19 years earlier to 25% in those who had the surgery 25 or more years before, with the highest rates occurring, not surprisingly, in those with the youngest wives.

Damage in other ducts and small tubes are a major reason for vasoepididymostomy failure. Ultrasound before the operation may be valuable to determine if these abnormalities exist, which would make it unlikely that the procedure would be successful.

If an initial vasoepididymostomy fails but conditions are favorable, a repeat procedure may still succeed.

If the patient did not contribute sperm for freezing and banking before vasectomy, some doctors suggest freezing sperm obtained during vasovasostomy as insurance against failure. Such sperm can be used in assisted reproductive methods later on if natural intercourse fails to achieve pregnancy.

There is some controversy, however, surrounding routine use of frozen sperm before a vasovasostomy. One study reported that so many sperm were non-motile at the time of the reversal surgery that freezing sperm obtained during the procedure provided little benefit. Nevertheless, new fertilization techniques are using even non-motile sperm with some success. Studies report successful pregnancies with frozen sperm. Some experts recommend routine sperm retrieval only for men undergoing bilateral vasovasostomy (those performed on both sides) and possibly for men who are having vasovasostomy with vasoepididymostomy. Men should discuss these options with their doctor.

Even though newer techniques such as intracytoplasmic sperm injection (ICSI) are improving pregnancy rates after vasectomy, vasovasostomy is still a better choice than assisted reproductive technologies (ART) for most men who want children.

Success rates with reversal surgeries are improving, and the costs are lower than with ART. In addition, a vasovasostomy does not pose a risk for multiple births. In one study, the pregnancy rate for vasovasostomy was 52%, whereas success after intracytoplasmic sperm injection (ICSI) was between 25 - 30%. (ICSI is the ART treatment of choice for men who have had vasectomy.) Even for men who have failed vasovasostomy, a repeat procedure appears to be less expensive than embarking on fertility treatments at that time.

ART may, however, be a better approach than reversal for men with evidence of anti-sperm autoantibodies due to vasectomy. ICSI may also be more effective than reversal surgeries in men whose vasectomy was conducted at least 15 years earlier.

Assisted Reproductive Technologies

Assisted reproductive technologies (ART) are available for men who want to conceive children after a vasectomy. The shorter the period since the vasectomy the better the chances of success. In one study, success rates after ART were highest (34%) when it was performed within 10 years of the vasectomy and lowest (8%) when ART occurred more than 20 years after vasectomy. Of course, the couples would be older as the duration between procedures increased, so pregnancy rates would be lower in any case. However, time elapsed after vasectomy appears to have an effect independent of a couple's age. Debate is ongoing about its advantages versus reversal surgeries for men who have had vasectomies and want children. Research presented at the 2007 American Urological Association annual meeting suggested that vasectomy reversal may work better than sperm retrieval or other ART.

The best assisted reproductive technology procedure for men who have had vasectomies or failed reversal surgery is intracytoplasmic sperm injection (ICSI). In this procedure, sperm are taken from the epididymis or testes using needles or microsurgical techniques.

The procedure itself injects a single sperm into an egg with the aid of powerful microscopic and robotic instruments. The fertilized egg is then implanted in the woman. [See In-Depth Report #67: Infertility in men.]

If a reversal surgery is not successful, a doctor may be able to retrieve sperm from the testes or the epididymis for use in assisted reproductive technologies (ART). Various techniques are now available for retrieval. The procedure may be done under local or general anesthesia, using a spring-loaded biopsy device, a thin needle, incisions, or microsurgical techniques. Rigorous trials on the best technique are lacking, although all can be successful. The choice will depend on the experience of the clinic and any underlying problems.

Testicular Fine Needle Aspiration. Testicular fine needle aspiration (TFNA) employs a fine needle to remove sperm. This can be performed with local anesthetic and by surgeons who do not have to be experienced in microsurgeries.

Microsurgical Epididymal Sperm Aspiration. Microsurgical epididymal sperm aspiration (MESA) uses microsurgical techniques to collect sperm that are close to blocked portions of the epididymis. It involves an open incision and may be done under general or spinal anesthesia in a hospital setting, although the patient can often go home the same day. The doctor accesses the epididymis and retrieves sperm with an extremely fine needle-like device. It has the advantage that it can retrieve the largest number of sperm compared to other procedures. However, as with any invasive procedure, it carries some risk of complications, such as bleeding or infection.

Percutaneous Epididymal Sperm Aspiration. Percutaneous epididymal sperm aspiration (PESA( uses a needle to obtain mature sperm from areas in the upper parts of the epididymis (the coiled tube where sperm are stored before ejaculation). It is done under local anesthesia, sometimes in the doctor's office, is less expensive than other techniques, and recovery is fairly painless. However, it has less of a chance of achieving sufficient sperm than MESA, and there is also a chance of hitting a blood vessel, causing bleeding.

Testicular Sperm Extraction. Testicular sperm extraction (TESE) is a microsurgery that removes a small amount of tissue from one or more areas of the testes using incisions and microsurgery techniques. The tissue is placed in a culture and chopped into tiny pieces. Sperm are liberated from the tiny tubes and extracted. It is a complex process, however. This is the second best method for men with vasectomies, according to some experts. It is more painful than PESA, however. In addition, if the procedure is repeated too often it can cause permanent alterations in testicular function that may reduce male hormone levels.

Testicular Sperm Aspiration. Testicular sperm aspiration (TESA) uses a needle-like biopsy device to draw a small sample of testicular tissue. Multiple attempts are sometimes required to retrieve sperm, and it is not as effective or as safe as TESE, although imaging techniques using ultrasound may improve results.

Resources

www.engenderhealth.org -- EngenderHealth
www.nichd.nih.gov -- National Institute of Child Health and Human Development
www.plannedparenthood.org -- Planned Parenthood
www.fhi.org -- Family Health International
www.auanet.org -- American Urological Association
www.urologyhealth.org -- Urology Health
www.newmalecontraception.org -- Male Contraception Information Center
www.imccoalition.org -- International Male Contraception Information Coalition
www.vasectomy.com -- Information on vasectomy

References

Amory JK, Muller CH, Page ST, Leifke E, Pagel ER, Bhandari A, et al. Miglustat has no apparent effect on spermatogenesis in normal men. Hum Reprod. 2007 Mar;22(3):702-7. Epub 2006 Oct 25.

Cook LA, Pun A, van Vliet H, Gallo MF, Lopez LM. Scalpel versus no-scalpel incision for vasectomy. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004112.

Mruk DD, Wong CH, Silvestrini B, Cheng CY. A male contraceptive targeting germ cell adhesion. Nat Med. 2006 Nov;12(11):1323-8. Epub 2006 Oct 29.

Review Date:
10/17/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

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