Jan. 28, 2002 -- Couples who've seen enough of the stork have two basic choices: birth control or sterilization.
Birth control can be very effective but has its drawbacks. Condoms and diaphragms get in the way, and health risks haunt users of the pill, implants, or IUDs. For those who've had enough little bundles of joy for one lifetime, sterilization is an attractive option.
The downside: somebody has to take responsibility. Usually it's the woman. In the U.S., female sterilization is more than 2.5 times more common than male sterilization. Yet a woman who has her tubes tied faces a far more complex, risky, and expensive operation than a man who has a vasectomy.
New, "no-scalpel" vasectomies have made male sterilization simpler. Will it ever get simple enough for more men to step forward? Maybe.
"With the current incisionless approach, one still has to make a puncture in the skin," Nathaniel M. Fried, PhD, tells WebMD. "We are trying to take things one step further. We want to completely avoid bleeding and scrotal pain."
Fried, an assistant professor of urology at Johns Hopkins University, leads a research team working on an ultrasound vasectomy machine. It's not ready for prime time -- animal studies continue -- but a technology firm is backing the approach with an eye to eventual human tests.
How does it work? A vasectomy cuts a piece out of the tube -- the vas deferens-- that lets sperm leave the testicles and enter the semen. This is why a man with a vasectomy is said to be "shooting blanks." His sexual function and semen production is otherwise normal -- except that he can no longer get a woman pregnant.
The ultrasound device has three parts. One is a water balloon that covers the skin. Chilled water runs through the balloon to keep the skin from burning. The second part is a clamp that holds the vas deferens in place. The third part is an ultrasound machine that focuses sound waves on the vas deferens. At the point of focus, the ultrasound energy creates intense heat.
"The idea is to heat up or cook the vas," Fried says. "It immediately cooks the tissue so that the vas closes. Then healing of the tissue creates scar tissue that further blocks the vas."
In theory, this would be more palatable to men than the current no-scalpel technique. Invented in China, the procedure first numbs the scrotum with an injection of local anesthetic into the skin. With a needle-like tool, the doctor makes a small hole in the scrotal sac. The flexible skin around the puncture is stretched, and the doctor uses a small instrument to pull the vas from each testicle through the opening. The vas is then severed and closed, often with a cauterizing tool that seals the vas shut. If done on a Friday, a man can go back to work on Monday -- and play sports the next weekend.
Even new, minimally invasive surgery to tie a woman's fallopian tubes isn't nearly as simple or painless as that. Yet it's still too scary for lots of guys.
Urologist Jay Sandlow, MD, is director of the male fertility clinic at the University of Iowa. He recently led a study that looked at the psychological issues of men who had decided to have vasectomies.
"Originally, I thought we would find that a certain number of guys would have concerns about the sudden loss of fertility -- one day you're fertile and the next day you're not," Sandlow tells WebMD. "I was surprised that the concerns about the finality of vasectomy weren't that much of an issue. Guys are much more concerned about pain and about their fear of the unknown."
Fried thinks the ultrasound device will address exactly this issue.
"It doesn't make much sense that female sterilization is still much more common than vasectomy," he says. "Presumably there is a psychology involved here in the sense of social or cultural issues of whether a couple chooses male or female sterilization -- and it falls on the female most often. If we can say we don't make any cuts in the scrotum, it may make it more popular for men."
There are still a certain number of men who regret having a vasectomy. Sandlow says this is most likely to happen when a couple finds that their financial and personal situations make them think again about having children. Sometimes -- but not always -- a vasectomy can be undone.
Vasectomy reversal is much more complicated than vasectomy itself. It's also much more expensive and there's no guarantee of success.
Very few men report erection or ejaculation problems after vasectomy. In nearly every case, this is a psychological problem and not a physical one. Even so, these men suffer. Sandlow says that in his experience, these problems go away as the man adjusts to being infertile. Sometimes he makes a referral to psychological counseling. In rare cases -- when the men exhausted all other solutions -- he performed vasectomy reversals.
"You do have guys that come and say their sex drive is less, their erections are not as good. But I can find nothing physically wrong with them," Sandlow says. "If they don't get better after psychological counseling, they do get better with a reversal. The few guys for whom I've performed a reversal in that situation have done very well."
Sandlow agrees that vasectomy is the best choice for couples seeking sterilization -- and he says it's not just because it's safer, cheaper, and simpler than female sterilization.
"If nothing else, it gives the man some participation in the whole process," he says. "A lot of guys come in for a vasectomy because both conception and contraception have always been the woman's responsibility. Here's the guy's chance to contribute and take some responsibility of his own."