By the time I was 38, I was sure that I didn't want children of my own so I decided to take responsibility and put my balls on the line. On Valentine’s Day 2015, I had a vasectomy. The procedure was performed by a family planning specialist at the Walton Family Health Center at the Bronx. I was working a corporate gig at the time, had pretty good health insurance, and was only charged a modest co-pay. Had I paid out of pocket, however, the one-time cost at this particular provider would have been just a little more than $300.
While the injection of lidocaine into my scrotum felt exactly as comfortable as you’d imagine a needle being plunged into your private parts would feel like, the sensations associated with the procedure itself were more than manageable. There was some tugging, there was a nasty, burning hair smell from the cauterization of my vas deferens—the tubes through which sperm travels from the testicles to be mixed with seminal fluid in the prostate—and that was it. Cut and shut. In fact, it was over so quickly that the snow in the treads of my winter boots hadn't fully melted by the time I left the clinic and gingerly took my numbed nuts home on the subway.
The following day, I was feeling so back to normal that I disregarded my instructions to refrain from intercourse for a few days and had sex just 36 hours post-procedure. Even though I woke up with a rather tender, black and blue scrotum, the results of my non-compliance dissipated in a few days.
Was that all there was to a vasectomy? It made me wonder why only one in 10 men in the United States are taking advantage of it—compare this with Canada and the UK with uptake rates of 22 and 21 percent respectively. Making me wonder further was the fact that worldwide, tubal ligation—a more costly, risky, and invasive procedure in which a woman's fallopian tubes are clamped or blocked and sealed—has a popularity of 33 percent, making it the most common form of birth control globally. (In the US, it’s a close second after the pill among women ages 15 to 44, though sterilization was the most popular method according to new data out this week on women ages 15 to 49.)
“It’s a much, much simpler procedure to get a vasectomy as opposed to tubal ligation,” says Harry Fisch, a clinical professor of urology and reproductive medicine at New York-Presbyterian Hospital/Weill Cornell Medical College. He says that beyond being simpler, cheaper, and having a much lower risk of serious complications, vasectomies are better at preventing pregnancy than tubal ligation, too—one in every 1,000 vasectomized men end up getting their partner pregnant, while five in every 1,000 women become pregnant after tubal ligation.
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Fisch explains that when pregnancies do occur post-vasectomy, there are two usual explanations: early unprotected intercourse prior to obtaining a sperm-negative semen analysis, or the recanalization of the vas deferens—meaning the two cut ends of the tubes somehow finding each other, reconnecting, and allowing sperm to travel from the testis to the prostate.
In the first instance, Fisch uses a neat analogy to explain what’s happening. “When you shut of the faucet, there’s still water in the hose, right?” For that reason, it’s typical for urologists to ask patients to come in for a semen analysis at least 12 weeks or 20 ejaculations after the operation to confirm that he is azoospermic (meaning without sperm). Until confirmed, urologists strongly recommend using another form of contraception. With regard to why recanalization happens, Fisch observes that “the body will do everything it can to bring those tubes back together because, after all, we’re fighting against nature here.” Fisch adds that recanalization is rare and, even when it does occur, only a very tiny amount of sperm heads toward the light.
While chatting with Fisch is enjoyable as it is enlightening, it’s leaving me even more perplexed as to why couples who've decided that their procreating days are behind them (or have opted out of parenthood altogether), are still opting for a riskier, costlier, and less effective method of permanent birth control. Fisch offers one explanation and it’s not something that shows my gender in a good light.
“The thing is, when a needle gets near the scrotum, a lot of men experience psychological discomfort and experience nausea or even faint.” Fisch used to perform vasectomies with a local anesthetic. He now uses sedation, too. “Though the procedure is quick and not particularly painful, a lot of men are frankly scared and are thrilled to be offered sedation,” he says.
Another reason, he says, is that many tubal ligations are performed during c-section deliveries, meaning that the costs of the operating room, the anesthesia—which push the cost of a conventional tubal ligation up to around $6,000 before insurance—are already sunk. Plus, in this scenario, the women getting c-sections are already having abdominal surgery so adding a tubal ligation isn't as much trouble. “In this instance, tubal ligation starts to makes a little more sense,” Fisch says.
Enterprising minds have long been developing ways to make a permanent female sterilization option as affordable and convenient as a vasectomy. “Female sterilization took a step forward when it became an in-office procedure, bringing it into the realm of the vasectomy,” says Paul Turek, San Francisco-based surgeon and men’s reproductive health specialist. Turek is referring to the Essure device. Introduced in 2002, Essure involved the placement of metal coil which, when placed into each fallopian tube, induces scar tissue to form—this blocks sperm from reaching the ovaries. The device required no operating room and no anesthesiologist, which bring the costs down—though is still many times more expensive than a vasectomy. Planned Parenthood of Greater Ohio for example, offered a sliding scale for the uninsured, the top end of which is $2500.
Essure seemed promising, until it wasn't for many women to got it implanted. “Typically in medicine, the good comes out early and the bad takes time,” says Turek explaining that Essure came with a lot of unacceptable side effects including hundreds of unintended pregnancies, intractable pain and bleeding leading to hysterectomies, and even possible device-related deaths. (There's an informative and truly horrifying Netflix doc about it and other medical devices, if you're interested.) In July 2018, Bayer, the makers of Essure, said it would halt US sales of the device but only after the FDA put restrictions on its sale and distribution. This means that, for the foreseeable future, the vasectomy remains the only non-surgical method for people looking for a permanent family planning solution.
One reason that vasectomy is more popular in many other countries is that it’s often free (insurance companies in the US aren't required to cover the procedure without cost-sharing like they are female birth control). Another reason? I suspect that it's ignorance. Unlike in much of the rest of the developed world, American kids aren’t required to know how sex works. (Incredibly, just 24 US states mandate that sex education is delivered to children, only 13 require that sex education be medically accurate, and a mere six require that sex ed be taught and be medically accurate.)
That goes some way in explaining several partners’ surprise when they discover that my having a vasectomy doesn’t mean that I no longer ejaculate. In fact, sperm only accounts for a hardly noticeable 2 to 5 percent of ejaculate volume. Other misunderstandings about vasectomies are that they can increase prostate cancer risk (they don’t) lower testosterone concentrations (they won’t), shuts down sperm production (they just block it off) or are more difficult, costlier, riskier than tubal ligation. Absolutely not.
An even more common misconception about tubal ligation and vasectomy is that they are not a permanent form of birth control. In actual fact, they most certainly are. While both can be reversed, the reversal procedure is more involved, painful, and costly than undergoing a sterilization procedure in the first place.
I’d be remiss if I didn’t speak to the overarching reason why the less costly, less risky, easier-to-recover-from vasectomy isn’t as popular as it ought to be: The systemic patriarchy which makes men’s reproductive rights more important than women’s. One manifestation of that imbalance is the unpalatable fact that women are sometimes urged to undergo a permanent sterilization procedure because, subconsciously or not, men may want to have their impregnating function intact in case they move on. Also, let's face it: Birth control is often viewed as something women are supposed to handle.
All this to say that if you're a guy who doesn’t want children or doesn’t want any more children, I feel that the move is to sack up and take reproductive responsibility. Particularly if, like me, you were worried sick at the prospect of the thing you like to do the most resulting in an outcome you desire the least.
And, hey, even if you're unwilling to shut the door on the possibility of having kids in future, you can bank your sperm before having a vasectomy. Not only is the cost of keeping your swimmers on ice for a decade less than that of a reversal, but sperm quality also decreases as you age so it’s a good idea to keep a good batch in reserve in case you change your mind. Options open. Vas deferens closed.
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