By Rebecca H. Allen, MD, MPH
Synopsis: In this retrospective cohort study of 2,567 patients at a single institution, 42.1% of men did not follow up at all after vasectomy for semen analysis. Of those with spermatozoa on the initial testing post-vasectomy, 43.3% of men failed to return for repeat testing.
Source: Sandler MD, Angulo-Llanos L, Dureja R, et al. Lost to follow up: Semen analysis compliance following potential vasectomy failure. Andrology. 2025; Mar 19. doi: 10.1111/andr.70027. [Online ahead of print].
Vasectomy, or permanent contraception for men, is a safe and effective outpatient procedure that has risen in popularity in the United States.1 The authors of this study sought to investigate real-world vasectomy follow-up rates. This was a retrospective cohort study from the University of Miami that included all adult men undergoing vasectomy between January 2004 and January 2024. Data collected included sociodemographic, procedure date, and any followup visits and semen analyses that were performed.
The patients were divided into three groups: those who underwent a postvasectomy semen analysis (PVSA) less than three months post-procedure, those who had a PVSA three months or more after the procedure, and those who never followed up at all. Failed vasectomy was defined as the presence of motile sperm or > 100,000 nonmotile sperm on semen analysis three or more months postprocedure. Pending failure were those patients who had this result at less than three months and still needed a repeat PVSA.
A total of 2,567 men had vasectomies during the period of the study, with the average age being 39.9 (standard deviation, 7.2) years. A total of 1,081 (42.1%) men did not follow up at all after vasectomy. Of those who had an initial PVSA, there was a success rate of 88.9%. Of the 645 (25.1%) men who returned for their PVSA prior to three months, 120 had sperm present; of those, 52 (43.3%) were lost to follow-up. Of the 841 (32.8%) men who had their initial PVSA at three months or more, 45 men had sperm present; of those, 21 (46.6%) were lost to follow-up.
Commentary
This is an interesting study documenting real-life vasectomy follow-up rates. Patients are advised that before they can rely on the vasectomy for permanent contraception, a post-vasectomy semen analysis is needed, usually scheduled eight to 16 weeks later.1
The American Urological Society recommends that patients may stop using other methods of contraception when examination of one well-mixed, uncentrifuged, fresh post-vasectomy semen specimen shows azoospermia or only rare nonmotile sperm (RNMS or ≤ 100,000 nonmotile sperm/mL).2 The later the PVSA is performed (for example, at 12 weeks), there is a higher probability of success. After this result is achieved, vasectomy is extremely effective, with failure rates of one out of 2,000.2 Therefore, follow-up for this testing is critical to prevent unwanted pregnancies. This study indicated poor rates of follow-up, with 42% of men not following up at all and about half of men not following up after their initial PVSA showed sperm present.
Per the authors, past studies have shown that barriers to PVSA include time, transportation, forgetfulness, or just being confident that the procedure worked and it was not necessary. At this institution, patients receive a text message a week prior to the appointment reminding them. If they fail to show up for the appointment, it is unclear if any other outreach is performed. Clearly both patient education and follow-up protocols can be improved. Limitations of this study include the fact that patients could have moved away or obtained the PVSA at an outside institution and not reported it to the urologist.
In conclusion, vasectomy is a highly effective and safe form of contraception.1 Male sterilization is performed in the office under local anesthesia and, thus, is safer than female sterilization, which requires abdominal surgery. Approximately 5% of men in the United States have undergone vasectomy.2 Initial reports suggest that the rates of vasectomy have increased in the United States since the Dobbs v. Jackson Women’s Health Organization decision in 2022 that severely restricted abortion rights.3 Younger men and men without children are becoming interested in vasectomy under the current reproductive health landscape.4 Therefore, as vasectomy grows in popularity, it will be important to improve adherence to follow-up rates.
Rebecca H. Allen, MD, MPH, is Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, RI.
References
1. Nguyen AT, Curtis KM, Tepper NK, et al. U.S. medical eligibility criteria for contraceptive use, 2024. MMWR Recomm Rep. 2024;73(4):1-126.
2. Sharlip ID, Belker AM, Honig S, et al. Vasectomy: AUA guideline. J Urol. 2012;188(6 Suppl):2482-2491.
3. Patel RD, Loloi J, Labagnara K, Watts KL. Search trends signal increased vasectomy interest in states with sparsity of urologists after overrule of Roe vs. Wade. J Urol. 2022;208(4):759-761.
4. Nguyen V, Li MK, Leach MC, et al. Comparison of childless and partnerless vasectomy rates before and after Dobbs v. Jackson Women’s Health Organization. Am J Mens Health. 2024;18(3):15579883241260511.
In this retrospective cohort study of 2,567 patients at a single institution, 42.1% of men did not follow up at all after vasectomy for semen analysis. Of those with spermatozoa on the initial testing post-vasectomy, 43.3% of men failed to return for repeat testing.
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