I authorize Dr. _____________ to perform a bilateral vasectomy
I understand that this procedure is performed through small
scrotal incisions or punctures and that a small portion of
each vas is removed and may or may not be sent for pathological
I understand that this procedure is being performed to achieve
permanent sterility, meaning I will be unable to father any
further children once my semen specimens are cleared of sperm.
I understand that this procedure is usually performed under
local anesthesia, however IV sedation may be required, and
this will be decided by my urologist.
I understand that there are complications with this procedure
which may include infection, bleeding, pain, sperm granuloma
formation, and recanalization. I realize that the chance of
having a complication that needs further surgery is about
1 per 1000. I also realize that recanalization may occur in
up to 3 per 1000 cases leading to a return of fertility.
I understand that I am not considered sterile until 2 semen
specimens are cleared of sperm at 6 and 12 weeks. I realize
that contraception must be used until these semen specimens
are cleared of sperm. I also understand that the chance of
delayed recanalization after obtaining 2 negative semen specimens
is extremely small.
I realize that there appear to be no significant long-term
effects of vasectomy, however, one study suggested a slight
increase in prostate cancer after vasectomy. This has not
been proven on larger studies.
I expect to be sterile after this operation, once my semen
specimens have been cleared of sperm at 6 and 12 weeks, however,
I understand that this cannot be guaranteed. I have read all
the information from the VasCenter.com and have no further
questions, and therefore give my consent to vasectomy.