I authorize Dr. _____________ to perform a bilateral vasectomy on me.

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 evaluation.

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.
 
SIGNED________________________________DATE_______________________
(Patient)