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Snip or Tie?
When couples are through with baby-making and don’t want to bother with birth control, they have to decide who goes under the knife: husband or wife.
Christine Grillo

Snip or Tie?When my third child was a few months old, I started having fantasies about the Exersaucer, and that’s how I knew. My fantasy went like this: instead of stashing the Exersaucer in the cellar for the next baby that might issue forth from my body, I would give it away, to be well used by some other baby that issued forth from some other woman’s body, while my womb stayed as empty as the day is long.

Like me, my husband was ready to put the brakes on baby-making for good. He was also ready to ditch the clunky birth control and figured he was on the hook for the next move—I had given birth to three children within five years, after all. Off to the urologist he went.

For couples like us (fertile, heterosexual and ready to stop having children), two sterilization options stand out as being low risk, with high rates of success: vasectomy for the man and tubal ligation for the woman.

For many couples I talked with, vasectomy seemed like the only fair way to go. Patty, a mother of two who lives in Arcadia, said, “I paid my reproductive dues, twice.” Erin, from Hampden, said, “I’d been messed with enough—it was his turn.”

Urologists are quick to say that of the two sterilization options, vasectomy is the lowest-risk with the lowest rate of failure. “A vasectomy is done under local anesthetic, it’s less than 30 minutes, you walk in and walk out,” says Dr. Brad Lerner, chief of urology at Union Memorial and the urology consultant for the Baltimore Ravens. “You take Friday off from work, and you’re back to work on Monday.”

Urologists have slightly different methods, but in all versions of the procedure the surgeon removes a segment of the vas deferens, which is the tube through which sperm travels during ejaculation, and seals off the ends so that they never re-connect. Many urologists, including Lerner, use a no-scalpel method in which a small puncture is made outside the scrotum and the vas deferens is pulled to the surface, cut and sealed off with a combination of electrocautery and sutures.

It may sound a little gruesome, but Lerner is quick to point out that a vasectomy doesn’t affect erection, pleasure or ejaculation. “Some people ask, ‘Can I still produce semen?’” he says. “Of course you can, because sperm is only 10 to 15 percent of ejaculate fluid and a vasectomy only stops the flow of sperm.” And it works nearly all the time—the statistical failure rate of a vasectomy is only one in 2,000.

Lerner performs about 180 vasectomies a year and says that most men who come for the consultation end up going through with the procedure.“In my parents’ generation, women got tubals,” says Lerner. “Now men step up to the plate more.”

But make no mistake. A vasectomy is not an easy thing, and it’s important to follow the doctor’s instructions. Paula, who lives in Lauraville, confesses that neither she nor her husband read the doctor’s handouts, one of which offered the important tip, “Wear close-fitting underwear the day of your procedure.” Her husband wore boxers, as usual, so on the three-block walk from the doctor’s office to the car, “he staggered along Fayette Street, gently supporting his poor testicles in his cupped hand.”

Mark, who lives in Charles Village, had a more harrowing case of what doctors call “noncompliance.” After his vasectomy, he sat in front of the television with a pack of frozen peas and a Percocet, happy to have the day off. “I drank a couple beers, went to bed, no pain,” he says. The next morning, still feeling good, he picked up his 32-pound child and threw him in the air.

“I heard and felt a loud pop in my groin. I thought, ‘Wow, that was probably a mistake.’ I felt funny immediately and went back to the couch with more frozen peas.” By the next day he had a fever and his urologist confirmed that he’d torn a suture, which had become infected. Antibiotics did the trick, but he had a huge hematoma on his testicle, which swelled to the size of a mango. He had to miss an extra three days of work and walked gingerly for about two weeks.

Operator error aside, the whole thing usually comes off smoothly. Emma, who lives in Towson, says, “Any man who makes a big fuss about it should rest assured that it is pretty painless and only requires walking like John Wayne for a few days. It is a huge relief and the best decision we ever made.”

While urologists like Lerner report that vasectomies are gaining in popularity in their practices, tubal ligations are still more common in the United States. A recent national survey conducted by the Centers for Disease Control and Prevention shows that tubals outnumber vasectomies about 3-to-1 in this country. Other studies show significant disparities along race, class and ethnic lines: white, educated, high-earning men are more likely to get vasectomies than minority, less-educated, low-income men. In the Western world, tubals are only twice as common as vasectomies; they’re eight times more common in Asia; and they’re 15 times more common in Latin America and the Caribbean.

Snip or Tie?When Amy, from Towson, was ready to stop making babies, she discovered that her husband was not comfortable with a vasectomy. “A procedure of any sort made him anxious,” she says. “But after having three kids, you get used to being poked and prodded.” In a laparoscopic tubal ligation, which involves general anesthesia, a small incision is made near the navel, and the surgeon blocks, ties or cuts the fallopian tubes. The procedure does not affect hormones or menstruation.

After her tubal, Amy found that she was “tender, but not incapacitated.” As for the decision, she says, “It’s simpler for a man to get a vasectomy, but you have to take everything into consideration, and a man and woman have to do it together. Everybody has their own feelings about medical procedures.”

When Tracy, who lives in Hampden, knew she was ready, she asked her husband at the time (they’re divorced now) to get a vasectomy, but that didn’t happen. So she went under the knife. “I was put under general anesthesia and had the whole thing: hospital robe, wheelchair, everything,” says Tracy.

As she was being wheeled into surgery, an older nurse scolded her. “Why didn’t you get your husband to get a vasectomy?” asked the nurse. “This is major surgery.”

It took Tracy a full week before she could really move around and she was surprised by the amount of pain. “It was more intense than I thought it would be,” she says. “You have to do a lot of healing.”

Of course, if you’re having a C-section anyway, maybe a tubal ligation is the way to go. But think ahead, especially if you’re delivering at a Catholic hospital. When Joyce, who lives in Woodberry, found herself having an emergency C-section at St. Joseph Medical Center, she and her husband decided that since she was already in surgery, she might as well get the tubal. No dice; neither St. Joseph nor Mercy will perform that procedure, which violates Catholic moral teaching against sterilization.

Dr. Endrika Hinton, a gynecologist and reproductive endocrinologist at Greater Baltimore Medical Center and Johns Hopkins Hospital, says she spends a lot of time convincing patients not to have tubals. “It’s almost a rare surgical procedure for me right now,” she says. She points out that although it’s a laparoscopic procedure, it’s intense. Her patients take off four days from work and there’s no lifting or vigorous exercise for two weeks.

Instead, Hinton recommends an IUD for most of her patients. “With an IUD, you come into the office, I pop it in and you have five to 10 years of birth control.” In addition to providing long-term contraception, IUDs can provide some protection against uterine and ovarian cancers. And, depending on the IUD, “you can have magnificent periods,” says Hinton.

How do tubal ligations stack up when it comes to fail rate? “When I was doing my training in 1989, we were doing tubals left and right, but honestly, now there’s more failure from tubals than from the IUD,” says Hinton.

Hinton steers many of her patients “of a certain age” toward IUDs, which help with perimenopause. In fact, some women whose husbands got vasectomies find themselves back on birth control—the pill or IUD—in their 40s to regulate their periods. As Patty from Arcadia mentioned, it seemed only fair for her husband to get a vasectomy. But several years later, when she became “a woman of a certain age,” she started taking birth control pills to regulate her periods. “So maybe it was money ill spent,” she says of the vasectomy. “I suppose we’re double covered now.”

Just as humans have invented a bunch of ways to make a baby, there are a bunch of ways to not make a baby. I can’t remember who ended up with my dear, old Exersaucer, but I’d be willing to bet that wherever it is, someone in that house is reviewing the options.

December 2012

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