People can engage in sexual intercourse for three reasons: To reproduce, for fun or to fulfill a requirement of mutual relationship. Contraception gives couples the opportunity to freely determine the purpose of each sexual intercourse. In our country, 39% of couples use contraceptive methods for family planning. At least one-third of couples using any method of contraception use a method that requires the active participation of the man. Withdrawal, condom and vasectomy are the main methods. Studies in recent years try to add hormonal male contraception to these.
Withdrawal (Coitus interruptus):
“Withdrawal” is a method that has been practiced for centuries since it was discovered that pregnancy develops as a result of sperm being released into the vagina. 30% of couples in Turkey use this method. In rural Greece, it is seen that the Orthodox prefer the condom and the Muslims prefer the “withdrawal” method.
Couples using this method continue sexual intercourse until ejaculation occurs, just before ejaculation, the man withdraws his penis from the vagina. Ejaculation should occur completely outside the vagina and away from the external genitalia of the woman. This method is not recommended for men who cannot predict when ejaculation will occur and men who have sexual intercourse for the second time in a row.
4-18% failure rates in the first year of application are the most important disadvantage of this method. In addition, interrupting the sexual intercourse during the plateau phase may reduce the sexual satisfaction of the partners.
“Withdrawal” provides much better contraception than using no method at all. The most positive aspect of this method is that it can be applied by anyone, in any situation, all over the world, without any tools or investigations and without fear of complications.
It is a non-permanent, effective and reliable barrier contraceptive method that men can use. A condom is a sheath that is put on the erect penis before vaginal penetration during sexual intercourse. It prevents sperm from entering the vagina. It is cylindrical with one end open and the edge of the open end is thick to make it easy to use. At the closed end, there is usually a reservoir for the collection of semen. Some condoms are also coated with spermicide. Failure rate in one year of use is around 2 – 5%.
The history of wearing a sheath on the penis BC. It dates back to the 1350s. Since the 18th century, these sheaths made from animal intestines have been called “condoms”. Condoms started to be produced from synthetic materials after the second half of the 19th century. Today, they are produced from latex, polyurethane or processed collagen tissues. It is used more frequently in developed countries (mostly in Japan, England, USA and Scandinavian countries) and in people with higher education levels. In our country, only 5% of couples prefer condom as a contraceptive. Sexually transmitted diseases and AIDS have increased the use of condoms.
The condom should be removed before the penis becomes flaccid. The condom should be discarded after one use, and it should be checked for the last time before throwing away. Condoms that are more than 5 years old from the date of manufacture should not be used. Those who are allergic to latex and spermicide should stay away from these types of condoms.
The positive aspects of this method are that it is cheap and easy to find, does not require examination and prescription, and also protects against sexually transmitted diseases. The most important negativities are the need for a new condom in every sexual intercourse, interrupting the sexual intercourse and sometimes causing problems if it is destroyed after use.
Vasectomy (Voluntary sterilization):
Vasectomy is the most effective, reliable and permanent method of contraception, which is becoming increasingly common in men all over the world. While approximately 8 million men in China and 500 thousand men annually in the USA, vasectomy is performed, this number is quite low in our country. However, the number of vasectomies worldwide is considerably less than tubal ligation in women. Although vasectomy is a cheaper, easier and less complicated method than tubal ligation, the most important reason why men prefer voluntary surgical sterilization less than women is their false belief that they will “lose their masculinity” with this procedure. Therefore, all sexually active adult men should have detailed knowledge of the main contraceptive methods.
According to the law numbered 2827, which was adopted in 1983 in our country, sterilization can be done with the consent of anyone who has completed the age of 18, and with the consent of their spouse if they are married. Clinics or individual health professionals to impose restrictions according to their own value judgments are both illegal and injure the right of individuals to choose. A detailed discussion about vasectomy should be made with the individual or couple before consent can be obtained. It should be learned whether the person has knowledge about other contraceptive methods, and it should be emphasized that vasectomy should be considered as a permanent sterilization method. The features of the procedure, where it will be performed, how the person may feel during the procedure, possible complications and the cost of the procedure should be explained in detail. After making sure that the person has made his choice voluntarily, the transaction can be carried out after the approval forms (Annex 1 and Annex 2) are filled and signed.
Vasectomy is a relatively simple procedure that can be performed safely with local anesthesia in “outpatient” conditions. After the surgical preparation is done, the person is placed on the table in the supine position and the penis is gently fixed to the anterior abdominal wall with a hypoallergic patch following proper genital area cleaning. The surgeon is located on the right side of the patient. The right vas deferens in the patient’s scrotum is detected between the left hand index, middle and thumb of the surgeon, and lidocaine is injected into an area of approximately 1 cm in the superficial skin layer with a needle. After the needle is advanced towards the external inguinal ring through the perivasal sheath without leaving the same injection site, 2-5 ml of lidocaine is injected around the vas without moving the needle. With this procedure, vasal nerve block is performed and edema at the actual vasectomy site is also reduced. The left vas deferens is also fixed and anesthetized with the same three-finger technique. Anesthesia and block operation can also be performed with a single needle insertion over the median raphe. In the conventional vasectomy technique, the vas deferens is exposed by entering the scrotal skin with an incision of approximately 1 cm from the anesthesia sites. After it is freed from the surrounding differential artery, vein and nerve, the vas is cut and a small segment is excised. After the proximal and distal ends of the vas deferens are cauterized and ligated, bleeding is controlled. The incision or incisions can be closed by suturing.
Vasectomy can be performed without using a scrotal incision (no-scalpel) following a similar anesthesia technique (Li, 1976). If the knifeless technique is to be applied, the temperature of the room and the liquids used for cleaning the scrotum should be warm. After the vas is taken between the three fingers of the left hand over the skin of the scrotum, it is fixed with a ring-tipped fixation clamp on the right hand. After the clamp is partially opened and the scrotal skin over the vas is slid out of the clamp, the clamp is locked again and the scrotal layer over the vas is made taut and as thin as possible. After the skin is passed with one of the open mouths of the sharp-tipped mosquito clamp, the entrance area on the skin is widened with the same mosquito clamp, making it visible. After the right end of the Mosquito clamp is inserted from the vas wall towards the lumen at an angle of 45 degrees, the clamp is rotated 180 degrees laterally, the vas is taken out and fixed with the fixation clamp. After cleaning around the vas, a 1 cm segment is excised. After cauterizing the proximal and distal vas lumens, both ends are clamped or sutured with a medium hemoclip. After both ends of the vas are pushed into the scrotum, the entrance holes close spontaneously and contractually without the need for suturing. After the procedure, it is recommended that the person rest for 2-3 days and come for the control a week later. Antibiotics are not recommended. It is recommended to be protected by another method for about three months during sexual intercourse. If no sperm is detected in the control spermiogram after three months or at least 20 ejaculations, the procedure is considered successful. If sperm is seen in the control spermiogram, the procedure should be repeated. The failure rate is less than 1/1000 in vasectomies in which a short segment is removed and the lumens are cauterized and clipped.
Significant side effects are seen in 2% of the cases in conventional vasectomy. This rate is much less in bladeless vasectomy. Mortality has been reported as 1/300,000 in the literature. The most common complications after vasectomy are hematoma, infection and sperm granuloma. The incidence of complications such as hematoma and infection is inversely proportional to the experience of the surgeon. For experienced surgeons (performing more than 50 vasectomies per year), this ratio is 1.6%. If sperm leak from the testicular end of the vas deferens, sperm granuloma occurs. Since the sperm is highly antigenic, it causes an intense inflammatory reaction. Sperm granulomas are rarely symptomatic.
As the long-term effects of vasectomy in humans; vasitis nodosa, chronic testicular and/or epididymal pain, testicular dysfunctions, epididymal obstruction and increased incidence of prostate cancer.
Although vasitis nodosa can be seen in 66% of cases, it has no clinical significance. Chronic testicular or epididymal pain occurs in 1 in 1000 cases. This pain is caused by increased pressure. In very severe cases, vasectomy reversal or total epididymovasectomy may be recommended. Vasectomy causes elevation of antispern antibodies in 60-80% of cases due to disruption of the blood-testis barrier. However, no immune complex or storage disease was found. Several studies have found a higher incidence of prostate cancer in men who had a vasectomy 20 years ago. Although there are conflicting publications on this subject, it is suggested that the reason for this increased incidence is a population that strictly adheres to health checks of those who underwent vasectomy, and that the incidence is high due to more frequent controls.
As a result of efforts to increase the role of men in contraception and to develop a reversible method of contraception, hormonal male contraceptives have also begun to emerge. Spermatogenesis depends on normal secretion of pituitary gonadotropins (FSH, LH). Exogenous gonadotropin-releasing hormone (GnRH) analogues, sex steroids such as testosterone, and progestins suppress gonadotropins and spermatogenesis.
Large multicentric studies have shown that weekly high-dose testosterone administration is highly effective in suppressing gonadotropins and spermatogenesis, and its contraceptive efficacy is comparable to female oral contraceptives. Results in studies with regimens that combined low testosterone with a progestin or a GnRH analogue were more successful. In most of these studies with male hormonal contraceptives, weight gain and suppression of serum HDL cholesterol were shown as the most important side effects. There is no hormonal contraceptive approved and marketed for men yet. However, it appears to be the first hormonal male contraceptive on the market to be a long-acting (injection or implant) androgen-progestin combination.
In male contraceptive development research, agents that can act on the post-testicular and epididymal regions are also being studied.
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