Many men choose vasectomy, Vasectomy demographics and postvasectomy desire for future children: results from a contemporary national survey

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1 Vasectomy demographics and postvasectomy desire for future children: results from a contemporary national survey Vidit Sharma, B.A., Brian V. Le, M.D., Kunj R. Sheth, M.D., Sherwin Zargaroff, M.D., James M. Dupree, M.D., John Cashy, Ph.D., and Robert E. Brannigan, M.D. Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois Objective: To describe the longitudinal demographics and family planning attitudes of vasectomized men with the use of the National Survey for Family Growth (NSFG). Design: Retrospective cohort analysis of the NSFG with the use of national projections and multivariable regressions. Setting: In-home survey. Patient(s): The NSFG sampled 10,403 men aged years from 2006 to 2010 regarding family planning attitudes. Intervention(s): None. Main Outcome Measure(s): Vasectomy and desire for children. Result(s): There were 3,646,339 (6.6%) vasectomized men aged years in the U.S. On multivariable regression the following factors increased the odds of having a vasectomy: currently married (odds ratio [OR] 7.814), previously married (OR 5.865), and increased age (OR 1.122) and income (OR 1.003). The odds of having a vasectomy increased with number of children. The following factors decreased the odds of having a vasectomy: immigrant status (OR 0.186), African American (OR 0.226), Hispanic (OR 0.543), Catholic (OR 0.549), and other non-protestant religion (OR 0.109). Surprisingly, an estimated 714,682 (19.6%) vasectomized men in the U.S. desire future children. Men practicing a religion (OR ) were more likely than atheists to desire children after vasectomy. 71,886 (2.0%) vasectomized men reported having a vasectomy reversal. Conclusion(s): This study highlights the importance of preoperative counseling for permanency of vasectomy and reveals an opportunity to counsel couples about vasectomy versus tubal ligation. (Fertil Steril Ò 2013;99: Ó2013 by American Society for Reproductive Medicine.) Key Words: Vasectomy, epidemiology, family planning, sterilization, vasectomy reversal Discuss: You can discuss this article with its authors and with other ASRM members at fertstertforum.com/sharmav-vasectomy-epidemiology-family-planning/ Use your smartphone to scan this QR code and connect to the discussion forum for this article now.* * Download a free QR code scanner by searching for QR scanner in your smartphone s app store or app marketplace. Many men choose vasectomy, with nearly a half-million American men undergoing vasectomy each year (1). The choice to undergo elective surgical sterilization through vasectomy is a personal one, but patterns of use can emerge from studying the population as a whole. Men with various socioeconomic and personal backgrounds make an active decision to pursue contraceptive sterilization for their family planning needs. Seeking to better characterize who chooses vasectomy and what their family planning attitudes are afterward, we conducted a contemporary and comprehensive risk factor analysis on vasectomy patients identified from Received July 27, 2012; revised February 14, 2013; accepted February 15, 2013; published online March 29, V.S. has nothing to disclose. B.V.L. has nothing to disclose. K.R.S. has nothing to disclose. S.Z. has nothing to disclose. J.M.D. owns stock in Procter & Gamble and Kraft. J.C. has nothing to disclose. R.E.B. has nothing to disclose. Reprint requests: Robert E. Brannigan, M.D., Galter Suite , 675 N. St. Clair Street, Chicago, Illinois ( r-brannigan@northwestern.edu). Fertility and Sterility Vol. 99, No. 7, June /$36.00 Copyright 2013 American Society for Reproductive Medicine, Published by Elsevier Inc. the National Survey of Family Growth (NSFG). By analyzing this detailed questionnaire about family planning from a nationally representative and stratified group of American men, our study aimed to gain better insights into the role of vasectomy in the family planning choices and attitudes of American men who have undergone the procedure. The decision to undergo vasectomy is made in the context of alternatives such as oral contraception for females, condom use, tubal ligation, intrauterine devices, and others for family planning needs. Thus, utilization of vasectomy may be affected by the perceived 1880 VOL. 99 NO. 7 / JUNE 2013

2 Fertility and Sterility risk-benefit ratio of alternatives and cultural, religious, or socioeconomic factors (2). Additional factors that may contribute to this choice may include marital status, number of children, health insurance type, race/ethnicity, and the estimated cost of raising a child from an unplanned pregnancy, among others. Several earlier studies have looked at the demographics of vasectomy from large national cohorts and have found a prevalence of 6% 8% in the United States (3 5). We hoped to build on those studies with the most up-to-date results of the NSFG and to validate some of their findings. Earlier studies have also looked at racial differences in vasectomy and focused on utilization by married men (6). We took a different approach in the present study, looking systematically at a wide range of factors, including race/ethnicity, but also looking at number of children, educational status, immigrant status, history of adopting a child, and others, that may influence why men choose vasectomy as part of their family planning needs. We also reported the prevalence of tubal ligation and compare it with the estimated prevalence of vasectomy. Additionally, when men choose to undergo vasectomy, they are counseled on the risks and benefits of the procedure and its role as a permanent surgical sterilization. It is generally assumed that men who choose permanent surgical sterilization have no desire for future children. To look into this we explored the survey's section on family planning attitudes, including the desire for future children among this cohort of men who had undergone vasectomy. Most earlier studies looking at postvasectomy regret or desire for future children come from vasectomy-reversal cohorts as patients present to their physician (3). Not being taken from a vasectomy-reversal cohort, the present analysis would provide a more accurate numerator and denominator of postvasectomy men with desire for future fertility. To our knowledge, this is the only study looking at postvasectomy desire for future fertility in a contemporary cohort of men not derived from a vasectomy-reversal population. METHODS In this study, we analyzed data from the NSFG administered from June 2006 to June 2010 by the National Center for Health Statistics. The survey was approved by the University of Michigan Institutional Review Board (7), and our institution does not require Institutional Review Board approval for analysis of a dataset that is publicly available and deidentified. The NSFG sampled 10,403 men and 12,279 women aged years to obtain nationally representative data on topics such as birth and pregnancy rates, sexual activity, sterilization, and family planning attitudes. The interviews were conducted across the United States in the homes of participants by trained female interviewers. The participants were given $40 as compensation, and the overall completion rate of the survey was 77%. It is important to note that the raw data is transformed into national estimates with the use of established and validated methodology set forward by the CDC. Surveys were conducted in 110 diverse primary sampling units, consisting of metropolitan areas or groups of counties, to allow survey data to be extrapolated nationally for all men and women in this age group. Sampling weights were assigned by obtaining census data on the total number of men included in a given demographic category, such as age and race/ethnicity, and dividing that total by the number of men in the survey meeting that demographic. In this process, blacks, Hispanics, and teens were oversampled and had a lower corresponding sampling weight to ensure survey accuracy. Confidence intervals for estimates were then obtained using the Proc Survey functions in SAS 9.2 software. Further information regarding the NSFG can be found in Groves et al. (7) and on the NSFG web page (8). Men R18 years old with a history of vasectomy at the time of interview were identified as those who had both a history of vasectomy and a sterilizing operation specifically. Demographic descriptors were analyzed for vasectomized and nonvasectomized men, and demographic parameters were grouped where appropriate to obtain prevalence estimates for a more epidemiologically relevant category of men. Furthermore, questions regarding the health care status of the respondent, respondent desire for future paternity, and whether the respondent has adopted children were also considered in our analysis. Our study used SAS 9.2 and SPSS Statistics 20 software to provide descriptive statistics and construct multivariable logistical regression models to infer trends in vasectomy among men R18 years old at the time of interview with a statistically significant P value set at <.05. Two multivariable regression models were constructed: the first to predict vasectomy status, and the second to predict desire for future children among vasectomized men. Potential predictors were selected by reviewing demographic and socioeconomic factors shown in earlier studies to affect the vasectomy prevalence (6, 9). Additionally, we included novel factors not previously studied, including immigrant status, presence of a health care home, and being an adoptive parent. In the latter regression on the desire for future children, age at vasectomy was an additional variable included. Variables were initially selected by performing a multivariable logistic regression with forward selection using the function Proc Logistic, with a significance level for entry of.05. In the regression for vasectomy status, education was the only variable excluded, and ultimately age, race/ethnicity, immigrant status, income, marital status, paternity status, presence of a health care home, and religion were retained in the model. Income data were collected as a percentage of the federal poverty line. In the regression on desire for future children, the only variables retained after the forward selection process were age at interview and religion. In both regression models, the same variables retained using the Proc Logistic forward selection procedure were then used with Proc Surveylogistic function to account for the complex survey design of the NSFG. RESULTS There were 368 out of 8,992 men R18 years old with a vasectomy in the NSFG. Using the NSFG's VOL. 99 NO. 7 / JUNE

3 ORIGINAL ARTICLE: ANDROLOGY established methodology, this translates to a vasectomy prevalence of 6.57% (95% confidence interval [CI] 5.56% 7.58%) or 3,646,339 (95% CI 3,048,768 4,243,910) men aged years in the United States. Likewise, among women aged years surveyed in the NSFG, 1,645/10,975 women had a tubal ligation, translating to a national prevalence of 16.35% (95% CI 14.73% 17.98%). An analysis of all men aged years was conducted to identify variations in vasectomy prevalence by demographic factors. Table 1 depicts the national prevalence of vasectomy across various demographics. As expected, the prevalence of vasectomy rose with age to reach 15.85% in the year age group. The prevalence was highest among whites (9.1%) compared with blacks (2.4%), Hispanics (2.1%), and men reporting themselves as belonging to another race/ethnicity (3.1%). Similarly, immigrants had a lower frequency of vasectomy than U.S.-born respondents (0.95% vs. 7. 8%; P<.001). The prevalence of vasectomy also increased with income, education level, and regular access to health care. Although a small proportion of men had a vasectomy while having one or no biologic children, TABLE 1 Demographics of patients undergoing vasectomy in the United States. Vasectomized men, n Unvasectomized men, n Estimated national vasectomy prevalence, % 95% CI Race White 292 4, Black 27 1, Hispanic 40 2, Other Born outside U.S. Yes 18 1, No 350 6, Age, y , , , Income as a % of FPL % , , , > , Highest education %12th grade 123 3, %4 y college 167 3, >4 y college Marital status Married 283 2, Separated Never married 13 5, No. of children , , , R Want future children Yes 72 6, No 293 2, Don't know Health care from usual place? Yes 314 5, No 54 2, Current religion None 87 2, Catholic 76 2, Protestant 192 3, Other Adopted children Yes No 354 8, Note: CI ¼ confidence interval VOL. 99 NO. 7 / JUNE 2013

4 Fertility and Sterility TABLE 2 Multivariate analysis of risk factors for undergoing vasectomy. Multivariate OR 95% CI P value Race White Ref. Ref. Black <.001 Hispanic Other Born outside U.S. No Ref. Ref. Yes <.001 Age, unit increase <.001 from 18 to 45 y Income, continuous <.001 as % of FPL Marital status Never married Ref. Ref. Married <.001 Separated <.001 No. of biologic children 0 Ref. Ref < < < < <.001 R <.001 Ever adopted children No Ref. Ref. Yes Health care from usual place? No Ref. Ref. Yes Current religion None Ref. Ref. Catholic Protestant Other <.001 Note: CI ¼ confidence interval; FPL ¼ federal poverty line; OR ¼ odds ratio. the majority (84%) of the vasectomized men had at least two biologic children. Interestingly, an estimated 21.1% of all men in the U.S. who are adoptive fathers reported having had a vasectomy. A multivariable regression analysis was conducted to determine significant predictors of having a vasectomy (Table 2). On multivariable regression, the following factors were found to significantly (P<.05) increase the odds of having a vasectomy: currently married (odds ratio [OR] 7.814) or separated (OR 5.865) increased age (OR 1.122), and higher income (OR 1.003). The strongest predictor of being vasectomized was the number of biologic children, with ORs ranging from to for those men having one to six or more children. The following factors decreased the odds of having a vasectomy: black (OR 0.226), Hispanic (OR 0.543), foreign-born (OR 0.186), and Catholic (OR 0.549) or other (OR 0.109) religion. Table 3 analyzes the location in which the vasectomy was performed. Although the majority of men had vasectomies in either a private physician's office (59.2%) or a hospital outpatient clinic (27.1%), an estimated 13.7% of vasectomies may be performed in nonconventional settings. Surprisingly, 72 of the 368 vasectomized men desired future children. Nationally, this translates to 19.6% (95% CI 13.25% 25.99%) of vasectomized men aged years having the desire for future children. A multivariable regression analysis was conducted among vasectomized men to identify predictive factors of men who report the desire for future children (Table 4). Vasectomized men who identified themselves as belonging to a religion were more likely to desire future children. Race/ethnicity, education level, age at vasectomy, marital status, and income were not significant predictors of desire for future children and they were not retained in the regression models. In the surveyed population, 5 of 368 vasectomized men reported having a vasectomy reversal, corresponding to a reversal rate of 1.97% (95% CI 0.0% 4.13%) nationally. DISCUSSION Using the NSFG, this analysis addressed the patterns of vasectomy utilization and postvasectomy desire for future children. Several interesting findings have come from this analysis, including new insight into utilization of vasectomy versus tubal ligation. As seen with earlier NSFG datasets, the current study shows that vasectomy continues to be a popular choice for permanent surgical sterilization among men, with a relatively steady degree of utilization of 6%. The majority of procedures were performed in private physician's offices as opposed to the operating room. Although many methods of permanent contraception are available to a couple, vasectomy is considered to be more cost-effective, less risky, and better tolerated than tubal ligation. It is highly effective in preventing pregnancies, with only 0.01% of women experiencing unintended pregnancies 5 years after sterilization, compared with 0.13% for tubal ligation, 0.1% for copper intrauterine device, and 8% with oral contraceptives with typical use (10). In light of this, we were surprised to find the prevalence of tubal ligation to be 16.4%, almost 3-fold higher than the vasectomy rate. This discrepancy between vasectomy and tubal ligation rates has been specifically assessed by Anderson et al. (9). Those authors studied married individuals from the NSFG dataset, and they attributed the differences in utilization to a number of factors, including access to contraceptive services and payment sources. The authors found that the prevalence of vasectomy was highest among men with private insurance, although tubal ligation use was more prevalent among women with no insurance or Medicaid, even though vasectomy is covered by Medicaid in most states (9). Additionally, there may be a component of cultural gender roles where masculinity is associated with virility, or the view that child-bearing is a female issue (11). Accordingly, some men prefer to preserve their potential for fatherhood for symbolic reasons and others may overlook the issue altogether under the belief that contraception is not their gender's responsibility. The findings from this survey highlight the fact that vasectomy is not equally adopted among all groups. When examining our risk factor analysis, men who previously fathered multiple children were most likely to have undergone VOL. 99 NO. 7 / JUNE

5 ORIGINAL ARTICLE: ANDROLOGY TABLE 3 Location of vasectomy operation and vasectomy reversals. Raw NSFG data, n (%) Weighted data, n (%) Average age at vasectomy, y 32.4 Vasectomy location Private doctor's office 123 (61.8) 1,103,439 (59.2) Hospital outpatient clinic 48 (24.1) 504,078 (27.1) Hospital regular room 10 (5.0) 118,280 (6.3) HMO facility 9 (4.5) 65,595 (3.5) Community health clinic 7 (3.5) 42,556 (2.3) Family planning clinic 1 (0.5) 27,185 (1.5) Other 1 (0.5) 2,300 (0.1) Had vasectomy reversed? Yes 5 71,886 (1.97%) (95% CI 0.0% 4.13%) No 363 3,574,453 (98.02%) (95% CI 95.87% 100%) Note: HMO ¼ Healthcare Maintenance Organization; NSFG ¼ National Survey of Family Growth. a vasectomy, with increasing number of children correlating highly with likelihood to pursue vasectomy. In other words, with each extra child that a man has, the higher are his odds of having had a vasectomy. Men describing themselves as currently married was the second strongest factor associated with vasectomy utilization, after number of children. The stability of a marriage removes the uncertainty of sexual partners and the uncertainty of a potential future partner's desire for more children. Another powerful predictor for vasectomy utilization was place of birth, such that only 0.95% of immigrants had a vasectomy compared with 7.8% of U.S.-born respondents. National census data suggests that immigrants tend to have larger families, be of lower socioeconomic status, have fewer assets and may thus be less savvy about utilization of health care resources for family planning purposes. Finally, religious affiliation was found to be independently predictive of vasectomy prevalence, such that Catholics and other religions were significantly less likely to report a history of vasectomy. Approximately 9.8% of Protestants had a vasectomy compared with 4.5% of Catholics and 1% of other religions. The lower percentage of Catholics reporting a history of vasectomy might reflect objection to vasectomy on religious grounds. Additionally, it is conceivable that certain men might have undergone the procedure but were uncomfortable in reporting this history TABLE 4 Predictive factors of men who retain the desire for future children. Multivariate OR 95% CI P value Age at interview, unit increase Current religion None Ref. Ref. Catholic <.001 Protestant <.001 Other Note: Abbreviations as in Table 2. at the time of the survey for religious reasons. There may be many reasons for the low vasectomy prevalence in other religions, because this is likely a heterogeneous group of individuals. A final interesting aspect of the analysis involves attitudes for future children. Surprisingly, almost 20% of men who had chosen to undergo vasectomy at the time of the survey listed a desire to have future children. This is juxtaposed with our finding that 1.9% of vasectomized men undergo a reversal. This finding suggests a potential lack of understanding of the permanency of vasectomy or a situation of regret. This desire for future children started as early as within a year of some vasectomies and the prevalence of the desire for future children seems to increase with time from the procedure. We view this discrepancy as an opportunity for better counseling. If patients were better counseled about the permanent nature of the procedure, perhaps fewer patients with a desire for future fertility would undergo a vasectomy. Miller et al. (12) looked at the Kaiser Permanente database to analyze situations of poststerilization regret among couples and found that 10% of couples experience regret. Predictors of regret included respondent motivation for additional children and against sterilization, poor husband-wife communication, conflict during decision-making, and dominance of the decision making by one spouse (12). Potts et al. (3) described in their study of vasectomy reversals that having a vasectomy performed at age <30 years was a significant risk factor for future reversal, and they also advocated better counseling. This was corroborated in an Australian manuscript looking at claims data (13). Our study did not find such a relationship between age of vasectomy and desire for future children, although that may not translate directly into vasectomy reversal. The main risk factor associated with desire for future children was the male self-identifying as being within a religious group. The reason for this is not readily apparent, but one explanation could be that increasing adoption of religion over time or life events could create a desire to expand the family. There are several study limitations worth mentioning. These studies are patient-provided responses from 1884 VOL. 99 NO. 7 / JUNE 2013

6 Fertility and Sterility a face-to-face interview and as such are subject to recall bias. However, we think that men typically have good recall of whether they underwent a vasectomy or not. Additionally, the NSFG surveys only men and women from age 15 to 45; there are a substantial number of men above 45 years of age who continue to use family planning services and vasectomy. Therefore, the present study may underestimate the actual utilization rate of vasectomy among all men >18 years of age because some men obtain a vasectomy after the age of 45, adding to the true vasectomy prevalence. Inherent in any discussion of race/ethnicity comes the inaccuracy of self-classification, though this study and others have consistently reported increased utilization of vasectomy by white men. Further factors, such as loss of children, multiple marriages, and length of a partnership, were not explicitly analyzed in this study. Additionally, the interview was not optimized to look at vasectomy, and therefore our conclusions are limited by the wording of the questions. For example, parameters that we may have wanted to look at on a continuum were sometimes worded for discrete yes or no responsse. Despite these limitations, this secondary analysis of the NSFG data set provides novel and informative insight into the patterns of vasectomy utilization. CONCLUSIONS We report a vasectomy prevalence of 6.6%, which was dramatically less than the tubal ligation prevalence of 16.4%. The frequency of vasectomy depended on multiple demographic factors, including but not limited to number of children, marital status, race-ethnicity, immigrant status, and religion. Additionally, we found a surprisingly high number of vasectomized men (19.6%) express the desire to have future children. This study reveals an opportunity to highlight the importance of preoperative counseling regarding the permanency of vasectomy and to counsel couples about the option of vasectomy vs. tubal ligation. REFERENCES 1. Sandlow JI, Westefeld JS, Maples MR, Scheel KR. Psychological correlates of vasectomy. Fertil Steril 2001;75: Pile JM, Barone MA. Demographics of vasectomy USA and international. Urol Clin North Am 2009;36: Potts JM, Pasqualotto FF, Nelson D, Thomas AJ Jr, Agarwal A. Patient characteristics associated with vasectomy reversal. J Urol 1999;161: Eisenberg ML, Lipshultz LI. Estimating the number of vasectomies performed annually in the United States: data from the National Survey of Family Growth. J Urol 2010;184: Barone MA, Johnson CH, Luick MA, Teutonico DL, Magnani RJ. Characteristics of men receiving vasectomies in the United States, Perspect Sex Reprod Health 2004;36: Eisenberg ML, Henderson JT, Amory JK, Smith JF, Walsh TJ. Racial differences in vasectomy utilization in the United States: data from the national survey of family growth. Urology 2009;74: Groves RM, Mosher WD, Lepkowski JM, Kirgis NG. Planning and development of the continuous National Survey of Family Growth. Vital Health Stat ;48: Centers for Disease Control and Prevention. National Survey of Family Growth. Available at: Accessed October 29, Anderson JE, Jamieson DJ, Warner L, Kissin DM, Nangia AK, Macaluso M. Contraceptive sterilization among married adults: national data on who chooses vasectomy and tubal sterilization. Contraception 2012;85: Trussell J, Lalla AM, Doan QV, Reyes E, Pinto L, Gricar J. Cost effectiveness of contraceptives in the United States. Contraception 2009;79: Ferber AS, Tietze C, Lewit S. Men with vasectomies: a study of medical, sexual, and psychosocial changes. Psychosom Med 1967;29: Miller WB, Shain RN, Pasta DJ. The pre- and poststerilization predictors of poststerilization regret in husbands and wives. J Nerv Ment Dis 1991;179: Holman CD, Wisniewski ZS, Semmens JB, Rouse IL, Bass AJ. Populationbased outcomes after 28,246 in-hospital vasectomies and 1,902 vasovasostomies in Western Australia. BJU Int 2000;86: VOL. 99 NO. 7 / JUNE