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Arizona State Urology, P.C.
Vasectomy Packet

Welcome and thank your for choosing Arizona State Urology, P.C.
Please read the information carefully before your vasectomy appointment.
A consent form is in your packet but do not sign it until you are in our office for
your vasectomy appointment.
To avoid any delay in your procedure and/or discharge teaching, it is
recommended that you do not bring any young children or infant to your
vasectomy appointment.
Make sure you have a driver and a car available. You may be sent to a
pharmacy for medications.
Make sure your packet contains the following items:
 History & Physical and Procedure form  Financial policy  Facts about vasectomy If you have any further questions after reading our vasectomy packet, please call us at 602-357-2400 during routine business hours. The physician will meet with you and your significant other prior to your vasectomy to review the information in this packet and answer any further questions you may have. Thank you. Arizona State Urology, P.C.
How to Get Ready For Your Vasectomy
 Our customary charge for a vasectomy is $800.00. (Laboratory services (semen analysis), pathology charges, post-vasectomy medical supplies (jock strap) and medications (pain medication, anxiolytics and antibiotics) are not included in this charge).  If you plan to pay for your vasectomy using your health insurance, you may be responsible for a co-payment. Make sure you bring your insurance card and any referral paperwork for your visit. (Prior authorization may not guarantee that your insurer will pay for your vasectomy. It is your responsibility to check with your insurance provider regarding coverage for your vasectomy)  Arrange to have someone accompany stay with you at your appointment. You may need a ride to pick up medication and you can’t drive after the procedure. If you take pain medication or sedatives prior to your appointment you should have someone drive you to the office.
Medications with anti-coagulation (blood thinning) effects such as aspirin, garlic
(ajo), ginko, ginseng, Advil, ibuprofen, Excedrin, Indocin, naprosyn, or any other
nonsteroidal ant-inflammatory medication (NSAID’s), Coumadin/warfarin, ticlid, plavix,
heparin, persantine or lovenox must be discontinued at least ten (10) days before
your vasectomy
. If you are on these medications due to a serious medical condition
such as an artificial heart valve, cardiac arrhythmia, or hypercoagulable state, please
inform our staff before scheduling your vasectomy. If these medicines are not
discontinued, your vasectomy will be cancelled.

 Please inform our staff if you have a medical condition such as a heart murmur, artificial heart valve and other internal prosthetic devices, which may the need for prophylactic antibiotic before scheduling your vasectomy.  Shave your scrotum. Concentrate on shaving the front and sides of your scrotum from the level of the penis down before your appointment. Use a razor and do not use any chemical hair remover such as Nair.  Bring a scrotal supporter (jock strap) to your procedure. Tight underwear is not acceptable. Loose pants (sweat pants) or shorts maybe worn to your appointment. Scrotal supporters are available at the office for $15.00.  Plan to rest and “take it easy” for at least two days after your vasectomy. Avoid any heavy lifting or strenuous activity (such as climbing ladders) for at least one week. Have ice packs ready at home (frozen corn or frozen peas).  Complete the history portion of the History & Physical and Procedure form before your  Review and sign the financial policy form.  Read the handouts titled Facts about Vasectomy and Vasectomy Aftercare Instruction.  BRING YOUR VASECTOMY PACKET TO YOUR APPOINTMENT! Arizona State Urology, P.C.
History & Physical and Procedure Form
Name: _____________________________ Referred by: _________________ Age: Patient ______Date of Birth: _____/_____/_____ Date: ____/____/____ Number of children and their ages: __________________________________ Reason for Vasectomy: ___________________________________________ Allergy (Include medication & iodine): ________________________________ Medical Illness:
Social History: Tob: Y or N Alcohol: Y or N Occupation: __________________
_______________________________
Patient Signature
Do not write below this line


Risks benefits and alternatives to vasectomy discussed with patient _________
Staff Initial
Anesthesia: Local using 1% plain lidocaine and/or 2% lidocaine – no needle
Technique: Ligation:
non-absorbable suture absorbable suture clips Vas segments sent to pathology: Left Right Both None Complication: No Yes,_______________________________________ Physician Signature
Arizona State Urology, P.C.

Operation or Procedure
I, _____________________________ (patient or guardian), authorize Dr. __________________
to perform the procedure known as a vasectomy.
I understand the reason for the operation/procedure is to make me sterile.
Risks and Possible Complications

This authorization is given with the understanding that any operation/procedures involves some
risks and possible complications. These risks include but are not limited to: Bleeding, infection,
hematoma and/or abscess formation, chronic pain, scar tissue formation, and future pregnancies.
Alternatives

The following methods of contraception are known alternatives to a vasectomy: use of a condom,
birth control pills/patch, tubal ligation, intrauterine device, and abstinence.
Perfect Results Are Not Guaranteed

I understand that no guarantees have been made as to the results of this operation/procedure,
and that it may not completely treat the condition for which it has been recommended.
Patient’s Acknowledgment of Informed Consent for Vasectomy

I have read and fully understand this consent form. I understand that I should not sign below
unless all of my questions and concerns have been explained or answered to my complete
satisfaction. Given the intent of this procedure, it is strongly recommended that you have
discussed your decision to undergo a vasectomy with your spouse or significant other in advance.
________________________________
Patient/Responsible
Signature
Signature

____/____/____ ____/____/____
Date

Provider Confirmation

I have explained the purpose of this procedure to this patient and have addressed all of his
questions and concerns. Risks benefits and alternatives were discussed and the patient have
given me consent to proceed with a vasectomy.
_______________________________
Physician
Signature
Arizona State Urology, P.C.
 Plan on minimal activity for forty-eight (48) hours.  Avoid any strenuous activity (lifting more than 10 lbs) for 1 week.  Apply an ice pack to the scrotum at thirty-minute intervals for twenty-four (24) to forty-eight (48) hours. Expect to see some swelling and bruising over the scrotum.  Keep the incision dry by covering it with a piece of gauze or band-aid. Change the dressing a minimum of twice a day.  Do not apply any ointment or cream to the wound unless otherwise  You may shower after twenty-four (24) hours. No bathing or swimming  Avoid sexual activity for at least two weeks.  Post-vasectomy semen analysis procedure o Perform your post-vasectomy semen analysis after 3 months and at least twenty (20) ejaculations. If there are still sperm present you will be asked to leave another specimen after 10 more ejaculations. o You may leave the specimen cups at the lab during routine business hours. Make sure the lab is authorized by your insurance plan. o Semen may be obtained by masturbation or coitus interruptus. Do no use any spermacide cream during this process. o It usually takes about two weeks before we receive the results and o PROTECTIVE INTERCOURSE IS MANDATORY UNTIL YOUR POST-VASECTOMY SEMEN ANALYSES SHOWS NO SPERM.  Call our office (602) 357-2400 if you should have any additional Arizona State Urology, P.C.
Vasectomy Fact Sheet

What is a vasectomy?
A vasectomy is surgical procedure designed to permanently disrupt the flow
of sperm from the testicles to the prostate gland during ejaculation. After a
vasectomy, a patient will still produce semen during ejaculation but it will
contain no sperm.
How soon will I be sterile after a vasectomy?
The time it takes for someone to become sterile after a vasectomy varies from
one individual to another. Protective intercourse is mandatory until your post-
vasectomy semen analyses show no sperm.
Are the effects of a vasectomy permanent?
For all intensive purposes, a vasectomy should be considered permanent.
There is a potential 0.1% (1 in 1000) chance that the vas deferens tube may
“grow back together.”
Is this operation reversible?
Your urologist can reverse a vasectomy in most cases but it is very
expensive. Most insurance plans will not cover the cost of a vasectomy
reversal. Although the success rate for a vasectomy reversal is relatively
high, the chance of an actual full-term pregnancy is less than fifty (50)
percent.
Will a vasectomy affect my sex life?
A vasectomy should not affect your sex life unless you are undergoing this
procedure with significant reservation.
Will my ejaculate be normal after a vasectomy?
Yes, although the seminal fluid will eventually contain no sperm, the actual
volume of the ejaculate may decrease only by a small amount.
Are there any long-term complications?
No long-term complication has ever been proven after a vasectomy. Previous
articles suggesting a potential higher risk of prostate cancer associated with
patients undergoing a vasectomy have been disproved by recent credible
studies. A slightly higher risk of coronary artery disease (CAD) has been
reported in laboratory animals have been described. However, no such link
could be identified in men.

Source: http://peedoc.com/wp-content/uploads/2012/08/Vas-packet-20122.pdf

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