Patient Registration and Consent Form

Please note that if you answered "Yes" to the above question, we strongly recommend you have someone drive you to and from your appointment. 

Please note that Medical Certificates will be emailed to you (usually within 2 hours) after your vasectomy

THE PROCEDURE

A vasectomy operation permanently stops the flow of sperm from the testicles to the outside, thus preventing a man from fathering children.

 

POTENTIAL COMPLICATIONS DURING AND AFTER YOUR PROCEDURE

 
All surgical procedures carry certain risks and have potential complications.  

During the procedure potential problems include:

1. Some men faint (about 1 in 100) when they receive the local anaesthetic needle. A period of brief unconsciousness usually resolves quite quickly. In most cases it is possible to complete the procedure when the patient regains consciousness. In rare cases it may not be possible to complete the procedure.

2. A small number of men (about 1 in 100) do not tolerate the tugging on the testicles that occurs during the procedure. Sometimes it is not possible to continue and it will be necessary to refer the patient for completion of the surgery under sedation or general anaesthetic
After the procedure most men will experience some bruising and mild pain and swelling in the days after the procedure. This will usually settle within 2 weeks.

Less common complications include:

1. Infection of the surgical wound, testicles, epididymis or urinary tract (Up to 1%): This may present as redness or discharge around the wound site, testicular pain and swelling, pain when urinating or fevers and feeling generally unwell. If this occurs you will require oral (tablet) antibiotics. More severe infections may require admission to hospital and intravenous antibiotics. 

 
2. Bleeding within the scrotum (Up to 1%) can occur during or after vasectomy. If this occurs within the scrotum, drainage of a scrotal hematoma (blood clot) in a hospital operating room could be necessary. Smaller haematomas do not require surgical drainage, but tender swelling can last for 2 to 4 weeks. If the scrotal skin bleeds at the vasectomy access site, the scrotum can become discoloured (black and blue) for about a week; this is more common than swelling, but painless and usually does not require treatment.

3. Early Recanalisation / Failure of the procedure: There is a chance your vasectomy does not work and you continue to have sperm in your ejaculate. For this reason it is essential to have semen analysis 3 months after your vasectomy to confirm the procedure has worked. If there has been a failure you will need a repeat procedure.

4. Delayed re-canalisation (Late Failure): There is a remote chance the vas may rejoin spontaneously even after you have been sterile for some time. The chance of delayed recanalisation is between 1 in 2000 and 1 in 3000 men

5. A granuloma (Up to 25%) is a pea-sized (sometimes tender) lump on the vas tube at the vasectomy site and sometimes requires treatment. Most are painless and will disappear within 12 months. Periodic tenderness usually responds to an anti-inflammatory medication like ibuprofen.

6. Congestion: tender buildup of sperm and white blood cells upstream from or at the vasectomy site, can occur anytime after vasectomy, but usually goes away with use of an anti-inflammatory drug such as aspirin or ibuprofen. The incidence of congestion has been greatly reduced by using the open-ended technique.

7. Post Vasectomy Pain Syndrome (PVPS): is an important potential complication whereby your vasectomy may result in chronic/ persistent pain in the testicles/scrotum that last months or years. It is not possible to predict which patients may end up with PVPS. The probability of developing PVPS has been quoted being as high as 5% although the current percentage of men affected by this condition who have had a vasectomy with Vasectomy Australia is approximately 0.5% (1 per 200 men) . PVPS has a variety of causes including congestion, a neuroma, an entrapped nerve, chronic epididymitis, chronic inflammation, perineural fibrosis or damage to the spermatic cord structures. Sometimes a cause for a man’s PVPS cannot be found. Most men who develop PVPS will be able to be successfully treated with medications and other non-surgical methods and their pain will eventually go away. In less common cases patients with PVPS may require surgery such as neurolysis (cutting the nerves that supply the testicles), vasectomy reversal or other surgical procedures to attempt to relieve their symptoms. These are not always successful and men with PVPS may develop long term psychological distress or depression if their pain cannot be cured.

PATIENT CONSENT AND DECLARATION

 
I, {name}, confirm that I have been given the following information via a video presentation which I have watched OR an information sheet which I have read OR via a telephone consultation with Dr Cashion, Dr Kalau or Dr Valentine or his delegate OR in person by Dr Cashion, Dr Kalau or Dr Valentine:

- What is a vasectomy
- What alternatives I could choose instead of having a vasectomy
- How the procedure is performed
- How long my recovery should take
- Precautions I need to take during recovery such as rest and avoidance of exercise, sex and heavy lifting
- The risks of having a vasectomy and potential complications that may arise during or after the procedure and their likelihood 
- The requirement for a sperm test 3 months after the vasectomy

 

I confirm that:

1. I understand the vasectomy procedure and its associated risks.  
2. I acknowledge other relevant procedures/treatment options and their associated risks
3. I understand that vasectomy is not my only option for contraception and that I could also use condoms, abstain from sex or my partner could use female forms of contraception (such as the pill or long acting contraceptives like Implanon,Mirena or a 3 month depot injection) to ensure I/we do not have children
4. I give the doctors and nurses permission to treat me if there is a life-threatening event during the procedure,
5. I confirm that I was able to ask questions and raise concerns with the doctor about vasectomy, its risks, and my other treatment options both before the day of the procedure and on the day of the procedure. I confirm that my questions and concerns have been discussed and answered to my satisfaction. With regard to the in-person consultation prior to the vasectomy, I understand that I have the option to defer my procedure based on the information provided by the doctor and go away and reflect as to whether I wish to proceed with the vasectomy or not
6. I am aware that, unless I request otherwise, Dr Cashion will use 2 or more small titanium clips during the operation to wrap some of my tissue around one of the ends of vas deferens and I am aware these clips will remain in my scrotum permanently. I am aware that I may elect to use absorbable sutures instead of titanium clips and that if I prefer this option I will advise Dr Cashion prior to my surgery. (Dr Valentine and Dr Kalau do not use clips and only use absorbable sutures)
7. I understand that I have the right to change my mind at any time, including after I have signed this form
8. I understand that I must get a semen test performed approximately 3 months after the procedure to confirm that the vasectomy procedure was successful and I am sterile. I understand that until I have been advised I am sterile following this test I should consider myself fertile and use appropriate contraception. I also understand their may be additional fees payable for this semen test to an external pathology laboratory and that fees paid to Vasectomy Australia do not include Post Vasectomy Semen Testing.
9. I understand that there is a chance the procedure may not work and I may still be fertile after the vasectomy has been performed
10. I have been advised to abstain from strenuous exercise, heavy lifting and sex for at least 1 week following my vasectomy, and to abstain from bike riding and contact sports for at least 3 weeks following my vasectomy.
11. I understand vasectomy is permanent sterilisation and after this operation I will not be able to father children
12. I understand that If it is not possible to perform the vasectomy or the procedure fails I may need to be referred to a surgeon. I also understand that I am responsible for any fees payable to the surgeon in this situation
13. I understand if there are post operative complications I may require referral to a specialist such as a urologist or a general surgeon. I understand that I am responsible for fees payable in this situation
14. I agree to receive my sperm results from Vasectomy Australia via SMS or email
15. I understand that if I am not happy to sign this electronic consent I may ask for a paper copy and one will be provided to me prior to my surgery
16. I confirm that I have been advised by Vasectomy Australia to have someone drive me home after my vasectomy. If this is not possible and I must drive, I agree to wait for at least 20 minutes after my procedure before driving a vehicle.  I also agree that if I feel lightheaded or dizzy, I will not commence driving until the symptoms are completely resolved.
17. I assign my right to Medicare benefits to Dr Geoffrey Cashion, Dr Matthew Valentine,Dr Marcel Kalau or Dr Jessica Jellins for the following services:
- Item 23 (or Item 5020 if the consultation was performed on a Saturday after 1pm) being a Level B Attendance by a General Practitioner and providing an assigned benefit of $41.40 (of $53.90 for Item 5020), for an in-person consultation performed prior to, and on the same date my vasectomy procedure
- Item 91891 being a Level B phone consultation and providing a benefit of $41.40 for discussion of Post Vasectomy Semen Testing result, a discussion of my post operative recovery, and a discussion regarding preventative health issues. This consultation will occur up to 12 months after my vasectomy procedure

- Item 92734 being a Level B phone consultation and providing a benefit of $41.40 for discussions regarding my Reproductive or Sexual Health at any time before or after my vasectomy
18. I consent to my doctor, or his delegated staff, obtaining my Medicare Card details from Medicare Australia using their PRODA online system, for the purpose of bulk billing my pre-vasectomy consultation and any phone or in-person consultations, and for processing my payment for my vasectomy (Item 37623) to allow a rebate to be paid back to my account or by cheque.

I, {name}, CONSENT TO HAVING A VASECTOMY UNDER LOCAL ANAESTHETIC