Patient Registration and Consent Form

If you answered "No" to the above question, we strongly recommend you watch the Counselling Video here: https://www.youtube.com/watch?v=gBMHye46fjE

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 (about 1 in 100) may experience fainting when the local anesthetic needle is administered. This brief loss of consciousness typically resolves quickly. In most cases, the procedure can be completed once the patient regains consciousness. However, in rare instances, it may not be possible to proceed with the procedure.

2. A small number of men (about 1 in 100) may find the sensation of tugging on the testicles during the procedure intolerable. In such cases, it may be necessary to discontinue and refer the patient for completion of the procedure under sedation or general anesthesia.

After the procedure, most men experience some bruising, mild pain, and swelling, which typically resolves within two weeks.

Less common complications include:

1. Infection of the surgical wound, testicles, epididymis, or urinary tract (up to 1%): Signs of infection may include redness or discharge at the wound site, testicular pain and swelling, pain during urination, fever, or a general feeling of being unwell. If infection occurs, oral antibiotics will be required. In rare cases of severe infection, hospital admission and intravenous antibiotics may be necessary.

 
2. Bleeding within the scrotum (up to 1%): Bleeding can occur during or after vasectomy. In cases where significant bleeding occurs within the scrotum, drainage of a scrotal hematoma (blood clot) in a hospital operating room may be necessary. Smaller hematomas usually do not require surgical drainage but may cause tender swelling lasting 2 to 4 weeks. If bleeding occurs at the vasectomy access site, the scrotal skin may become discolored (black and blue) for about a week. This discoloration is more common than swelling, typically painless, and usually does not require treatment.

3. Early Recanalisation / Procedure Failure: There is a chance that your vasectomy may not be successful, resulting in the presence of sperm in your ejaculate. It is essential to complete a semen analysis three months after your vasectomy to confirm the procedure’s effectiveness. If the vasectomy has failed, a repeat procedure will be necessary.

4. Delayed Recanalisation (Late Failure): There is a very small chance that the vas deferens may spontaneously rejoin even after you have been confirmed sterile. The likelihood of delayed recanalisation is approximately 1 in 2,000 to 1 in 3,000 men.

5. Granuloma (up to 50%): A granuloma is a small, pea-sized lump that can form on the vas deferens at the vasectomy site. While these lumps are usually painless and tend to disappear within 12 months, they can occasionally be tender and may require treatment. Periodic tenderness typically responds well to anti-inflammatory medications like ibuprofen.

6. Congestion: A tender build-up of sperm and white blood cells may occur upstream from or at the vasectomy site. This can happen at any time after the vasectomy but usually resolves with anti-inflammatory medications such as aspirin or ibuprofen. The incidence of congestion is greatly reduced with the open-ended vasectomy technique.

 

7. Reactive Hydrocele (up to 1%): A reactive hydrocele is a benign condition in which fluid collects around one or both testicles, usually within two weeks following the procedure. In most cases the fluid resolves naturally within a few weeks without the need for surgery. In very rare instances (fewer than 1 in 10,000), if the fluid persists beyond 12 months and significantly impacts daily activities, a referral to a urologist may be necessary for drainage.  

 

8. Post Vasectomy Pain Syndrome (PVPS): PVPS is a potential complication of vasectomy, characterised by chronic or persistent pain in the testicles or scrotum that may last for months or even years. Unfortunately, it is not possible to predict which patients may develop PVPS. The risk of PVPS has been estimated as high as 5%, though the rate among men who have undergone vasectomy with Vasectomy Australia is approximately 0.5% (1 in 200 men).

PVPS may result from various causes, including congestion, neuroma formation, nerve entrapment, chronic epididymitis, chronic inflammation, perineural fibrosis, or damage to structures in the spermatic cord. In some cases, the exact cause cannot be determined.

Most men with PVPS can be successfully treated with medications and other non-surgical options, and their pain will eventually subside. In less common instances, surgical treatments—such as neurolysis (cutting nerves supplying the testicles), vasectomy reversal, or other procedures—may be required to attempt pain relief. However, these surgeries are not always successful. For men whose pain remains unresolved, PVPS can lead to long-term psychological distress or depression.

Consent Confirmation: I, {firstName} {lastName}, confirm that I have received the following information either via a video presentation I have watched, an information sheet I have read, a telephone consultation with Dr. Cashion, Dr. Kalau, or Dr. Valentine (or their delegate), or in person by Dr. Cashion, Dr. Kalau, or Dr. Valentine:

• An explanation of what a vasectomy is
• Alternatives to vasectomy that I could consider
• Details on how the procedure is performed
• Expected recovery time
• Precautions during recovery, including recommended rest and restrictions on exercise, sex, and heavy lifting
• Risks and potential complications of vasectomy and their likelihood
• Requirement of a sperm test three months after the vasectomy to confirm effectiveness

Confirmation Statements:

1. I understand the vasectomy procedure and its associated risks.
2. I acknowledge other available procedures and treatment options, along with their associated risks.
3. I understand that vasectomy is not my only option for contraception. Alternatives include condoms, abstinence, or female contraception methods (e.g., the pill, long-acting contraceptives like Implanon, Mirena, or a three-month depot injection) to avoid unintended pregnancies.
4. I give permission to doctors and nurses to treat me in the event of a life-threatening emergency during the procedure.
5. I confirm that I had the opportunity to ask questions and raise concerns about the vasectomy, its risks, and other treatment options, both before and on the day of the procedure. My questions and concerns have been addressed to my satisfaction. I understand that I have the option to defer my procedure and reflect further based on the in-person consultation.
6. I am not suffering from any mental health conditions that would affect my decision to seek a vasectomy
7. I understand that Dr. Cashion will, unless I specifically request otherwise, use two or more small titanium clips to secure tissue around one end of the vas deferens during the operation. These clips will remain in my scrotum permanently. I understand that I may request not to have these clips used. Dr. Valentine and Dr. Kalau do not use titanium clips. For more information about the titanium clips Dr Cashion uses, click here
8. I understand my right to change my mind at any time, including after signing this form.
9. I understand that I have the option to freeze some of my sperm to allow me to have IVF later in life should I change my mind to have children in the future. I am aware that this sperm storage needs to be completed before I have my vasectomy
10. I understand that some men, particularly men who did not have children when they had their vasectomy, change their mind in the months or years following their vasectomy and choose to seek to have their vasectomy reversed
11. I acknowledge the requirement for a semen test at least 8 weeks post-procedure to confirm that the vasectomy was successful and that I am sterile. I understand that until I am advised otherwise, I should consider myself fertile and use contraception. Additional fees usually apply for this semen test through an provider such as a pathology laboratory or mail-in provider, which are separate (and not included) from the fees paid to Vasectomy Australia.
12. I understand there is a chance the procedure may not be effective, and I could remain fertile after the vasectomy.
13. I have been advised to avoid strenuous exercise, heavy lifting, and sexual activity for at least one week following my vasectomy, and to abstain from bike riding and contact sports for at least three weeks.
    I understand that vasectomy is a permanent form of sterilisation, and after this procedure, I will not be able to father children.
14. If the procedure cannot be completed or fails, I understand that I may need to be referred to a surgeon and am responsible for any fees incurred.
15. I understand that post-operative complications may require referral to a specialist, such as a urologist or general surgeon, and I am responsible for any fees.
16. I agree to receive my sperm test results from Vasectomy Australia via phone call, SMS or email.
17. I confirm that Vasectomy Australia has advised me to have someone drive me home after my vasectomy. If I must drive myself, I agree to wait at least 20 minutes post-procedure. I will not drive if I feel lightheaded or dizzy until these symptoms fully resolve.
18. I assign my right to Medicare benefits to Dr. Geoffrey Cashion, Dr. Matthew Valentine, Dr. Marcel Kalau, or their delegate doctor for the following services to allow them to be bulk billed:
    Item 23 (or Item 5020 if on a Saturday after 1 pm): Level B GP attendance, assigned benefit of $43.90 ($57.15 for Item 5020) for the in-person consultation on the date of my vasectomy.
    Item 91891: Level B phone consultation, providing a $42.85 benefit for discussing post-operative issues , semen test results and/or any other medical issue, up to 12 months post-procedure.
    Item 92734: Level B phone consultation, providing a benefit of $42.85 or Item 92731: Level A phone Consultation, providing a  benefit of $19.60 for discussions on reproductive or sexual health (including providing Post Vasectomy Semen Analysis results) at any time before or after my vasectomy.
19. I consent to my doctor or their delegate obtaining my Medicare Card details through Medicare Australia's PRODA online system for bulk billing my pre-vasectomy and any other consultations, as well as processing payment for my vasectomy (Item 37623) to allow a rebate to be credited to my account or by cheque.

Based on the above information, I, {firstName} {lastName}, consent to having a vasectomy under local anaesthetic