VASECTOMY OPERATIVE PERMISSION FORM

I________________________________, give

permission for Dr. med. Klaus Söffker

/ Dr. med. BarbaraDietrich to perform the following operation

(lay terms) bilateralpartial vasectomy (cutting of the tubes which

carry sperm) on me on ___________(date). I understand that

the conditionnecessitating such surgery is (lay terms) a desire

to becomesterile (unable to father children). I understand that

as with anysurgical procedure or anesthetic, there are certain risks.

Thepossibility of a non-fatal complication is approximately 2 in 100.

Some non-fatal complications that we know can occur from

time to time, despite excellent technique, are infection, pain,

excessive bleeding, and a reaction to the anesthetic.

The procedure does not affect sex life, sex drive (libido), the

ability to get an erection, or change the amount of the ejaculate

produced. Any disturbance must be considered psychological.

There is no increased chance of developing cancer or any

other health problems by having a vasectomy performed. I

understand that complications are usually relatively minor and

can be corrected without difficulties.

However, I have been advised that certain complications are

more serious and may even need further surgery. Two of the more

serious complications are explained below.

1.     Pain after a vasectomy is rare and occurs because of

blockage to the system and will resolve over time. In some

men in whom this pain continues, further surgery may need

to be performed to possibly resolve this issue. The chance

of this occurring is less than 5%.

2.     The operation may not make me sterile. Failure occurs

rarely, 1 in 2500 men, and results from the two ends of the

vas deferens coming back together and a connection

formingin the reproductive tract allowing sperm to return

to the ejaculate. Again, this is extremely rare, it cannot be

prevented absolutely, and can result in an unwanted

pregnancy.

The reason for this procedure and the involved risks have been

explained to me and I do understand that it is likely and/or certain

that this procedure will render me sterile (unable to father children).

 I understand that I will not be considered sterile after the procedure

until I have 2 consecutive semen specimens that show no sperm.

________________________________(Patient’s Signature/Date)

________________________________(Surgeon’s Signature/Date)