VASECTOMY OPERATIVE PERMISSION FORM
permission for Dr. med. Klaus Söffker
/ Dr. med. BarbaraDietrich/ Dr. med. Tobias Bothmann to perform the following operation (lay terms) bilateralpartial vasectomy (cutting of the tubes which carry sperm) on me on ___________(date). I understand thatthe 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
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.
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