Stesura Seveso Archivio Italiano di Urologia e Andrologia 2025; 97(2):13644 1 REVIEW ance. Some studies suggest that one of the sexual per- formance problems can be linked to psychological factors (1) However, other studies indicate that vasectomy can have positive effects on patient’s sexual lives (4). Because of these conflicting findings, the purpose of this article is to examine the sexual outcomes post-vasectomy using a systematic review of current studies. METHODS This study was designed and reported, adhering to the PRISMA guidelines. We took a proactive approach by prospectively registering our protocol with PROSPERO (CRD42025634993), ensuring transparency and adher- ence to established standards. Search strategy and selec- tion criteria were following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Figure 1. For the literature search, we used electronic databases such as MEDLINE, Pub Med, and Science Direct. We also manually reviewed and searched references for any possi- ble information from conferences. The systematic search used the following terms and combinations : “vasectomy”, “vasectomies”, “sexual outcome”, and “sexual quality”. Inclusion criteria Original research articles were included if they met the following criteria: a) male participants aged 20 and older who underwent vasectomy, b) studies that provided results on sexual function, including but not limited to erectile function, orgasm, sexual desire, satisfaction, and overall sexual quality, c) studies published in English in order to ensure comprehension of the methodologies and outcomes. Exclusion criteria We exclude the articles if: a) studies exclusively focused on psychological aspects of vasectomy without assessing sexual function, b) articles were not published in English to avoid translation issues and interpretation errors. Data extraction and Risk of Bias Two independent reviewers performed data extraction (MH, RS). Disagreements were resolved in a discussion among all investigators, and if necessary, GW analyzed and clarified them. After discussion, all the study data in Introduction: Vasectomy is one of the most effective ways of contraception. However, it still has various complications, including post-vasectomy sexual dysfunction. Some studies suggest that one of the sexual per- formance problems can be linked to psychological factors. However, other studies indicate that vasectomy can have posi- tive effects on patient’s sexual lives. Because of these conflicting findings, the purpose of this article is to examine the sexual out- come post-vasectomy using a systematic review of current stud- ies. Methods: We performed the search using electronic databases MEDLINE, Pub Med, and Science Direct. We used “vasectomy”, “vasectomies”, and “sexual outcome”, and “sexual quality” in the text keywords. Eleven studies, six case-control studies, and five cohorts met the inclusion criteria for this review. Results: Studies reported a significant improvement in IIEF scores, sexual desire, sexual satisfaction, and orgasm domain after vasectomy. However, a study found that low acceptance of vasectomy can lead to erectile dysfunction, and vasectomized men are slightly more likely to report problems in maintaining their erections. Conclusions: This systematic review shows that, although rare, there are complications after vasectomy. These complications can be related to decreased sexual function for patients after vasectomy. As a urologist, it is essential to offer adequate coun- seling to patients before vasectomy. KEY WORDS: Vasectomy; Sexual function; Erectile function; Sexual satisfaction; Systematic review. Submitted 18 January 2025; Accepted 6 March 2025 INTRODUCTION Vasectomy is one of the most effective ways of contracep- tion (1). Vasectomy has been used in 5% of married cou- ples and is more popular in countries such as New Zealand, the United States, the Netherlands, South Korea, Australia, China, and India (2). It is the most common operation performed by a urologist in the US, and its effectiveness is comparable to tubal ligation despite being less invasive (3). However, although rare, vasectomy still has various com- plications. A significant concern among men considering the procedure is the potential impact on sexual perform- Sexual outcome of vasectomized patients: A systematic review Marshal Harvy Wicaksono 1, Ronald Sugianto 2, Gede Wirya Kusuma Duarsa 1 1 Department of Urology, Prof. dr. I.G.N.G. Ngoerah General Hospital, Denpasar, Indonesia; 2 Department of Urology, Faculty of Medicine, Universitas Airlangga, Indonesia. DOI: 10.4081/aiua.2025.13644 Summary Archivio Italiano di Urologia e Andrologia 2025; 97(2):13644 M. Harvy Wicaksono, R. Sugianto, G. Wirya Kusuma Duarsa 2 the review were entered into an Excel spreadsheet, includ- ing population characteristics, methodology, and the risk of bias assessment. Each included study was assessed for risk of bias using the Newcastle-Ottawa Scale (NOS), a tool designed to evaluate the quality of non-randomized stud- ies. If there are any discrepancies in bias assessments or justifications, they were resolved through discussions among the authors until a consensus was reached. RESULTS The PRISMA diagram for the entire studies searched is shown in Figure 1. The initial search for the databases yielded 1406 articles of which 1201 articles were exclud- ed because of duplication. After further analysis, 11 stud- ies met our criteria and were included in this systematic review. The details of included studies characteristics are detailed in Table 1. The studies included in our systematic review are 6 case-control and 5 cohort studies. The combined sample size from our 11 studies is 6,187 patients. Four of the studies included used the International Index of Erectile Function (IIEF-15) and the other seven studies used the combination of their own questionnaires or other tools like Enriching & Nurturing Relationship Issues, Communications, & Happiness (ENRICH) questionnaire and the Index of Sexual Satisfaction (ISS). The risk of bias assessment using the Newcastle-Ottawa Scale (NOS) results in 5 good-quality studies and 6 moder- ate-quality studies. The details of the included studies assessment are in Table 2. For the selection aspect, 8 out of 11 articles have 3 stars and the other 3 have 2 stars. The comparability aspects are all 1 star across our 11 included articles and for the outcome aspect, 2 articles have 3 stars, 5 articles are 2 stars, and 4 articles receive 1 star. Erectile sunction Seven studies evaluate erectile function in vasectomized men using the IIEF-15 or similar measures. One study by Engl et al. (2017) (5) found a significant improvement in the erectile function domain post-vasectomy, while 4 other studies by Bertero et al. (2005),(6) Al-Ali, et al. Figure 1. PRISMA flow diagram. Archivio Italiano di Urologia e Andrologia 2025; 97(2):13644 3 Sexual outcome of vasectomized patients (2014) (4), Arratia-Maqueo et al. (2010) (7), and Touil et al. (2024) (8) found no significant improvement in the erectile function post-vasectomy. In contrast, Smith et al. (2009) (9) noted that vasectomized men were slightly more likely to experience problems maintaining an erec- tion, and Buchholz et al. (1994) (10) found an association between erectile function after vasectomy and low accept- ance from the patients towards the procedure. Orgasm quality The effect of vasectomy on orgasm quality was assessed in some of the included studies, with results showing a generally positive outcome. Articles by Arratia-Maqueo et al. (2010) (7), Engl et al. (2017) (5), and Bertero et al. (2005) (6) found a positive effect on orgasm quality post-vasectomy, although only Arratia-Maqueo et al. (2010) (7) stat- ed a significant improvement in orgasm quality. Another study by Santiso et al. (2010) (11) with 500 participants found that vasectomy had no neg- ative impact on orgasm quality. Sexual desire Seven studies assessed sexual desire and reported either no change or improvements in sexual desire after vasectomy. Studies by Engl et al. (2017) (5) and Bertero et al. (2005) (6) reported significant improvement in sexual desire for the participants Table 1. Study characteristics. Study Sample Mean age Mean child Indicator Relevant results Bertero, et al. (2005) (6) 64 35 3 IIEF-15 - 67% improved IIEF scores after vasectomy - Sexual desire and sexual satisfaction domain show significant improvement Engl, et al. (2017) (5) 90 Not Stated Not stated IIEF-15 - Significant improvement in erectile function, orgasm, sexual desire, and sexual intercourse domain Santiso, et al. (2010) (11) 500 36 3.9 Sexual drive - Vasectomy has had a positive effect or no effect at all on sex life Sexual Satisfaction and marital relations in the majority of cases Orgasm quality Guo, et al. (2015) (1) 353 Not Stated Not Stated Sexual frequency - Vasectomized men had an 81% higher odds of having intercourse at least once a week Al-Ali, et al. (2014) (4) 76 39 2.6 IIEF-15 - No significant improvement in IIEF domains Buchholz, et al. (1994) (10) 61 47.7 Not Stated Reduced libido - Low acceptance for vasectomy might cause erectile dysfunction Weaker erection Decreased orgasm frequency Decreased sexual activity Smith, et al. (2009) (9) 3234 43.1 Not Stated Lacked interest in having sex - Vasectomy was not associated with specific sexual problems Unable to reach orgasm - Vasectomized men slightly more likely to report problems maintaining Orgasm too quickly or too long erection Problems maintaining erection - Vasectomized men are significantly more likely to be extremely satisfied Extremely satisfied sexually, and relationship with their relationship overall Jackson, et al. (1982) (13) 1508 Not Stated Not Stated Improves physical and mental health - Improvement in physical, mental health, or both in 371 participants Improves physical health only - None regrets in having a vasectomy Improve mental health only Regrets Hofmeyr, et al. (2011) (12) 64 33.7 Sexual frequency - Vasectomy does not negatively influence the sexual satisfaction in men. Sexual satisfaction (ENRICH) - Sexual frequency is maintained after vasectomy Sexual satisfaction (ISS) Arratia-Maqueo, et al. (2010) (7) 29 Median: 38 3 IIEF-15 - 38% participant shows improvement in IIEF total scores - Significant improvement shows in orgasm domain Touil, et al. (2024) (8) 208 Not Stated Not Stated Libido - Participant libido remained unchanged at 79% and improved at 13%. Sexual activity - The harmony of the relationship with their partners improves Quality of erection in 33% of participants Ejaculate volume Relationship Table 2. Risk of bias in the included study using Newcastle Ottawa Scale (NOS). Study Newcastle-Ottawa Scale Total Quality Selection Comparability Outcome score of the study Bertero, et al. (2005) (6) *** * *** 7 Good Engl. et al. (2017) (5) ** * *** 6 Good Santiso, et al. (2010) (11) *** * ** 6 Good Guo, et al. (2015) (1) *** * * 5 Moderate Al-Ali, et al. (2014) (4) ** * ** 5 Moderate Buchholz, et al. (1994) (10) *** * ** 6 Good Smith, et al. (2009) (9) *** * * 5 Moderate Jackson, et al. (1982) (13) *** * * 5 Moderate Hofmeyr, et al. (2011) (12) *** * ** 6 Good Arratia-Maqueo, et al. (2010) (7) ** * ** 5 Moderate Touil. et al. (2024) (8) *** * * 5 Moderate Archivio Italiano di Urologia e Andrologia 2025; 97(2):13644 M. Harvy Wicaksono, R. Sugianto, G. Wirya Kusuma Duarsa 4 after vasectomy. Studies by Smith et al. (2009) (9), Hofmeyr et al. (2011) (12), and Al-Ali et al. (2014) (4) found no sig- nificant negative impact on sexual desire post-vasectomy, and studies by Santiso et al. (2010) (11) and Touil et al. (2024) (8) found that most participants maintained their sexual desires post-vasectomy. Sexual satisfaction Results regarding sexual satisfaction were reported in 10 of the included studies, with most studies showing improvements or neutral outcomes post-vasectomy. Bertero et al. (2005) (6), and Arratia-Maqueo et al. (2010) (7) reported an improvement in sexual satisfaction post- vasectomy. Related to sexual satisfaction, Touil et al. (2024) (8) also report a 33% improvement in relationship harmony post-vasectomy, and Smith et al. (2009) (9) found that post-vasectomized men are significantly more likely to be satisfied with their relationship overall. Study by Hofmeyr et al. (2011) (12), and Santiso et al. (2010) (11) reported that vasectomy did not have a negative impact on sexual satisfaction, and most participants maintained their levels of sexual satisfaction. Studies by Al-Ali et al. (2014) (4) and Engl et al. (2017(5) found that there was no significant improvements in the sexual sat- isfaction domain of the IIEF questionnaire. Other related results by Guo et al. (2015) (1) found that vasectomized men had a higher chance of having sexual activity at least once a week. In contrast, Buchholz et al. (1994) (10) sug- gested that low acceptance of vasectomy can result in a decrease in sexual satisfaction post-vasectomy. Overall satisfaction All studies highlighted a high level of overall satisfaction among vasectomized men, with most reporting either no change or an improvement in their sexual relationship. Studies by Touil et al. (2024) (8), Smith et al. (2009) (9), and Jackson et al. (1982) (13) report that overall satisfac- tion post-vasectomy was improved with minimal regrets. Other studies by Bertero et al. (2005) (6), Al-Ali et al. (2014) (4), Arratia-Maqueo et al. (2010) (7), and Engl et al. (2017) (5) found that overall score on the IIEF question- naire was improved after vasectomy. In addition, studies by Santiso et al. (2010) (11) and Hofmeyr et al. (2011) (12) found that over half of their patients have a positive effect or no effects on overall satisfaction post-vasectomy. Related to satisfaction, Guo et al. (2015) (1) reported about the sexual frequency of men post-vasectomy who had an 81% chance of having intercourse at least once a week. However, Buchholz et al. (1994) (10) concluded that the satisfaction of post-vasectomy patients is related to the psychosocial environment that can cause psychological disturbances and lead to reduced satisfaction. DISCUSSION Vasectomy is one of the most effective contraceptive methods for men (1). It is the most common operation performed by urologists. Vasectomy has many benefits to prevent unplanned childbirth. However, vasectomy is not the most commonly used contraception for men (3, 8). Men are concerned that vasectomy might decrease their sexual life quality, including pain, erectile function, and others. Complications that can happen after vasectomy ranges from chronic pain, recanalization, and post-vasec- tomy sexual dysfunction (8). According to our review, we found that, overall, vasecto- my does not negatively impact the sexual outcomes of the patients. Studies show an improvement in overall sexual satisfaction (8, 9). Studies that use IIEF also show an improvement in the overall satisfaction domain for vasec- tomized patients (5, 6). Other domains of IIEF-15, e.g. sexual desire, erectile function, and orgasm domain, also show improvement in various other studies (5, 7). A sys- tematic review shows that the sexual frequency of vasec- tomized patients is higher than non-vasectomized patients and vasectomized patients had slightly more chance of having difficulty maintaining an erection (1, 12). However, there are some studies reports of minor difficulties in maintaining an erection (9). According to our review, we found that the sexual dys- function post-vasectomy is related to low acceptance of vasectomy (10). Therefore, we believe that proper counsel- ing is essential for patients before vasectomy to improve understanding the procedure and its risks as well as the complications. The counseling should also ensure the patient understands that erectile dysfunction after vasecto- my has been linked to psychosocial factors and vasectomy does not affect erection, ejaculation, and orgasm (14, 15). CONCLUSIONS This systematic review shows that, although rare, there are complications after vasectomy. This complication can be related to decreased sexual function for patients after having vasectomy. As a urologist, it is essential to do counseling for patients before vasectomy. Our study did not include meta-analysis of data retrieved. Hopefully, studies in the future can better represent the picture of vasectomized patients in our country. DECLARATIONS Ethical statement: Not applicable. Availability of data and material: The data utilized and/or analyzed in this study are accessible from the corresponding author upon request. Competing interests: The authors declare that they have no competing interests. Funding sources: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors’ contributions: Marshal Harvy W.P (MHWP): Methodology, Data Collection, Data Analysis, Writing - Original Draft. Ronald Sugianto (RS): Methodology, Data Collection, Writing - Review & Editing, and Critical Revisions. Gede Wirya Kusuma Duarsa (GWK): Conceptualization, Supervision, Methodology, Validation, Writing - Review & Editing, and Final Approval of the Manuscript. Acknowledgments: All authors have read and approved the final version of the manuscript and agree to be accountable for all aspects of the work. Archivio Italiano di Urologia e Andrologia 2025; 97(2):13644 5 Sexual outcome of vasectomized patients REFERENCES 1. Guo DP, Lamberts RW, Eisenberg ML. Relationship between vasectomy and sexual frequency. J Sex Med. 2015; 12:1905-10. 2. Schwingl PJ, Guess HA. Safety and effectiveness of vasectomy. 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Correspondence Marshal Harvy Wicaksono Pantjoro (Corresponding Author) marshalharvy@gmail.com Department of Urology, Prof. dr. I.G.N.G. Ngoerah General Hospital, Denpasar, Indonesia Wisata Bukit Mas 2 Palais Du Louvre i1 number 5, Lidah Wetan, Lakarsantri, Surabaya, East Java, 60213 Gede Wirya Kusuma Duarsa gwkduarsa@gmail.com Department of Urology, Faculty of Medicine, Universitas Airlangga, Indonesia Ronald Sugianto rsugianto@student.unair.ac.id Department of Urology, Prof. dr. I.G.N.G. Ngoerah General Hospital, Denpasar, Indonesia