A systematic review evaluating the effects of vasectomy on male and female sexual function and satisfaction
Highlight box
Key findings
• Vasectomy does not adversely affect key aspects of sexual function and satisfaction and may have minor beneficial effects on many of these measures.
What is known and what is new?
• While vasectomy is widely utilized, many questions arise amongst patients and their partners regarding potential sexual side effects. There is no cohesive literature that addresses the effects of vasectomy on sexual function.
• This systematic review of 20 studies provides the first comprehensive evaluation of sexual function and satisfaction outcomes in both men and their female partners following vasectomy.
What is the implication, and what should change now?
• These findings support current American Urologic Association (AUA) guidelines stating that most patients who undergo vasectomy may be reassured that psychosocial and sexual problems are rarely encountered after vasectomy.
Introduction
Vasectomy is currently the most effective option for male contraception and approximately 500,000 vasectomy procedures occur annually in the United States (1,2). Although it is considered a relatively low-risk procedure, many questions arise amongst patients and their partners regarding potential sexual side effects (3). The American Urologic Association (AUA) guideline on vasectomy states that patients may be reassured that psychosocial, sexual and endocrine problems are rarely encountered following vasectomy (4). There are a significant number of studies that have investigated the sexual outcomes of vasectomy. Despite this, there is currently no cohesive piece of literature that addresses or reviews the effects of vasectomy on sexual function in males and/or females.
The objective of this research was to review and summarize existing literature on the impact of vasectomy on male and female sexual function and satisfaction. Our aim was to develop a source for clinicians to reference when counseling patients and their partners considering vasectomy as a form of definitive contraception.
We reviewed and summarized all recent literature that investigates male and female sexual function and satisfaction after a vasectomy. Our systematized review found that vasectomy does not adversely affect the important aspects of sexual function and satisfaction in men and women and may even have minor beneficial effects on these measures. This supports the recommendations by the AUA and provides useful support for clinicians counselling men and their partners regarding the effects of vasectomy (4). We present this article in accordance with the PRISMA reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-494/rc).
Methods
With the assistance of a reference librarian, a systematic review was conducted on January 17th, 2024. EMBASE, MEDLINE, CINAHL, PsychINFO, the Cochrane Library, and Scopus were searched utilizing a combination of keywords and subject headings containing “vasectomy”, “sexual dysfunction”, “erectile dysfunction”. A narrative description of the search may be referenced in Appendix 1. The review returned 556 records. These were first screened for broad relevance, resulting in 128 sources selected for full-text review. Each source was reviewed by two reviewers independently.
Studies were eligible for inclusion if they evaluated sexual function and/or satisfaction following vasectomy in men and/or their partners. Both qualitative and quantitative studies were considered. Eligible studies included those that reported on any aspect of sexual function or satisfaction before and after vasectomy. We included peer-reviewed research articles published in English between 1990 and 2024. These criteria allowed for the inclusion of studies with accessible full texts and helped minimize the risk of inaccurate or incomplete data.
Ultimately, twenty records (3,5-23) evaluating sexual function and satisfaction post-vasectomy were included in the study. Data collection was conducted by two authors independently. Figure 1 illustrates the identification, screening, and inclusion process used for study selection (24). Fourteen papers (5-11,14-17,20-22) evaluated sexual function and satisfaction in males only, 5 papers (3,12,13,18,23) in couples, and 1 paper (19) in females. Four of the 5 papers evaluating sexual function and satisfaction post-vasectomy in couples administered validated and non-validated surveys to both the male and female in the relationship (3,12,18,23). The other paper administered validated and non-validated surveys about the couple’s satisfaction post-vasectomy to only the male in the relationship, such that questions related to sexual functioning and relationship outcomes centered around the male perspective. This paper was included in the male analysis only and not included in the female analysis of this review (13). The results from 5 papers, 1 with female-only methods (19) and 4 with couples-based methods (3,12,18,23), were utilized to study sexual function and satisfaction in females post-vasectomy.
Four validated surveys were utilized within the papers: International Index of Erectile Function (IIEF), Index of Sexual Satisfaction (ISS), Female Sexual Function Index (FSFI), and Evaluation and Nurturing Relationship Issues, Communication, and Happiness (ENRICH) Marital Satisfaction (EMS) Scale. The IIEF is composed of 15 questions evaluating five sexual domains: erectile function, sexual satisfaction, orgasm, sexual desire, and overall satisfaction. Each domain is rated 0 to 5, with 0 being never/dissatisfied/low and 5 being always/very high/satisfied. The total score for each domain is a total of the scores. The maximum scores for the domains are as follows: erectile function 25, sexual/intercourse satisfaction 15, orgasm 10, sexual desire 10, and overall satisfaction 10 (23).
Eight sex-specific domains of sexual function and satisfaction were identified. These domains were subsequently evaluated as improved, unchanged, or worsened after vasectomy across the 20 papers. The eight male domains analyzed included intercourse satisfaction, erectile function, sexual desire, ejaculatory function, orgasmic function, sexual life satisfaction, sexual frequency, and relationship satisfaction. The eight female domains analyzed included intercourse satisfaction, sexual desire, sexual arousal, lubrication, orgasm, pain, sexual frequency, and relationship satisfaction.
A formal meta-analysis was not performed because individual patient-level data were not available. For studies reporting pre- and post-vasectomy mean values with standard deviations, we calculated mean differences, approximate 95% confidence intervals, and P values for both total IIEF scores and individual domain scores, using the reported means and standard deviations and assuming a correlation coefficient of 0.5 between pre- and post-intervention values (25). A risk-of-bias (RoB) assessment was performed independently by one author (MH) using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist (Table 1) (26).
Table 1
| Study | Were the criteria for inclusion in the sample clearly defined? | Were the study subjects and the setting described in detail? | Was the exposure measured in a valid and reliable way? | Were objective, standard criteria used for measurement of the condition? | Were confounding factors identified? | Were strategies to deal with confounding factors stated? | Were the outcomes measured in a valid and reliable way? | Was appropriate statistical analysis used? | Overall |
|---|---|---|---|---|---|---|---|---|---|
| Engl et al., 2017 (3) | Yes | Yes | Yes | Yes | No | No | Yes | Yes | Low risk |
| Ahmadipour et al., 2011 (5) | Yes | Yes | Yes | Yes | Unclear | Unclear | Yes | Unclear | Unclear risk |
| Andi et al., 2022 | Yes | Yes | Yes | Yes | No | No | Yes | Yes | Low risk |
| Arratia-Maqueo et al., 2010 (7) | Yes | Yes | Yes | Yes | No | No | Yes | Yes | Low risk |
| Bertero et al., 2005 (8) | Yes | Yes | Yes | Yes | No | No | Yes | Yes | Low risk |
| Canter et al., 1995 (9) | Yes | Yes | Yes | Yes | No | No | Yes | Yes | Low risk |
| Chen et al., 2005 (10) | Yes | Yes | Yes | Yes | No | No | Unclear | Yes | Unclear risk |
| Dilbaz et al., 2007 (11) | Yes | Yes | Yes | Yes | No | No | Yes | Unclear | Unclear risk |
| Guo et al., 2015 (12) | Yes | Yes | Yes | Yes | No | No | Yes | Yes | Low risk |
| Hofmeyr et al., 2002 (13) | Yes | Yes | Yes | Yes | No | No | Yes | Yes | Low risk |
| Jahnen et al., 2023 (14) | Yes | Yes | Yes | Yes | No | No | Yes | Yes | Low risk |
| Mafakhkharul et al., 1991 (15) | Yes | Yes | Yes | Yes | No | No | Unclear | Unclear | High risk |
| Manhoso et al., 2005 (16) | Yes | Yes | Yes | Yes | No | No | Unclear | N/A | Unclear risk |
| Miltsch et al., 1999 (17) | Yes | Yes | Yes | Yes | Unclear | Unclear | Unclear | Yes | Unclear risk |
| Mohamad Al-Ali et al., 2014 (18) | Yes | Yes | Yes | Yes | No | No | Yes | Yes | Low risk |
| Shain et al., 1991 (19) | Yes | Yes | Yes | Yes | Unclear | Unclear | Yes | Yes | Unclear risk |
| Sharma et al., 2014 (20) | Yes | Yes | Yes | Yes | No | No | Unclear | Unclear | High risk |
| Skriver et al., 1997 (21) | Yes | Yes | Yes | Yes | No | No | Unclear | Yes | Unclear risk |
| Smith et al., 2010 (22) | Yes | Yes | Yes | Yes | No | No | Unclear | Yes | Unclear risk |
| Toorzani et al., 2010 (23) | Yes | Yes | Yes | Yes | No | No | Yes | Yes | Low risk |
JBI, Joanna Briggs Institute; N/A, not applicable.
Results
Male sexual function after vasectomy
Nineteen papers (n=4,081) evaluated male sexual function and satisfaction post-vasectomy (Table 2) (3,5-18,20-23). Six papers (n=586) utilized validated questionnaires to assess the effects of vasectomy on sexual function (3,7,8,13,14,18). Five papers (n=553) (3,7,8,14,18) utilized the IIEF questionnaire, and one paper (n=33) (13) utilized both the ISS and the ENRICH Marital Satisfaction Scale.
Table 2
| Domain | Papers that analyzed the domain | Sample size studied across papers | Improved | Unchanged | Worsened |
|---|---|---|---|---|---|
| Male intercourse satisfaction | 10 | 1,805 | 3 | 6 | 1 |
| Male erectile function | 9 | 1,800 | 3 | 6 | 0 |
| Male sexual desire | 13 | 2,611 | 3 | 10 | 0 |
| Male ejaculatory function | 4 | 1,306 | 0 | 4 | 0 |
| Male orgasmic function | 6 | 1,140 | 3 | 3 | 0 |
| Male sexual life satisfaction | 8 | 2,315 | 3 | 5 | 0 |
| Sexual frequency | 4 | 898 | 1 | 3 | 0 |
| Relationship satisfaction | 3 | 866 | 1 | 2 | 0 |
The average total IIEF score among male patients pre-vasectomy was 65.8 and the average score post-vasectomy was 67.08 (3,7,8,18). Study-level statistical analyses for total IIEF scores revealed no significant changes following vasectomy across all included studies. Mean differences ranged from 0.7 to 1.6 points, with all confidence intervals crossing zero (all P>0.05) (Table 3). Individual domain scores and analyses are discussed below.
Table 3
| Study | n | Scores | Mean difference | 95% CI | P value | |
|---|---|---|---|---|---|---|
| Pre | Post | |||||
| Arratia-Maqueo et al., 2010 (7) | 29 | 67.1±5.2 | 67.8±5.7 | 0.7 | −1.38 to 2.78 | 0.50 |
| Mohamad Al-Ali et al., 2014 (18) | 76 | 66.2±7.8 | 67.8±7.6 | 1.6 | −0.16 to 3.36 | 0.07 |
| Bertero et al., 2005 (8) | 64 | 64.06±7.49 | 65.64±7.89 | 1.58 | −0.34 to 3.50 | 0.11 |
Data are presented as mean ± standard deviation unless otherwise indicated. CI, confidence interval; IIEF, International Index of Erectile Function.
Intercourse satisfaction
Male intercourse satisfaction was evaluated in 10 papers (n=1,805), with 3 papers (3,6,8) reporting improved intercourse satisfaction, 6 papers (7,13,15,20,22,23) reporting unchanged intercourse satisfaction, and 1 paper (18) reporting worsened intercourse satisfaction post-vasectomy. The average score for the intercourse satisfaction domain of the IIEF pre-vasectomy was 11.8 and post-vasectomy was 12.2 (3,7,8,18). Study-level statistical analysis revealed mixed results, with significant changes in three of four studies, with mean differences ranging from −0.7 to 1.69. Two studies showed significant improvement, while one showed significant decline (Table 4).
Table 4
| Study | n | Scores | Mean difference | 95% CI | P value | |
|---|---|---|---|---|---|---|
| Pre | Post | |||||
| Arratia-Maqueo et al., 2010 (7) | 29 | 11.5±2.2 | 11.8±2.4 | 0.3 | −0.58 to 1.18 | 0.49 |
| Engl et al., 2017 (3) | 90 | 10.6±3.9 | 12.29±1.94 | 1.69 | 0.98 to 2.40 | <0.001 |
| Mohamad Al-Ali et al., 2014 (18) | 76 | 13.4±1.7 | 12.7±1.8 | -0.7 | −1.10 to −0.30 | <0.001 |
| Bertero et al., 2005 (8) | 64 | 11.59±2.27 | 12.16±2.08 | 0.57 | 0.03 to 1.11 | 0.04 |
Data are presented as mean ± standard deviation unless otherwise indicated. CI, confidence interval.
Erectile function
Male erectile function was evaluated in 9 papers (n=1,800), with 3 papers (3,14,18) reporting improved erectile function and 6 papers (5,7-9,21,22) reporting unchanged erectile function post-vasectomy. The average score for the erectile function domain of the IIEF pre-vasectomy was 27.2 and post-vasectomy was 28.3 (3,7,8,18). Study-level statistical analysis showed significant improvement in two of four studies, with mean differences ranging from −0.1 to 3.12 (Table 5).
Table 5
| Study | n | Scores | Mean difference | 95% CI | P value | |
|---|---|---|---|---|---|---|
| Pre | Post | |||||
| Arratia-Maqueo et al., 2010 (7) | 29 | 29±1.8 | 28.9±1.6 | −0.1 | −0.75 to 0.55 | 0.76 |
| Engl et al., 2017 (3) | 90 | 25.8±7.6 | 28.92±2.27 | 3.12 | 1.70 to 4.54 | <0.001 |
| Mohamad Al-Ali et al., 2014 (18) | 76 | 27.2±2.8 | 28.5±2.2 | 1.3 | 0.72 to 1.88 | <0.001 |
| Bertero et al., 2005 (8) | 64 | 26.8±3.41 | 27.05±3.5 | 0.25 | −0.61 to 1.11 | 0.56 |
Data are presented as mean ± standard deviation unless otherwise indicated. CI, confidence interval.
Sexual desire
Male sexual desire was evaluated in 13 papers (n=2,611), with 3 papers (3,6,8) reporting improved sexual desire and 10 papers (5,7,9,11,14,15,18,20-22) reporting unchanged sexual desire post-vasectomy. The average score for the sexual desire domain of the IIEF pre-vasectomy was 7.9 and post-vasectomy was 8.3 (3,7,8,18). Study-level statistical analysis showed significant improvement in two of four studies, with mean differences ranging from 0.0 to 0.73 (Table 6).
Table 6
| Study | n | Scores | Mean difference | 95% CI | P value | |
|---|---|---|---|---|---|---|
| Pre | Post | |||||
| Arratia-Maqueo et al., 2010 (7) | 29 | 8.9±1.4 | 9±1.7 | 0.1 | −0.50 to 0.70 | 0.73 |
| Engl et al., 2017 (3) | 90 | 7±1.8 | 7.73±1.64 | 0.73 | 0.37 to 1.09 | <0.001 |
| Mohamad Al-Ali et al., 2014 (18) | 76 | 8.1±1.1 | 8.1±1.3 | 0 | −0.28 to 0.28 | >0.99 |
| Bertero et al., 2005 (8) | 64 | 7.75±1.4 | 8.25±1.11 | 0.5 | 0.18 to 0.82 | <0.001 |
Data are presented as mean ± standard deviation unless otherwise indicated. CI, confidence interval.
Ejaculatory function
Male ejaculatory function was evaluated in 4 papers (n=1,306), with all 4 papers reporting unchanged ejaculatory function post-vasectomy (9,11,14,22).
Orgasmic function
Male orgasmic function was evaluated in 6 papers (n=1,140), with 3 papers (3,7,18) reporting improved orgasmic function and 3 papers (8,9,22) reporting unchanged orgasmic function post-vasectomy. The average score for the orgasmic function domain of the IIEF pre-vasectomy was 8.9 and post-vasectomy was 9.4 (3,7,8,18). Study-level statistical analysis showed significant improvement in three of four studies, with mean differences ranging from 0.16 to 0.86 (Table 7).
Table 7
| Study | n | Scores | Mean difference | 95% CI | P value | |
|---|---|---|---|---|---|---|
| Pre | Post | |||||
| Arratia-Maqueo et al., 2010 (7) | 29 | 9±0.8 | 9.4±0.3 | 0.4 | 0.13 to 0.67 | <0.001 |
| Engl et al., 2017 (3) | 90 | 8.8±2.9 | 9.66±1.15 | 0.86 | 0.33 to 1.39 | <0.001 |
| Mohamad Al-Ali et al., 2014 (18) | 76 | 8.6±1.1 | 9.4±1 | 0.8 | 0.56 to 1.04 | <0.001 |
| Bertero et al., 2005 (8) | 64 | 9.03±1.45 | 9.19±1.51 | 0.16 | −0.21 to 0.53 | 0.39 |
Data are presented as mean ± standard deviation unless otherwise indicated. CI, confidence interval.
Sexual life satisfaction
Male sexual life satisfaction was evaluated in 8 papers (n=2,315), with 3 papers (3,14,18) reporting improved sexual life satisfaction and 5 papers (7,8,10,17,22) reporting unchanged sexual life satisfaction post-vasectomy. The average score for the sexual life satisfaction domain of the IIEF pre-vasectomy was 8.7 and post-vasectomy was 8.9 (3,7,8,18). Study-level statistical analysis showed no significant change across all four studies (P>0.05) (Table 8).
Table 8
| Study | n | Scores | Mean difference | 95% CI | P value | |
|---|---|---|---|---|---|---|
| Pre | Post | |||||
| Arratia-Maqueo et al., 2010 (7) | 29 | 8.6±1 | 8.8±1 | 0.2 | −0.18 to 0.58 | 0.29 |
| Engl et al., 2017 (3) | 90 | 8.6±1.7 | 8.57±1.71 | -0.03 | −0.39 to 0.33 | 0.87 |
| Mohamad Al-Ali et al., 2014 (18) | 76 | 8.9±1.1 | 9.1±1.3 | 0.2 | −0.08 to 0.48 | 0.15 |
| Bertero et al., 2005 (8) | 64 | 8.89±1.43 | 9±1.4 | 0.11 | −0.24 to 0.46 | 0.54 |
Data are presented as mean ± standard deviation unless otherwise indicated. CI, confidence interval.
Sexual frequency
Sexual frequency was evaluated in 4 papers (n=898), with 1 paper (12) reporting increased sexual frequency and 3 papers (3,10,13) reporting unchanged sexual frequency post-vasectomy.
Relationship satisfaction
Relationship satisfaction was evaluated in 3 papers (n=866), with 1 paper (22) reporting increased relationship satisfaction and 2 papers (13,16) reporting unchanged relationship satisfaction post-vasectomy.
Female sexual function after vasectomy
Five papers (n=1,301) evaluated female sexual function and satisfaction post-vasectomy (Table 9) (3,12,18,19,23). Three papers (n=290) utilized the FSFI as a validated questionnaire to assess the effect of vasectomy on sexual function in females (3,18,23). One paper (n=670) (12) utilized data from the National Survey of Family Growth (NSFG), and the other (n=106) (19) collected data using non-validated methods.
Table 9
| Domain | Papers that analyzed the domain | Sample size studied across papers | Improved | Unchanged | Worsened |
|---|---|---|---|---|---|
| Female intercourse satisfaction | 4 | 631 | 1 | 3 | 0 |
| Female sexual desire | 3 | 491 | 1 | 1 | 1 |
| Female sexual arousal | 2 | 150 | 2 | 0 | 0 |
| Female lubrication | 2 | 150 | 1 | 1 | 0 |
| Female orgasm | 2 | 150 | 1 | 1 | 0 |
| Female pain | 1 | 74 | 0 | 1 | 0 |
| Sexual frequency | 3 | 1,085 | 1 | 1 | 1 |
| Relationship satisfaction | 1 | 74 | 0 | 1 | 0 |
Female intercourse satisfaction was evaluated in 4 papers (n=631), with 1 paper (18) reporting improved intercourse satisfaction and 3 papers (3,19,23) reporting unchanged intercourse satisfaction post-vasectomy. Female sexual desire was evaluated in 3 papers (n=491), with 1 paper (18) reporting improvement in sexual desire, 1 paper (3) reporting unchanged sexual desire, and 1 paper (19) reporting worsening in sexual desire. Female sexual arousal was evaluated in 2 papers (n=150), with both papers reporting improved sexual arousal post-vasectomy (3,18). Female lubrication was evaluated in 2 papers (n=150), with 1 paper (18) reporting improvement in lubrication and the other paper (3) reporting unchanged lubrication. Female orgasm was evaluated in 2 papers (n=150), with 1 paper (18) reporting improvement in orgasm and 1 paper (3) reporting unchanged orgasm in females. Female pain was evaluated in 1 paper (n=74), the paper reported unchanged pain during intercourse post-vasectomy (3). Sexual frequency was studied in 3 papers (n=1,085), with 1 paper (12) reporting increased sexual frequency, 1 paper (3) reporting unchanged sexual frequency, and 1 paper (19) reporting decreased sexual frequency. Relationship satisfaction was evaluated in 1 paper (n=74), Engl et al. reported that 92.6% of patients had the same partner when surveyed 1–5 years post-vasectomy as a marker of sexual satisfaction (3).
Discussion
There are many factors to consider when making a contraception choice, such as affordability, efficacy, reversibility, and risk/side effect profile. While vasectomy is the most effective contraception option for male contraception, many patients express concerns over future sexual health and function in the aftermath of vasectomy. This review specifically focused on the sexual health side effect profile of vasectomy to evaluate the prevalence and degree to which sexual health and function changes following the procedure, and to validate current AUA guidelines which state that patients may be reassured that psychosocial, sexual and endocrine problems are rarely encountered following vasectomy (4).
Within the domains we evaluated across males, we saw an improvement or no change in 7 of 8 domains. Only a singular study within the domain of male intercourse satisfaction showed a worsened condition, with 5 studies reporting no change in condition, and 4 reporting an improvement. Within the domains we evaluated across female segments, we saw an improvement or no change in 6 of 8 domains evaluated. Two domains, female sexual desire and sexual frequency, contained studies that showed worsened conditions, but most studies within these domains also showed no change or improvement in condition. Importantly, while some studies reported improvement and/or beneficial effects, these effects are likely statistical rather than clinically significant and lack a known physiologic mechanism. Therefore, findings of improvement should be interpreted with caution.
Although there is no direct physiologic mechanism that explains improved sexual function and satisfaction after vasectomy, several psychological and behavioral mechanisms may be considered. These include reduced anxiety about unintended pregnancy, changes in sexual confidence, and discontinuation of birth control methods. Such factors may influence sexual function and satisfaction indirectly in both male and female patients but require further study.
This systematized review supports current AUA guidelines, which indicate that most patients who undergo vasectomy do not experience adverse effects on sexual function (4). To the contrary, many patients within the studies evaluated reported improvement within the sexual domains studied following the procedure. From these findings, patients and physicians can more readily consider the prevalence and degree of change of sexual health and function side effects of vasectomy.
This review is limited by a variety of factors. Only peer-reviewed articles published in English were included in the study, which may introduce selection bias and limit generalizability. We included studies published between 1990 and 2024; while earlier research exists regarding this topic, we focused contemporarily as the vasectomy procedure itself has evolved in recent decades. Overall, there was substantial variability in study design and follow-up duration across the included studies. Due to this, short-term versus long-term follow-up was inconsistently reported within studies, which may influence reported results and conclusions. While this review presents our findings in a systematized review, we do not statistically analyze the data in the method of a meta-analysis, which limits the comparison of findings between studies. Approximately half of the included studies were rated as high or unclear risk of bias. We did not weight or stratify our conclusions according to study quality, which limits confidence in our findings. Finally, the availability of research is inherently a limitation in this review. Research was particularly limited when considering female-specific sexual side effects of a male-partner vasectomy.
Further opportunities exist to expand this research by domain type, study type, and population of interest. While the domains investigated here focused specifically on sexual health and function, other domains, such as satisfaction with contraception choice in comparison to other methods, affordability, and overall ease of access, are all valuable areas for future exploration. Additionally, expanding this study to evaluate results between studies can help to further define the prevalence and degree of change of sexual health side effect profiles within the context of a vasectomy. Finally, further focusing on female-specific sexual side effects of a male-partner vasectomy would allow study in a current underdeveloped research area that would help better define vasectomy choice and side effect profile holistically.
Conclusions
This systematized review of the effects of vasectomy on males and females, using several validated scales, indicates that vasectomy does not adversely affect key aspects of sexual function and satisfaction and may have minor beneficial effects on many of these measures. These findings support current AUA guidelines stating that most patients who undergo vasectomy may be reassured that psychosocial, sexual and endocrine problems are rarely encountered after vasectomy (4). This is a descriptive summary of relevant literature with reasonable conclusions.
Acknowledgments
We would like to thank Cindy Schmidt, MD, MLS from Leon S. McGoogan Health Sciences Library at University of Nebraska Medical Center for her assistance in conducting the systematized literature search.
Footnote
Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-494/rc
Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-494/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-494/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
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