ln1
J Gynaccol Obs1c1
16: 493- 496, 1979
Vasectomy: Benefits and Risks C. F. D. Ackman, S. G. Macisaac and R. Schual Departmtnl of Surgery, M cGill University, Montreal, Quebec, Canada
ABSTRACT Ackman CFD, Macisaac SG, Schual R (Dept of Surgery, McGill University, Montreal, Quebec, Canada). Vasectomy: benefits and risks. lntj Gynaecol Obstet 16: 493- 496, 1979 Bilateral occlusion of the vas deferens, vasectomy, is progressively becoming the method of choice for couples seeking permanent contraception at a younger age, with smaller families. They are apparently well-informed and view the procedure as a natural step. Vasectomy is an inexpensively performed office procedure that causes minimal disruption of routine and has a high degree of community acceptance. The risks of significant hematoma, infection, discomfort and other sequelae are within acceptable limits. Improved techniques will continue to reduce the small failure rate. Antibodies observed in half of the patients have not been linked to systemic disease, although they are a hazard for the one patient in 500 returning for a vasovasostomy. Refinements in microsurgery and availability of artificial insemination enhance vasectomy as the method of choice. Evidently, extending the minimum time of sterility confirmation permits detection of occasional recanalization from technical failures. Adequate screening of the couple's motivation and expectations can prevent the rare psychologic disturbances, the greatest risk with this procedure and a problem associated with all options. For the male, there is no competitive technique at this time. In a world striving for equal rights, where the female still carries the burden of temporary contraception, the simplicity and popularity of vasectomy for permanent contraception add the desired undertones of social equilibrium.
INTRODUCTION Reflecting the media of the communications age, young couples are entering married life with increasingly sophisticated physiologic knowledge regarding control over reproduction. Recent studies indicate that women are completing their childbearing earlier, averaging 30 years in 75% of cases. In another group, the mean number of children has declined from 3.05 to 2.28 in couples seeking vasectomy
during the last decade (17), a trend noted by Peel and Carr (16). With l0- 15 years of further exposure to conception, there is strong motivation for the couple to seek a reliable, safe and inexpensive form of permanent steri lization. Under conditions in which both parties have access to unbiased information, and either would accept the procedure, there remains the task of further clarifying the benefits and risks of the various permanent sterilization techniques. Bilateral occlusion of the vas deferens, now universally known as vasectomy, has been performed on more than 80 million males, with increasing frequency, over the past three decades. In North America, the number exceeds 15% of the annual marriage rate, and is now the most popular form of permanent steril ization utilized. In contrast, while temporary male contraception is under intensive study, no technique has yet reached the level of clinical acceptance.
TECHNIQUE The procedure is easily performed with local anesthetic, using simple surgical equipment and a minimal amount of inexpensive, disposable material. A safe, sterile environment is easily maintained , and the technique may be performed in 15 minutes by a physician, or a trained technician, if warranted . Separate, lateral 1-cm scrotal incisions reduce the risk of inadvertent unilateral double ligation and prevent the spread of potential infection or hematoma. Occlusion techniques include simple ligation with catgut, nonabsorbable sutures or clips; cutting and ligating the vas with or without segment removal; and the install ation of sophisticated valves a llowing demand reversibility, which has not met with wide acceptance. Experience now favors the method advocated by Schmidt in which the lumen of the cut ends is destroyed by thermal coagulation. One end is then sutured outside the normal fascial plane. This eliminates crushing ligatures thought to contribute to recanalization (21). Absorbable su-
lntj Gynaecol Obstet / 6
494
Ackman et al
tures close the wound and dressings are avoided. A scrotal support is recommended. Most patients are able to resume light duties, but strenuous activity is avoided for a day or two. Freund and Davis (10) have shown that sperm concentrations drop below 10 000 after ten ejaculations. Most clinics advise a period of two months of normal contraceptive use before sterility confirmation by semen analysis. Flushing the vas at the time of surgery has been suggested to hasten this interval. However, Klapproth and Young (15) observed that the 0.5%- 1.0% recanalization rate reported was usually detected within the first three months. While this rate should be lower with the coagulation technique, it now appears prudent to advise a threemonth contraception period, followed by two negative sperm counts. RESULTS Short-term risks The problems encountered immediately after vasectomy are now well defined (8). The use of 3 cc- 5 cc of local anesthetic solution reduces the risk of anaphylactic reaction, as the severity is dose-related. However, the surgeon should be prepared for this infrequent event. Discomfort and pain after the procedure is minimal and often related to the patient's general level of apprehension. Significant local pain is experienced by approximately 1%. With the majority of patients, local subcutaneous ecchymosis will be reported. Anxiety concerning this will be avoided by forewarning the patients. Several authors report the incidence of significant hematomas between 0.4% and 1.6% (9, 21). Most will resolve spontaneously, while large ones should be drained to avoid prolonged convalescence. Clinical infection is reported in approximately 1% of cases (15). Many of these men have a previous history of epididymitis and associated prostatitis, and prophylactic antibiotics should be considered for them. Staphylococcus albus or enterococci are usually found. Abscess formation should be promptly drained and any foreign material removed. All of these problems occur within acceptable limits for such a procedure and do not detract from its safety and modest cost since expensive hospital facilities are not involved and the inconvenience to the vast majority of patients is minimal. Long-term risks A 30-year experience with large numbers of vasectomies has so far failed to reveal any long-term lnt J Gynaecol Obstel 16
deleterious effects directly related to the procedure. Nevertheless, there is considerable ignorance about the exact events which occur in the occluded system, in spite of a high degree of patient and physician acceptance (7). Hormone response Rosemberg et a! (18) have noted that serum . follicle-stimulating hormone and luteinizing hormone levels are unchanged on long-term follow-up. Similar studies have failed to show any alteration in peripheral testosterone levels, although Smith et a! (23) reported a shift to the right within the normal distribution curve. The effect on interruption of androgen-binding protein movement within the lumen has yet to be clarified. The quantity of ejaculate is unchanged following vasectomy and patients should be reassured about this, as well as potency. Structural alterations Obstruction of the vas deferens leads to hydrostatic dilatation of the proximal system. Biopsy and other studies for up to 17 years following the procedure have failed to reveal any diminution in spermatogenesis (13). The epididymis becomes engorged with spermatozoa, and many sperm-laden macrophages are present. Their relationship to messenger ribonucleic acid and the immune response is well known. Throughout the epididymis, epithelial cells are flattened, but appear to function normally. They are observed to rest on a uniformly thickened basal layer, thought to be immunologically derived (14). Sertoli cell function appears normal, although Hagedorn and Davis ( 12) suggest the possibility that some sperm may be broken down within the seminiferous tubules. The secretion and absorption of fluids by the epididymis appear to be unaltered. It is becoming increasingly clear that spermatogenesis is virtually unaffected. The removal of sperm takes place at an equal pace within the epididymal complex and associated structures by mechanisms not yet fully understood. Following successful vasovasostomy, the sperm count usually returns to slightly below previous levels in most cases. Immature forrns and cellular debris remain for many months (11). Immunologic changes Spermatozoa and seminal fluid have both been demonstrated to be antigenic. Antibodies to at least 15 sperm antigens are found throughout the entire globulin range, usually in the form of immobilizing, agglutinating or cytotoxic antibodies, all of which are deleterious to fertility (1). Circulating antisperm
Vasectomy
antibodies are detected within 4- 10 days in 50% of those having vasectomy and have been shown to persist for years (2). It is not clear whether this is related to antigen spill at the surgical site. Many feel that the major autoimmune response develops within the congested epididymal system (6). There are several known consequences to the autoimmune response. Various authors report an incidence of between 0.5% and 10.0% of spermatic granulomata, both at the suture site and within the epididymis (19). This immune complex, foreign body reaction, may appear any time after the surgery, but Schmidt (20) feels that his coagulation technique greatly reduces its incidence. The small tender masses are frequently confused with foreign body granulomata at the suture site and normally have no clinical significance. Large or painful masses should be explored and excised. The presence of high titers of antisperm antibodies in males having vasovasostomy is thought to explain the poor correlation between subsequent presence of sperm and the reduced pregnancy rate. This problem will not be easily resolved. The possibility of nonspecific side effects, such as serum sickness, complex nephritis and arthritis, has attracted much attention, but reports have failed to stand up to critical evaluation to this time.
Psychologic effects It is becoming increasingly evident that large numbers are seeking and tolerating vasectomy without significant related psychologic effects, in spite of the fact that fertility management has traditionally been a female burden and constitutes a marked alteration in male role identification. There has been no significant change in the incidence of impotence in males after vasectomy. It is obviously impossible for the examining physician to gain comprehensive insight into the psychologic status of either the male or his sexual partner. However, attention should be given to the patient's motivation, expectation and attitude towards the procedure as well as his partner's. Zeigler (24) and others have distinguished between those who seek the procedure solely for permanent sterilization, as opposed to those who are motivated toward sexual performance or marital problems and are more prone to have adjustment problems. Since the male retains the ability to procreate throughout life, conflicts may enter into the decision process. Also, strong domestic domination by either party may be intensified when the procedure is accepted by the nondominant individual. This should clearly be avoided in obvious situations. Extensive psychologic evalu-
4!:15
ation has not been found to be either practical or rewarding. On the other hand, doubtful cases might best be screened in this manner (3).
Vasovasostomy It is now estimated that one patient in 500 will eventually seek vasovasostomy for a variety of reasons. The technical procedure is undergoing rapid evolution with the introduction of microsurgery, and sperm recovery rates as high as 90% now seem realistic (4, 22). Unfortunately, the pregnancy rate is considerably lower, 50% being a reasonable expectation at present. The differential, due to the presence of a high titer of autoimmune antibodies that cause sperm agglutination and immotility, is a problem not easily solved (5). In addition, artificial insemination may now be offered to those couples who persist in their desire for children. At present, many patients seeking vasovasostomy are actually found in the artificial insemination clinics. While not absolute, this high salvage potential is certainly one of the benefits of vasectomy as an option for permanent sterilization.
CONCLUSION Vasectomy has the benefit of being inexpensively performed as an office procedure, causing minimal disruption of routine and having a high degree of community acceptance. The risk of significant hematoma, infection, discomfort and other sequelae are within acceptable limits. Improved techniques will continue to reduce the small failure rate. Antibodies observed in half of the patients have not been linked to systemic disease, although they are a hazard for the one patient in 500 returning for vasovasostomy. Better results with microsurgery and the availability of artificial insemination further increase the acceptability of vasectomy as the method of choice. Evidence suggests that extending the minimum time of sterility confirmation to three months will permit detection of the occasional recanalization from technical failures. Although psychologic disturbances are rare, inadequate screening of the couple's motivation and expectations probably represents the greatest risk with this procedure. However, the same problem exists for all options. For the male, there is no competitive technique at this time. In a world striving for equal rights, and where the female presently carries the burden of temporary contraception, the simplicity and popularity of vasectomy as the preferred method of permanent contraception carries the additional undertones of social equilibrium. lnt J Gynaeco/ Obstet 16
496
Ackman et a!
REFERENCES I. Alexander NJ, Schmidt SS, Free MJ, Danilchik MY, Hill WT: Sperm a ntibodies a ft er vasectomies with ful gura tion. J Urol 115(1):77 , 1976. 2. Ansbacher R , Keun g- Yeun g K , Wurster JC : Sperm a ntibodies in vasectomized men. Fertil Steril 23:640 , 1972. 3. Bl oom LJ, Houston BK: T he psychological effects of vasectomy for American men . J Gen Psycho) 128(2): 173, 1976. 4. Brueschke EE, Zaneveld LJD, Rodzen R , Wingfi eld JR , M a ness JH : Development of a reversible vas deferens occlusive device. Fertil Steril 26:29, 19 75. 5. Bullocks JY , Gilmore LL, Wilson JD : Autoantibodies following vasec tomy. J Urol 11 8:604, 19 77 . 6. Crewe P, Dawson L, Tidm arsh E, Cha narin I, Barnes RD : Autoimmune im plications of vasectom y in man . C lin Exp Immunol 24:368, 1976. 7. Davis J E : Vasectom y: benefits versus risks. lnt J Gynaecol Obstet 15: 163, 1977 . 8. Davis J E, Lubell 1: Ad va nces in understanding the effects of vasec tomy. Mt Sina i J M ed NY 42:39 1, 1975. 9. Fin kbeiner AE, Bissada NK, Redma n J F: Com plications of vasectomies. Am Fam Physician 15: 86, 1977 . 10. Freund M , Da vis J E: Disappearance ra te of sperma tozoa from the ejacula te following vasectomy. Fertil Steril 20: 163, 1969. II. Gupta AS, Koth a ri LK, Dhruva A, Ba pna R : Surgica l sterilization by vasectomy a nd its effects on the structure a nd fun ction of the testis in ma n. Br J Surg 62:59, 19 75. 12. Hagedorn JP, Davis J E: Fine structure of the seminiferous tu bules a ft er vasectomy in man. Physiologist / 7:236, 1974. 13. Hell er V, Rothchild I : The influence of the surgical techniq ue used for vasectomy on testis fun ction in ra ts. J Rep rod Fertil 39:8 1, 1974. 14. Isidori A, Dondero F, Lombardo D : Antit esticula r immu-
I
l nt J Gynaecol Obstet 16
15. 16. 17. 18.
19. 20. 2 1. 22. 23 .
24.
nit y: role of the basement membra ne. Experientia 26: 1375 , 19 70. Kla ppro th HJ, Youn g IS: Vasectomy, vas ligation and vas occl us ion. Urology / :292, 1973. Peel J , Carr G : Contraception and Fa mil y Design, p 39. Churchill Livingstone, Edinburgh, 19 75 . R amos-Cordero RA, Na ftolin F, Ackma n CFD: Cha nging profil es in vasectom y subj ects in the past decade. J Steril Infertil (in press). Rosemberg E, M a rks SC , Howard PH : Serum. levels of FSH a nd LH before a n'd a ft er vasectomy in men. J Urol 3: 626, 19 74. Rumke P : Sperm antibodies a nd their action upon huma n sperm a tozoa. Ann Inst Pasteur (Lille) 118:525, 1970. Schmidt SS: Prevention of fa ilure in vasectomy. J Urol 109: 296, 19 73. Schmidt SS: Technic a nd complications of elective vasectom y: role of sperma tic gra nuloma in sponta neous recana l· ization. Fertil Steril 17:46 7, 1966. Schmidt SS: Vasovasostomy: a review of principles. Contem p Surg 7:13, 1975. Smith KD, C howdhury M , T cho1a kia n RK : Endocrine effects of vasectom y in humans. In Control of M a le Fertilit y: PARFR Series on Fertilit y Regula tion (ed JJ Sci arra, C M a rkla nd , JJ Speidel), p 169. H arper & Row, Hagers town , MD 1 19 75. Ziegler FJ: The psychological effects of vasectom y. Psychosom Med 37: 186, 19 75.
Address for reprints: C. F. D. Ackman 3550 Cote des Neiges, Suite 600 Montreal , Quebec Canada
J Gynaccol Obs1c1
16: 493- 496, 1979
Vasectomy: Benefits and Risks C. F. D. Ackman, S. G. Macisaac and R. Schual Departmtnl of Surgery, M cGill University, Montreal, Quebec, Canada
ABSTRACT Ackman CFD, Macisaac SG, Schual R (Dept of Surgery, McGill University, Montreal, Quebec, Canada). Vasectomy: benefits and risks. lntj Gynaecol Obstet 16: 493- 496, 1979 Bilateral occlusion of the vas deferens, vasectomy, is progressively becoming the method of choice for couples seeking permanent contraception at a younger age, with smaller families. They are apparently well-informed and view the procedure as a natural step. Vasectomy is an inexpensively performed office procedure that causes minimal disruption of routine and has a high degree of community acceptance. The risks of significant hematoma, infection, discomfort and other sequelae are within acceptable limits. Improved techniques will continue to reduce the small failure rate. Antibodies observed in half of the patients have not been linked to systemic disease, although they are a hazard for the one patient in 500 returning for a vasovasostomy. Refinements in microsurgery and availability of artificial insemination enhance vasectomy as the method of choice. Evidently, extending the minimum time of sterility confirmation permits detection of occasional recanalization from technical failures. Adequate screening of the couple's motivation and expectations can prevent the rare psychologic disturbances, the greatest risk with this procedure and a problem associated with all options. For the male, there is no competitive technique at this time. In a world striving for equal rights, where the female still carries the burden of temporary contraception, the simplicity and popularity of vasectomy for permanent contraception add the desired undertones of social equilibrium.
INTRODUCTION Reflecting the media of the communications age, young couples are entering married life with increasingly sophisticated physiologic knowledge regarding control over reproduction. Recent studies indicate that women are completing their childbearing earlier, averaging 30 years in 75% of cases. In another group, the mean number of children has declined from 3.05 to 2.28 in couples seeking vasectomy
during the last decade (17), a trend noted by Peel and Carr (16). With l0- 15 years of further exposure to conception, there is strong motivation for the couple to seek a reliable, safe and inexpensive form of permanent steri lization. Under conditions in which both parties have access to unbiased information, and either would accept the procedure, there remains the task of further clarifying the benefits and risks of the various permanent sterilization techniques. Bilateral occlusion of the vas deferens, now universally known as vasectomy, has been performed on more than 80 million males, with increasing frequency, over the past three decades. In North America, the number exceeds 15% of the annual marriage rate, and is now the most popular form of permanent steril ization utilized. In contrast, while temporary male contraception is under intensive study, no technique has yet reached the level of clinical acceptance.
TECHNIQUE The procedure is easily performed with local anesthetic, using simple surgical equipment and a minimal amount of inexpensive, disposable material. A safe, sterile environment is easily maintained , and the technique may be performed in 15 minutes by a physician, or a trained technician, if warranted . Separate, lateral 1-cm scrotal incisions reduce the risk of inadvertent unilateral double ligation and prevent the spread of potential infection or hematoma. Occlusion techniques include simple ligation with catgut, nonabsorbable sutures or clips; cutting and ligating the vas with or without segment removal; and the install ation of sophisticated valves a llowing demand reversibility, which has not met with wide acceptance. Experience now favors the method advocated by Schmidt in which the lumen of the cut ends is destroyed by thermal coagulation. One end is then sutured outside the normal fascial plane. This eliminates crushing ligatures thought to contribute to recanalization (21). Absorbable su-
lntj Gynaecol Obstet / 6
494
Ackman et al
tures close the wound and dressings are avoided. A scrotal support is recommended. Most patients are able to resume light duties, but strenuous activity is avoided for a day or two. Freund and Davis (10) have shown that sperm concentrations drop below 10 000 after ten ejaculations. Most clinics advise a period of two months of normal contraceptive use before sterility confirmation by semen analysis. Flushing the vas at the time of surgery has been suggested to hasten this interval. However, Klapproth and Young (15) observed that the 0.5%- 1.0% recanalization rate reported was usually detected within the first three months. While this rate should be lower with the coagulation technique, it now appears prudent to advise a threemonth contraception period, followed by two negative sperm counts. RESULTS Short-term risks The problems encountered immediately after vasectomy are now well defined (8). The use of 3 cc- 5 cc of local anesthetic solution reduces the risk of anaphylactic reaction, as the severity is dose-related. However, the surgeon should be prepared for this infrequent event. Discomfort and pain after the procedure is minimal and often related to the patient's general level of apprehension. Significant local pain is experienced by approximately 1%. With the majority of patients, local subcutaneous ecchymosis will be reported. Anxiety concerning this will be avoided by forewarning the patients. Several authors report the incidence of significant hematomas between 0.4% and 1.6% (9, 21). Most will resolve spontaneously, while large ones should be drained to avoid prolonged convalescence. Clinical infection is reported in approximately 1% of cases (15). Many of these men have a previous history of epididymitis and associated prostatitis, and prophylactic antibiotics should be considered for them. Staphylococcus albus or enterococci are usually found. Abscess formation should be promptly drained and any foreign material removed. All of these problems occur within acceptable limits for such a procedure and do not detract from its safety and modest cost since expensive hospital facilities are not involved and the inconvenience to the vast majority of patients is minimal. Long-term risks A 30-year experience with large numbers of vasectomies has so far failed to reveal any long-term lnt J Gynaecol Obstel 16
deleterious effects directly related to the procedure. Nevertheless, there is considerable ignorance about the exact events which occur in the occluded system, in spite of a high degree of patient and physician acceptance (7). Hormone response Rosemberg et a! (18) have noted that serum . follicle-stimulating hormone and luteinizing hormone levels are unchanged on long-term follow-up. Similar studies have failed to show any alteration in peripheral testosterone levels, although Smith et a! (23) reported a shift to the right within the normal distribution curve. The effect on interruption of androgen-binding protein movement within the lumen has yet to be clarified. The quantity of ejaculate is unchanged following vasectomy and patients should be reassured about this, as well as potency. Structural alterations Obstruction of the vas deferens leads to hydrostatic dilatation of the proximal system. Biopsy and other studies for up to 17 years following the procedure have failed to reveal any diminution in spermatogenesis (13). The epididymis becomes engorged with spermatozoa, and many sperm-laden macrophages are present. Their relationship to messenger ribonucleic acid and the immune response is well known. Throughout the epididymis, epithelial cells are flattened, but appear to function normally. They are observed to rest on a uniformly thickened basal layer, thought to be immunologically derived (14). Sertoli cell function appears normal, although Hagedorn and Davis ( 12) suggest the possibility that some sperm may be broken down within the seminiferous tubules. The secretion and absorption of fluids by the epididymis appear to be unaltered. It is becoming increasingly clear that spermatogenesis is virtually unaffected. The removal of sperm takes place at an equal pace within the epididymal complex and associated structures by mechanisms not yet fully understood. Following successful vasovasostomy, the sperm count usually returns to slightly below previous levels in most cases. Immature forrns and cellular debris remain for many months (11). Immunologic changes Spermatozoa and seminal fluid have both been demonstrated to be antigenic. Antibodies to at least 15 sperm antigens are found throughout the entire globulin range, usually in the form of immobilizing, agglutinating or cytotoxic antibodies, all of which are deleterious to fertility (1). Circulating antisperm
Vasectomy
antibodies are detected within 4- 10 days in 50% of those having vasectomy and have been shown to persist for years (2). It is not clear whether this is related to antigen spill at the surgical site. Many feel that the major autoimmune response develops within the congested epididymal system (6). There are several known consequences to the autoimmune response. Various authors report an incidence of between 0.5% and 10.0% of spermatic granulomata, both at the suture site and within the epididymis (19). This immune complex, foreign body reaction, may appear any time after the surgery, but Schmidt (20) feels that his coagulation technique greatly reduces its incidence. The small tender masses are frequently confused with foreign body granulomata at the suture site and normally have no clinical significance. Large or painful masses should be explored and excised. The presence of high titers of antisperm antibodies in males having vasovasostomy is thought to explain the poor correlation between subsequent presence of sperm and the reduced pregnancy rate. This problem will not be easily resolved. The possibility of nonspecific side effects, such as serum sickness, complex nephritis and arthritis, has attracted much attention, but reports have failed to stand up to critical evaluation to this time.
Psychologic effects It is becoming increasingly evident that large numbers are seeking and tolerating vasectomy without significant related psychologic effects, in spite of the fact that fertility management has traditionally been a female burden and constitutes a marked alteration in male role identification. There has been no significant change in the incidence of impotence in males after vasectomy. It is obviously impossible for the examining physician to gain comprehensive insight into the psychologic status of either the male or his sexual partner. However, attention should be given to the patient's motivation, expectation and attitude towards the procedure as well as his partner's. Zeigler (24) and others have distinguished between those who seek the procedure solely for permanent sterilization, as opposed to those who are motivated toward sexual performance or marital problems and are more prone to have adjustment problems. Since the male retains the ability to procreate throughout life, conflicts may enter into the decision process. Also, strong domestic domination by either party may be intensified when the procedure is accepted by the nondominant individual. This should clearly be avoided in obvious situations. Extensive psychologic evalu-
4!:15
ation has not been found to be either practical or rewarding. On the other hand, doubtful cases might best be screened in this manner (3).
Vasovasostomy It is now estimated that one patient in 500 will eventually seek vasovasostomy for a variety of reasons. The technical procedure is undergoing rapid evolution with the introduction of microsurgery, and sperm recovery rates as high as 90% now seem realistic (4, 22). Unfortunately, the pregnancy rate is considerably lower, 50% being a reasonable expectation at present. The differential, due to the presence of a high titer of autoimmune antibodies that cause sperm agglutination and immotility, is a problem not easily solved (5). In addition, artificial insemination may now be offered to those couples who persist in their desire for children. At present, many patients seeking vasovasostomy are actually found in the artificial insemination clinics. While not absolute, this high salvage potential is certainly one of the benefits of vasectomy as an option for permanent sterilization.
CONCLUSION Vasectomy has the benefit of being inexpensively performed as an office procedure, causing minimal disruption of routine and having a high degree of community acceptance. The risk of significant hematoma, infection, discomfort and other sequelae are within acceptable limits. Improved techniques will continue to reduce the small failure rate. Antibodies observed in half of the patients have not been linked to systemic disease, although they are a hazard for the one patient in 500 returning for vasovasostomy. Better results with microsurgery and the availability of artificial insemination further increase the acceptability of vasectomy as the method of choice. Evidence suggests that extending the minimum time of sterility confirmation to three months will permit detection of the occasional recanalization from technical failures. Although psychologic disturbances are rare, inadequate screening of the couple's motivation and expectations probably represents the greatest risk with this procedure. However, the same problem exists for all options. For the male, there is no competitive technique at this time. In a world striving for equal rights, and where the female presently carries the burden of temporary contraception, the simplicity and popularity of vasectomy as the preferred method of permanent contraception carries the additional undertones of social equilibrium. lnt J Gynaeco/ Obstet 16
496
Ackman et a!
REFERENCES I. Alexander NJ, Schmidt SS, Free MJ, Danilchik MY, Hill WT: Sperm a ntibodies a ft er vasectomies with ful gura tion. J Urol 115(1):77 , 1976. 2. Ansbacher R , Keun g- Yeun g K , Wurster JC : Sperm a ntibodies in vasectomized men. Fertil Steril 23:640 , 1972. 3. Bl oom LJ, Houston BK: T he psychological effects of vasectomy for American men . J Gen Psycho) 128(2): 173, 1976. 4. Brueschke EE, Zaneveld LJD, Rodzen R , Wingfi eld JR , M a ness JH : Development of a reversible vas deferens occlusive device. Fertil Steril 26:29, 19 75. 5. Bullocks JY , Gilmore LL, Wilson JD : Autoantibodies following vasec tomy. J Urol 11 8:604, 19 77 . 6. Crewe P, Dawson L, Tidm arsh E, Cha narin I, Barnes RD : Autoimmune im plications of vasectom y in man . C lin Exp Immunol 24:368, 1976. 7. Davis J E : Vasectom y: benefits versus risks. lnt J Gynaecol Obstet 15: 163, 1977 . 8. Davis J E, Lubell 1: Ad va nces in understanding the effects of vasec tomy. Mt Sina i J M ed NY 42:39 1, 1975. 9. Fin kbeiner AE, Bissada NK, Redma n J F: Com plications of vasectomies. Am Fam Physician 15: 86, 1977 . 10. Freund M , Da vis J E: Disappearance ra te of sperma tozoa from the ejacula te following vasectomy. Fertil Steril 20: 163, 1969. II. Gupta AS, Koth a ri LK, Dhruva A, Ba pna R : Surgica l sterilization by vasectomy a nd its effects on the structure a nd fun ction of the testis in ma n. Br J Surg 62:59, 19 75. 12. Hagedorn JP, Davis J E: Fine structure of the seminiferous tu bules a ft er vasectomy in man. Physiologist / 7:236, 1974. 13. Hell er V, Rothchild I : The influence of the surgical techniq ue used for vasectomy on testis fun ction in ra ts. J Rep rod Fertil 39:8 1, 1974. 14. Isidori A, Dondero F, Lombardo D : Antit esticula r immu-
I
l nt J Gynaecol Obstet 16
15. 16. 17. 18.
19. 20. 2 1. 22. 23 .
24.
nit y: role of the basement membra ne. Experientia 26: 1375 , 19 70. Kla ppro th HJ, Youn g IS: Vasectomy, vas ligation and vas occl us ion. Urology / :292, 1973. Peel J , Carr G : Contraception and Fa mil y Design, p 39. Churchill Livingstone, Edinburgh, 19 75 . R amos-Cordero RA, Na ftolin F, Ackma n CFD: Cha nging profil es in vasectom y subj ects in the past decade. J Steril Infertil (in press). Rosemberg E, M a rks SC , Howard PH : Serum. levels of FSH a nd LH before a n'd a ft er vasectomy in men. J Urol 3: 626, 19 74. Rumke P : Sperm antibodies a nd their action upon huma n sperm a tozoa. Ann Inst Pasteur (Lille) 118:525, 1970. Schmidt SS: Prevention of fa ilure in vasectomy. J Urol 109: 296, 19 73. Schmidt SS: Technic a nd complications of elective vasectom y: role of sperma tic gra nuloma in sponta neous recana l· ization. Fertil Steril 17:46 7, 1966. Schmidt SS: Vasovasostomy: a review of principles. Contem p Surg 7:13, 1975. Smith KD, C howdhury M , T cho1a kia n RK : Endocrine effects of vasectom y in humans. In Control of M a le Fertilit y: PARFR Series on Fertilit y Regula tion (ed JJ Sci arra, C M a rkla nd , JJ Speidel), p 169. H arper & Row, Hagers town , MD 1 19 75. Ziegler FJ: The psychological effects of vasectom y. Psychosom Med 37: 186, 19 75.
Address for reprints: C. F. D. Ackman 3550 Cote des Neiges, Suite 600 Montreal , Quebec Canada
