Elliott Smith Figure 8 Review
Roxine Denison
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The issue of tantamount importance with regard to vasectomy is not
its effectiveness or the specific technique used, but the long-term side
effects, primarily chronic pain and auto-immune reactions. Most techniques
yield effective results. The fundamental problem with vasectomy is that
occlusion of the vas leads to damage to the epidymides, the testicles, and
the blood testes barrier with subsequent auto-immune reponse that has
unknown health effects.
Testicular biopsy results at vasovasostomy show interstitial
fibrosis.(1) Sperm granuloma formation leads to dynamic and persistent
presentation of sperm surface and sperm component antigens to the patients
immune system. In some men, this leads to auto-immune orchitis. This has
been seen in rodents and the histologic changes in human testes at biopsy
mimic the changes in animal models. In human studies after obstructive
etiologies (torsion, or obstruction of the sperm ducts), the lesions are
the same as those seen in the animal models.
The antibodies directed against soluble sperm proteins (from
macrophagic breakdown of sperm in the obstructed epididymus or in sperm
granulomas) can cause auto-immune orchitis, testicular fibrosis and/or
endocrine dysfunction and may involve fixation of complement causing
basement membrane lesions, vacuolation of Sertoli cells and subsequent
decreases in effective spermatogenesis or interstitial fibrosis affecting
Leydig cell testosterone production.
Future studies should be done on men with auto-immune orchitis,
persistent epididymal inflammation, or post-vasectomy congestive
epididymitis to elucidate the specific anti-sperm antibodies or antibodies
to soluble sperm antigens in these patients. Perhaps if the specific
antibody species can be found, some sort of pre-vasectomy testing could
reduce the incidence of these unfortunate complications and their effect
on quality of life and post-vasectomy testicular function (spermatogenesis
and endocrine functions).
I read with interest the article by Aradhya, Best, and Sokal entitled
"Recent Developments in Vasectomy" (BMJ, May 2005). Of interest is their
assertion that the failure rate of cautery with fascial interposition was
superior to ligation and excision with fascial interpostion.
At a Kaiser Hospital in Southern California, in the mid 90's, we
reviewed 1179 vasectomies performed by two family physicians. The failure
rate was 0.17%, which was defined as the presence of spermatozoa in the
ejaculate after 15 consecutive ejaculations. If there was spermatazoa
present after one sample, then a second sample was obtained 2 to 4 weeks
later. These were then defined as "failures." The technique of vasectomy
was ligation with excision of an at least 2 cm segment of vas, followed by
fascial interposition. Of note, the complication rate of bleeding and
infection was no different than that reported in the literature.
The reported failure rates in the article by Aradhya et al do not
appear to take into account the length of vas excised. I believe that the
length of vas removed may be an independent factor in the failure rate.
Obviously further research would have to be done to determine if this is
the case.
Editor: The frequency of seminal fluid analysis after vasectomy,
mentioned in the article, Recent developments in vasectomy sends a wrong
message, not based on evidence.1
The whole process of spermatogenesis takes 64-70 days.2
Simplifying the arrangement of post-vasectomy analysis has a strong case.
It is cost-effective and logical. Uniformity would reduce the likehood of
the medico-legal implications of variation. Compliance would improve since
some patients do not provide more than one sample despite request to
contrary. Absence of spermatozoa in a semen sample at 16 weeks should be
enough documentation of operative success.3, 4
One semen sample taken 16 weeks post vasectomy, and further sample taken
only if motile sperms are seen is considered prudent. Non-motile sperm is
not an indication for checking further semen sample.3, 4, 5
Rate of recanalisation could not be associated with the experience of the
operating surgeon. Recanalisation and consequent paternity can occur at
any time after bilateral vasectomy and does not depend on the surgical
procedure. There appears to be no association between the length of vas
excised and the risk of recanalisation.5
We welcome the timely article on vasectomy techniques by Aradhya et
al [1] and agree with their conclusion that the highest priority for
future research is a well constructed randomized controlled trial
comparing currently used techniques.
However, we were somewhat surprised that the expert consultation did not
identify the use of non-invasive methods for male sterilization as a
future research priority.
High intensity focused ultrasound (HIFU) is one such rapid non-invasive
trans-cutaneous technique. HIFU thermally ablates subsurface structures,
by focusing ultrasonic energy on a target point, thereby inducing
molecular agitation, frictional heating and ultimately coagulative tissue
necrosis, without injuring intervening tissues.
Although human studies are currently lacking, Roberts et al [2] have shown
the feasibility of HIFU vasectomy in a pre-clinical canine model, by
demonstrating thermal occlusion of the vas without significant
complications to surrounding tissues. Subsequently, Roberts et al [3]
successfully evaluated the feasibility of HIFU ablation of the canine
epididymis as an alternative to vasectomy, and it is anticipated that
refinement of this technology may provide a rapid non-invasive alternative
to conventional vasectomy. This may be a simple and acceptable approach,
but clearly, financial implications would need to be considered in low
resource settings.
The Elliot-Smith Clinic in Oxford, UK has been undertaking
vasectomies using intra-luminal electrocautery applied to both ends of the
divided vas deferens after removal of a 1-2cm segment. Fascial
interposition is not routinely performed, nor are clips applied. Since
1974, over 30,000 vasectomies have been performed by this method.
Pending more data (which we agree are needed), we conclude that intra
-luminal electrocautery applied to both ends of the divided vas deferens
after removal of a 1-2cm segment has an acceptably low early failure
rate.
The superiority of cautery over ligation of the vas seems
established. However we agree that what are now needed are randomised
control trials comparing the cheaper thermal cautery with and without
fascial interposition: using as end-points both failure of early
achievement of azoospermia and late sperm reappearance.
this otherwise excellent article was entitled recent advances in
vasectomy, and labelled with the blue GP icon to indicate relevance to
ordinary family doctors. In that context it is a pity that the article
failed to highlight 2 of the recommendations made in the recent edition of
the British RCOG guidelines on Sterilisation.
2 Following vasectomy the previously standard procedure of testing
until 2 azoospermic samples is unnecessary. A single sample is no less
effective as an indicator of a successful procedure, and a second sample
is a waste of resources and an unneeded inconvenience to the patient.
Thermal cautery equipment is probably preferable for low-resource
settings because it is much simpler to use and to maintain, and is much
less expensive. In experienced hands, thermal cautery plus fascial
interposition can offer extremely low failure rates with minimal
destruction of the vas (5, 6).
The Manikandan study has a serious limitation due to potential
response bias. The low percent response to the questionnaires in his two
study groups, 40% and 48%, could lead to an overestimate of pain, because
men who experienced pain were probably more likely to respond to the
survey. So the estimates from the two study groups, 14% and 16% are
likely to be overestimates. The true values are probably between those
estimates and the lower estimates that one could calculate by using the
full sample populations, i.e. 460 men as the denominator. Those lower
estimates would be 5.4% and 7.8% respectively.
As Christiansen noted, the post-vasectomy pain syndrome is poorly
defined, and additional research is needed to better describe its
frequency and severity, and, in men with severe pain, to better evaluate
treatment options.
I believe Doctor Mortensen did not correctly interpret Figure 2. This
figure represents only one of the step of a vas occlusion technique with
thermal cautery. A video of the full technique of vas occlusion with
thermal cautery of the abdominal segment of the vas combined with fascial
interposition using a metal clip (which can be replaced by any suture
material in low-resource settings) is available at the bottom of the
following Internet page: