Q) I have been a long-term WDDTY sub-scriber since 1988, and am planning to have a vasectomy.
I need your help in making a decision about which type of operation to have. Most vasec-tomies are now 'no-scalpel' types, but I cannot find any information about whether to opt for an open or closed vas. I am inclined towards an open type, but which would you consider better?-R.C., Co Leitrim, Ireland
A) Your nitty-gritty question reflects the growing sophis-tication of this increasingly popular sterilization tech-nique. Since first becoming available in the late 1950s, vasectomy is now a routine, outpatients procedure. Worldwide, an estimated one in 20 couples now rely on vasectomy for contraception, although the national averages vary hugely-in the UK, for example, it's one in five couples.
However, despite its routineness, relatively few clinical trials have tested the various possible techniques, perhaps because the operation is so simple. All it involves is severing the vas deferens, the sperm-carrying tube in the scrotum. However, there may be complications such as prolonged inflammation and bleeding, chronic pain and bruising, and even heart problems. Sometimes, the operation fails outright, although this is said to be becoming rarer. 'No-scalpel' vasectomy (NSV) is rapidly taking over from the older cut-and-snip operation. The major difference is that the scrotum is pierced rather than incised. Using the pierced hole, the vas is hooked out, a short length of it removed and the cut ends reinserted into the scrotum. NSV causes less bleeding, bruising and pain during surgery, less postoperative pain and a quicker resumption of sexual activity. (Cochrane Database Syst Rev, 2007; 2: CD004112).
Your question has to do with the cut ends of the vas: should they be left open, or sewn shut? In the early days, both ends were routinely sutured, but there's now a school of thought that says that the sperm-producing end of the vas should be kept open. The idea is that preventing the sperm from escaping could cause a buildup of pressure within the vas, leading to pain. This appears to be borne out by the facts. In one study, the closed-end technique produced prolonged pain in 6 per cent of men compared with2 per cent with the open method (Contraception, 1992; 46: 521).
However, the open technique is not without its own set of problems. There is an increased risk of sperm granulomas, where the sperm cause the formation of knotty lumps that are around half a centimetre in diameter. These may cause pain like a kidney spasm and last for up to a year (Ugeskr Laeger, 1990; 152: 2282-4).
Another issue is the success rate of the operation. China has one of the worst records, with a failure rate of nearly 10 per cent. In the West, upto 2 per cent of vasectomies fail to work, but the rate varies considerably among the various techniques.
The most reliable method appears to be the crudest. Cauterizing the vas (burning it shut) appears to have the lowest failure rate (BMC Urol, 2004; 4: 12).
The open technique you favour may be less reliable because the sperm granulomata can lead to the formation of a 'bridge' between the two severed ends, allowing sperm to flow again. However, as there is little hard data on this so-called 'recanal-ization' issue, and it's not necessarily permanent, it may be a risk that you are prepared to take.
One advantage of the open-ended technique is if you change your mind, as reversing this operation is easier.
However, there are still those issues as to whether vasectomy causes cancer (see box below), and what happens to the antibodies to sperm found in the blood of men who have had the procedure.
In this light, you may wish to consider an alternative form of contraception, one that carries no question marks over its long-term safety.
Does vasectomy cause disease?
Over the years, there have been many concerns over the health consequences of vasectomy, with fears that either preventing or allowing sperm release could cause disease. What's more, antibodies to sperm are routinely found in the blood of most vasectomized men, so could this be bad news, too?
With over 30 years of data, the most recent review of the evidence has found an "unexpected and unexplainable" increase in lung cancer deaths, but a reduction in others such as colorectal and kidney cancers. These were explained away as being "chance findings"; nevertheless, the crude figures show a relatively small (10 per cent) increase in death rates among men who had a vasectomy more than 20 years ago. On the other hand, more recent vasectomy shows fewer cancer deaths than expected (Fertil Steril, 2000; 73: 923-36).
There has also been particular fears over prostate cancer, with some doctors screening for prostate risk, or discouraging vasectomy in men with a family history of the cancer. This has been a huge area of controversy, mainly because the epidemiological data are conflicting. For example, a recent statistical survey of all New Zealand vasectomies found no increase in prostate cancer (JAMA, 2002; 287: 3110-5), whereas a similar but larger survey in the US showed an almost threefold increase in 'low-grade' prostate cancer risk (Cancer Causes Control, 2005; 16: 1189-94).
However, some experts believe such a connection is spurious, as the possibility of 'detection bias' cannot be ruled out. Simply put, people with vasectomy are more likely to be screened for prostate cancer, so it is inevitable that more such cancers will be found.