In a review of the literature available on the subject of vasectomy, Ashley Cooper’s name stands out as that of the man who started experimental work on this procedure in the early part of the nineteenth century. In subsequent years various workers undertook study of the subject, but there was no unanimity in their observations; meanwhile, the operation came into clinical use in the late nineties. The experimental and clinical work was then continued simultaneously.
Cooper (1830) started the experimental work in dogs. He ligated one vas deferens and on the opposite side ligated the artery and vein without interfering with the vas deferens. The testis whose artery and vein were ligated "gangrened and sloughed". The dog was killed after six years, during which time it was observed in coitus on two occasions, but no issue followed. Post mortem study revealed that the vasectomized testis with its epididymis, was notably increased in size and that the latter, with the short stub of appended vas deferens, was gorged with spermatozoa. Occlusion of the duct had been complete, and the two ends of the severed duct were separate. This conclusive experiment showed that merely closing the outlet duct of the testis had no effect on the germinal portion of the testis; spermatogenesis continued for six years after the operation, and the epididymis became enlarged to accommodate the products of germinal cell activity.
Gosselin, some years later (1847) dissected human cadavers and noted cases in which the vas deferens was entirely occluded and had undoubtedly been so for many years; the enlarged epididymis contained quantities of spermatozoa. Gosselin undertook the experimental study of effects of ligation and resection of the vas deferens, using dogs as experimental material. He noted that normal spermatogenesis was present four to six months after such an operation.
Brissaud (1884), working on rabbits and dogs respectively, observed that occlusion of the outlet duct had no influence on spermatogeneis. Simmonds (1921) in human autopsies, found occlusion of the vas deferens of years’ standing without any injury to the generative part. Neither testicular degeneration nor loss of the germinal epithelium had occurred, and the epididymis was enlarged by the immense number of spermatozoa carried to it.
The extensive study of sex glands conducted by Bouin and Ancel (1903) and (1904) was the chief factor in changing the tide of opinion as to the effect of occlusion of the vas deferens. Summarizing many of their different studies, Bouin and Ancel declared that closing the outlet from the testes by ligation and resection of portions of the ducti deferenti, invariably leads to degeneration of the germinal tissues of the testis.
They worked with guinea pigs, dogs and rabbits, young and adult. According to their account, ligation of the outlet duct before puberty does not interfere with the attainment of complete germ cell differentiation, but after this the seminiferous tubules rapidly lose their lining epithelium and become converted into a testis entirely similar to the cryptorchid testes found in nature (i.e. with seminal tubules reduced and having a single layer of columnar sertolli cells prolonged into filamentous processes, with no sperm forming cells present). They dismissed the contrary observations of the earlier writers by assuming that insufficient time elapsed after operation before the animals were killed.
Shattock and Seligman (1940) performed double vasectomy on Hardwick rams. Despite complete bilateral occlusion of the vas deferens for eighteen months. the testes were normal in size and spermatogenesis continued; the epididymis was much larger than normal, owing to the retention of the products of spermatogenesis. They noted that testes might be abnormal if the blood vessels had been included in ligation of the vas deferens.
Kunts (1921), after experiments on the dog, stated that thirty days after unilateral vasectomy the testis on the same side showed degeneration; but similar degeneration was seen on the untreated side also. He conceived of some influence operating through the nervous system that caused degeneration on the opposite side. He reported later experiments on both the dog and the rabbit, in which practically all animals showed testicular degeneration as the result of ligation and resection of the vas. In control animals, however, Kunts noted that the testes were likewise aspermatic and recognized the fact that confinement and care of the animals had been such that the testes not operated on had degenerated to about the same extent as those of the experimental animals. He then withdrew his former suggestion that sympathetic nervous influences set up by one degenerating testis caused degeneration of the opposite one, but he allowed the idea to stand that, within a month after operation, the degenerated testis shows the influence of ligation of the vas deferens.
The greatest impetus to the conception of seminiferous tubule degeneration following occlusion of the vas deferens (since Bouin and Ancel) has been the striking and apparently conclusive work of Steinach (1910-1920), culminating in his suggestive work on rejuvenation. In 1921, after ligation of the vas deferens in rats.
He expressed the opinion that an animal so old as to have Steinach reported degeneration of the germinal epithelium accompanied by hypertrophy of the interstitial cells, the hormone-producing tissue; secondarily, this stimulating hormone causes renewed germ cell production lost its capacity for germ cell production is reinvigorated by unilateral ligation of the vas deferens, and that the opposite testis, after the stimulation, begins to produce germ cells again and the animal returns to a functional condition. Steinach maintained that ligation between the epididymis and the testis proper hastens degeneration and hypertrophy of the interstitial tissue. (On his is based the Steinach II operation).
Tiedje (1921) followed Steinach in postulating degeneration of the germinal epithelium and then regeneration after vasectomy. Wheelon (1921) observed that nine months after occlusion of the vas deferens in the dog the testis contained all elements of the germinal epithelium. In his opinion, either all the tubules did not degenerate or regeneration occurred.
Sand (1921) studied the effects of vasectomy on the rat, guinea pig and dog. He confirmed the theory of Bouin and Ancel, that ligation of the vas deferens causes degeneration of the germinal epithelium. He also employed the operation in clinical practice.
Moore and Quick (1924) performed the operation on a series of rabbits, studying the testes at intervals from thirteen days to six month after the operation. They encountered no evidence leading them to assume that early degeneration of the germinal epithelium occurred and was followed by regeneration.
In view of the conflicting results, Oslund (1924) undertook a detailed study of the changes in the germinal tissue of the testis of rats and guinea pigs after vasectomy. In his paper describing this work, published in 1924, he divided the experiment into two parts. In the first, no special regard was paid to the position of the testis. Degeneration followed vasectomy in some of the case; spermatogenesis continued in others. During one of these experiments he noted that the testis, after vasectomy, had come to occupy an intra-abdominal position as a result of an adhesion, since his operation had been done by the abdominal route. He then embarked on the second series of operations, in which he controlled and observed the position of the testis. In some of the cases, thirty to sixty days after bilateral vasectomy, one of the testes was pulled into the abdomen and the other left in the scrotum. The animals were killed two to three weeks later. From a study of the changes following these various operations Oslund concluded most emphatically, that vasectomy alone does not cause degeneration, and that the condition observed was due to the intra-abdominal position of the testis and was, therefore, of the nature of artificial cryptorchidism.
Gordon (1953) referred to many cases reported by many different clinicians in which sexual precocity was associated with functioning interstitial cell tumors of the testis. He also cited cases in which there was testicular deficiency associated with absence or scarcity of Leydig cells. This association of the testicular hormone with the Leydig cells lends support to the observations of Steinach. (Steinach claimed that vasectomy, by causing backpressure in the seminiferous tubules, leads to degeneration of the germinal epithelium, while there is a corresponding increase in the interstitial tissue, and that this proliferation of the interstitial tissue leads to hypertestoidism and rejuvenation. On the basis of this theory he advocated the use of vasectomy for rejuvenation) Wright (1952) supported the conclusion that sexual function is related to the activity of the interstitial tissue.
In 1954 we undertook studies of the histological changes in rat testes following vasectomy after variable periods. At the end of the experiment we concluded that spermatogenesis is temporarily and incompletely depressed. Spermatogenesis will restart as before if the obstruction to the vas deferens is removed. Interstitial cells showed definite proliferation, which could be the cause for the reported sexual and physical improvement in the clinical cases. It was decided that "the study of the 17 ketosteroids excretion in urine, before and after the vasectomy" in men may throw further light on the subject. This work has been started, but some time will be required before conclusions can be drawn.
In the late 1890's vasectomy began to be widely used by genitourinary surgeons, mainly in connection with operations on the prostate. Ochsner (1899) observed that his patients reported no change whatsoever in their sex lives after vasectomy.
Harry Sharp (1937), a physician in a penal institution at Jeffersonville, Indiana, had a patient, a young man, who complained of excessive masturbation and insisted upon castration. Sharp advised him not to undergo that mutilating operation and advised vasectomy instead. The patient agreed, and it was performed. Six months after the operation the patient reported that he had stopped masturbating and felt little desire to do so. This encouraged Sharp to carry out further work on these lines. In ten years he did 4d56 operations and reported that he had seen no unfavorable results. Benjamin (1922) carried out experimental and clinical work and published a favorable report on the subject. Sand and Steinach did important clinical work, and the later inaugurated his new technique of dividing the vas deferens between the testis and the epididymis as he considered that this led to rejuvenation. He had a large following, who came to be known as "rejuvenators".
Clifford Morson (1933) described the complications following vasectomy. Morson concluded that there were no bad effects due to division of the duct and that such results were due to faults in technique. Mathew (1947) did vasectomy in 106 cases for rejuvenation purposes between 1931 and 1946. He published the figures and commented on the usefulness of the operation. Phadke (1952) commented favorably on vasectomy for sterilization.
Kenneth Walker (1953) stated: "It can be said with confidence that vasectomy has no adverse effects on the physical or mental welfare of the patient. Operative patients have now been watched for a period of 30 years and no delayed adverse results have been noted." He undertook the clinical work in 1958 and followed up the cases at varying intervals. It was observed that complications occurred because of technical surgical errors.
It used to be the consensus that vasectomy, once done, was irrevocable. An accidental vasectomy during a herniorraphy led to the first attempt to anastomose the vas deferens (Cameron, 1945). Twyman and Nelson (1941) reported cases of vasorraphy following vasectomy for contraception, and the operation was done four to seven years after vasectomy. Handley, in 1951, reported a case in which vasorraphy was done ten years after vasectomy, with complete recovery of function, so that the patient’s wife became pregnant about six months after the operation. Phadke (1958) has done the vasorraphy operation with success. This shows that rejoining the cut ends of a severed vas deferens can restore function. O’conor (1948) described the technique of vasorraphy in detail. Dorsey (1957) reported favorably on surgical correction of post vasectomy sterility.
Natural reunion and canalization has followed the division of the vas deferens both in human beings and in animal experiments (Evridge and Vernon, 1956). In the follow up studies of these authors (1958), natural reunion was observed in some cases.
"If the natural reunion could be timed, by using different ligature material, to the divided or crushed vas deferens, the spacing of children could be achieved. To establish this the authors have undertaken an experimental and clinical study, which may be proved or otherwise after some time".
In a final review of the whole subject, a few important facts stand out. The first is that, from 1830 (when this subject first began to interest investigators) until today, the experimental results dealing with both the germinal epithelium and the interstitial tissue changes have been contradictory and inconclusive, Against this stands the unquestioned clinical observation that there have been no bad effects after this operation and that most of the patients have been immeasurably benefited. It is also known that the operation can be undone. These heartening clinical observations encourage us to study the subject further.
BIBLIOGRAPHY
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* Lecturer in Surgery, M.G.M. Medical College, Indore
** Professor of Surgery, M.G.M. Medical College, Indore