CLINICAL USE OF VASECTOMY FOR STERILISATION
Work on Vasectomy in its various aspects is about a century and a quarter old. Earlier work was experimental and concerned mainly with the study of the effects of Vasectomy on the germinal epithelium of the seminiferous tubules. There was no unanimity in the findings of the various workers until the end of the nineteenth century and meanwhile the operation came to be used clinically. First it was used as treatment for senile enlargement of the prostate as an alternative to castration, later, it was used for sterilization. It use was extended for the prevention of ascending and descending infection in genito-urinary tuberculosis. Many patients reported improvement in their physical and sexual lives following the operation. This led to the consideration and use of the operation for rejuvenation. It also led some workers to investigate into the changes in the interstitial cells of the testes after the operation, in an attempt to seek the cause of the reported sexual improvement. Even from this work no conclusions could be drawn as the various workers expressed diverse opinions. Of late circumstances have led to investigations on the possibility of the reunion of the vas, with a view to re-establishing reproductive functions. During this work we came across cases in which accidental automatic reunion of the vas occurred after the operation. This opens another subject of study, the possibility of temporary sterilization for spacing the children.
One of the earliest observations on the effects of occluding the vas deferens is that of Sir Ashley Cooper (1830). Noted amongst those who contributed to the experimental work on the subject are Brissaud (1880) Shattock and Seligman and Oslund (1924).
The clinical use of vasectomy was pioneered by Oschner (1899) and he submitted an interesting paper on it. He was followed by Sharp (1937) who did extensive clinical work on the subject. Steinache, (1921) on the basis of clinical and experimental work put forward the theory of ‘Rejuvenation following Vasectomy’. He tried to prove his claim by experimental work, which is still disputed. Benjamin (1922) did clinical work and believed in Steinache’s theory of rejuvenation. Clifford Morson (1933) was the first to report the various complications due to technical surgical errors. Y. Furusawa (1955) reported his observations on vasectomy. In the Indian Medical Literature, the earliest report on the subject is by Mathews (147). He performed one hundred and six operations for rejuvenation in a period of twelve years and reported very favorable results. Kenneth Walker (1953) reported no adverse delayed effects as late as thirty years after vasectomy. Phadke (1952) reported a follow up of 500 cases done in twenty years, with no adverse results.
Literature on vasorraphy, to undo the vasectomy includes successful reports by Cameron (1945), O’Connor (1948), Handley (1951) Dorsey (1957) and Phadke (1956).
The work to study the effects of Vasectomy was started at the Medical College Hospital, Indore, in 1952 in the form of an experimental work, to study the changes, which took place in the testes in sterilized (vasectomised) rats. Clinical study consisted of vasectomy in men for conception control or rejuvenation or both. During the period 1954 to 1957, five hundred and forty two operations were done on men and the result has been followed up for varying periods largest numbers are coming now for the operation but have not been included in this study because of the too short period of follow-up.
The cases selected for the operation had volunteered themselves. Most of them came because they already had too many children- varying from four to seventeen (living children). Some of the cases expected rejuvenation in addition. These persons ranged between the ages of 25 and 60. A careful history of the cases was taken, personal, family and about marital life. They were interviewed to study their state of mind regarding the fear of possible bad after effects of the operation. Those with fears about the consequences were advised not to undergo the operation to avoid any psychological complication.
The selected cases were advised to report on the morning of the operation day. The first fifty cases were operated on by the standard two-incision technique (under local infiltration anesthesia). Since then the operation is being carried out through the one central scrotal incision of about half an inch in length, and bilateral vasectomy done through the same. A piece of vas deferens 2 cms. to 5 cms. in length was excised and ends ligatured with chromic catgut No.1. One stitch is applied to close the skin incision. A firm scrotal support and analgesics were prescribed besides antibiotics for four days. Operation cases did not stay in the hospital and were advised to report after two days when the stitch was removed. Contraceptives were advised for a period of about six to eight weeks, after which the semen was checked up for living spermatozoa. A follow-up of these cases was done, by a set questionnaire mailed to them after periods of six months to four years.
EXPERIMENTAL STUDIES
Thirty six month old male rats of the species Rattus were selected each weighing 150 gms to 160 gms. The normal life span of these rats is estimated to be two to three years; they enter the reproductive phase at the age of six months. The advantage in the choice of this animal is that the study of the progressive testicular changes after vasectomy over a period of six months represents a quarter of its sexual life which would, therefore, correspond to a study of about 10 years’ duration in man. They were divided into three batches: two batches of five each and the third of twelve (eight were kept as stand by). The first batch of five was anaesthetized and their testes removed for the study of the normal histology. The second batch of five served as controls ((unvasectomised) and their testes were removed at the end of six months to note the changes due to age. The experiment itself was done on the third batch of twelve rats. Rats were anaesthetized with either in the animal anesthesia box, and maintained under anesthesia with a cap. After preliminary preparation of the abdomen and scrotal regions by clipping of hair followed by painting with an alcoholic solution of iodine, the scrotal sac was opened by a transverse incision and the vas deferens identified. Other structures were separated from it to ensure that no damage was caused to them. The vas itself was crushed over an inch between two artery forceps and excised. The ends were tied with chromic catgut No.00, and the scrotal sac closed in layers.
One rat was subjected to orchidectomy every fifteen days, thus twelve rats were experimented upon and studied in six months.
These rats were throughout kept in separate cages. Given a mixed diet, sufficient always so that some was left over in the cage. They were looked after carefully and protected against heat and disease. In this series there were no operative or anesthetic causalities.
After orchidectomy each testis was weighed and hardened in formalin, embedded in paraffin, and sections, four microns thick, were made. They were stained with eosin and haemotozylin and the histological changes in the interstitial tissue and the seminiferous tubules studied.
In the unvasectomised rats the histology showed normal testicular tissue with active spermatogenesis both before and after the experiment. This shows that the operation of vasectomy was done after the commencement of spermatogenesis and that within the course of the experiment there were no changes due to aging of the rats: nor due to confinement and care. Any changes that were noticed following vasectomy could, therefore, be rightly considered to result from that operation.
The study of the histology in the vasectomised rats shows that within 2 weeks following the operation the seminiferous tubules began to show degenerative changes accompanied by congestion of the stoma. This degree of degeneration seemed to increase during the first 8 weeks. This is explained by the fact that sudden blockage of the outlet inhibits the activity of the testes. Subsequently, however, spermatogenesis was seen. There appear to be two possible explanations:
(a) That the degeneration induced by the operation is temporary.
b) That it is incomplete.
Previous workers have also made this observation and explained it as a temporary degeneration followed by renewal of the function of at least some of the seminiferous tubules.
In sections of the testes removed eight week after vasectomy, the appearance was striking, consisting of islands of normal seminiferous tubules surrounded by degenerated tubules and vice versa. This appearance seems to be the result of active regeneration of a focal type contrasting with the surrounding features of degeneration.
The interstitial tissue shows hardly any change immediately following the operation. From the tenth week onwards it is more noticeable that it usually is in a normal unvasectomised rat. The proliferation of the interstitial tissue is quite striking towards the end of the experiment. This observation though not exactly in accordance with that of the former workers is in keeping with the generally observed increase of interstitial tissue following vasectomy, and may well be factor conducive to hypertestoidism. A simultaneous histological study of the testes and estimation of androgens (17 ketesteroids) in animals would possible throw more light on the subject.
During the clinical work great care was taken to avoid the complications due to technical surgical errors that have been described in the literature on the subject and which are responsible for the operation not gaining its right place. Precautions against known defects in technique hardly increased the time of operation and produced encouraging results. The operations were done in the major operation theatre. The single incision technique adopted by one of us (P.S.J) was found more satisfactory and convenient than the usual two incision methods. Approach to the vas deferens is antero-medial in the single incision technique is compared to antero-lateral in the two incision operation. There is no disadvantage in the single incision technique and it is better as it causes less pain and only one small incision. The difference in the technique can be appreciated in (figures 1 and 2).
It has long been observed that many patients felt an increased sexual capacity after the operation. Indeed this observation formed the basis of Steinache’s work on rejuvenation. Our observation in this series has been that six persons complained of diminution of sexual capacity, eighty-six reported an increased sexual strength and desire, while one hundred and ninety eight maintained that their sexual capacity remained as before. A young man of thirty complained that he felt too much desire for sex and that later he felt tired. He stated that the frequency of the sexual act had increased, with resultant tiredness and requested “to unlink the brain and sex as he was all the time thinking of sex only”. Two others from the same age group commented that they had nocturnal emissions, even when they remained with their wives. The other three belonged to the age group of the forties. They felt a lesser desire for sex, but said that when they met, the pleasure remained as before.
We do not claim that there is definite rejuvenation but we assure them most emphatically that their sexual capacity will not diminish but may increase; and most of those undergoing the operation for conception- control are encouraged.
One hundred and eighteen cases reported an improvement in the sense of general physical well being, one hundred and fifty six reported no change and sixteen complained of poor health. All those who reported poor health concluded by stating that on the whole they felt happy. Eighteen cases reported diminished weight after the operation, one hundred and sixty reported the same weight as before and one hundred and twelve had put on weight following the operation.
Relief from the anxiety of further additions to the family has probably been the cause of the pleasant mental reaction to the operation. To a certain extent this pleasure has been associated with the increase of sexual capacity, especially in the older men, who feared senility. Of those who reported that they were unhappy, four were those in whom the operation was not successful, other described all their present illness including indigestion and threadworms to the operation. No amount of explanation could convince them that these diseases had nothing to do with the operation. Two hundred and sixty eight felt very happy after the operation and many have been lavish in their praise of the operation. Theirs is the most eloquent testimony in support of vasectomy for conception control.
An increase in capacity for work and concentration has been reported by only a few and is probably the result of lessening of anxiety and greater sense of security.
The reactions of the wives of the patients have been varying. Ninety-six feel happy because of the freedom from further child bearing. One hundred and ninety however, have not recorded any particular reaction. Four reported conception after the operation. Improvement in the health of their wives would result mainly from freedom from child bearing but it would take some time for the difference to be felt (Table 1).
TABLE 1
The Answers to the Questionnaire
|
General Body |
Health |
Weight |
Libido |
Capacity for work |
Capacity for concentration |
Wife's health |
Mental reaction |
|
Same |
156 |
160 |
198 |
134 |
218 |
204 |
190 |
|
Better |
118 |
112 |
86 |
138 |
68 |
80 |
96 |
|
Worse |
16 |
18 |
8 |
18 |
4 |
4 |
4 |
The material to ligate the cut ends of the vas deferens was chromic cutgut No: 1. For some time in the year 1956, plain catgut No 00 was used, one of these case reported that his wife conceived ten month after the operation of vasectomy. The semen of this patient was examined and actively motile spermatozoa were detected. A second operation was then performed by the inguino-scrotal incision; the spermatic cord was pulled up to look for the site of breach in the vas deferens caused at the 1st operation. At the site of breach the tissues were adherent, a fusiform swelling was seen and at the tapering ends of this vas deferens was identified on either sides. This was separated and excised along with about 1/2 “ of the vas deferens on either side. The cut ends of the vas deferens were ligatured with thread and dropped back. The piece so removed was then injected with saline through the lumen of the vas deferens; it swelled up the fusiform swelling and appeared at the other cut end of the vas deferens. Three such cases followed. All of these were done at the same period, and the same ligature material was used. In the large number of cases then chromic catgut No 1 was used no communication followed re-establishment of connection of the tube ends.
The literature available on the subject reveals similar observations by other workers. Thus, there is a distinct possibility of automatic reunion of the vas deferens (if it is not breached but crushed and ligatured with plain catgut) and if this could be achieved at the desired time, temporary sterilization will be possible, for those who need spacing of the children. In the event the automatic reunion does not take place vasorraphy will be easier in these cases, as the vas deferens will be found in continuity.
CONCLUSIONS AND SUMMARY
1. Five hundred and forty two operations (vasectomy) for sterilization in men were performed in the last four years. The two-incision technique and the rest did the first fifty cases by a single scrotal incision. Follow-up was done in three hundred and seventy six cases to assess the clinical effects of the operation.
2. Young rats were vasectomised. Every two weeks up to six months orchidectomy was done in one of them, and the testicular sections studied histologically, similar studies were done on the same age group to serve as controls.
3. The available literature on the subject is reviewed.
4. Vasectomy as a measure for conception control, and other purposes, has no untoward effects, on the physical, mental and sexual faculties.
5. Bad effects reported, are never due to the operation itself, but result from technical errors, namely, sepsis, injury to the blood vessels and nerves of the spermatic cord, or to accidental cutting of structures other than the vas deferens.
6. There is physical and sexual improvement in most cases and great mental relief.
7. Phsychologically unstable cases, and those prejudiced to the operation, should be advised not to undergo vasectomy.
8. Temporary sterilization, for spacing the children is a subject, which needs consideration and study.
9. The operation of vasectomy by a single scrotal incision is an ideal and safe procedure (Opinion not shared by one of us. B.B.Ohri)
10. Vasectomy is followed by degeneration of the seminiferous tubules at this degeneration is either incomplete or temporary. Rejoining of the vas therefore offers every hope of spermatogenesis restarting and a consequent restoration to the individual of his reproductive function.
11. Following vasectomy there is proliferation of the interstitial tissue of the testes.
12. There appears to be a correlation between the rejuvenation effect of clinical vasectomy, and the experimentally observed interstitial tissue proliferation. To establish the similarity or otherwise of the two problems, simultaneous estimation of androgens (17 ketosteroids) is suggested.
ACKNOWLEDGEMENTS
Our thanks are due to Dr. C. Mohanrangam, Professor of Pathology for generous help, which enabled us to carry out the histological studies.
We are also indebted to Dr. R. Bhattacharya, Superintendent M.Y Hospital, who has been very kind to help us at various stages during this work.
We are grateful to Dr. C. Bose, Principal, M.G.M.Medical College for allowing us to undertake the work.
REFERENCES
1. Benjamin H. (1922), Endocrinology, 6: 776-786
2. Brissaud, E. (1889) Arch. de. physiol. 769-789
3. Cameron C.S (1945) J.A.M.A 127: 1119-1120
4. Cooper A, (1830) Observations on the structures and diseases of the testes, 1st Ed. London
5. Dorsey, J.W (1957) Jour. of I.C.S April XXVII No 4 453
6. Furusawa Y. (1955) Paper read at the Fifth International Conference on Planned Parenthood at Tokyo
7. Gossiline, L (1847) Arch Gen. Ed. Med. 4th Sept. 14: 405
8. Handley, R.S 1951, Arch. Middlesex Hosp. 1, 74
9. Mathews K.V (1947), the ANTISEPTIC, May, 297-299
10. Morison, C (1933) BMJ Jan 54-55
11. O’Connor, V.J. (1948) J.Urol, 59: 229-233
12. O’ condor, V.J. (1953) J.A.M.A. 952 532-534
13. Oschner, A.J. (1899) J.A.M.A April 32, 8678
14. Oslund, R (1924) Am. J. Physiol 67: 422
15. Phadke G.M. (1952) paper read at the third International Conference on Planned Parenthood at Bombay
16. Phadke G.M. (1956), Paper read at the A.I.S Conference
17. Sharp, H.C (1937) J. Hered, Nov 374-376
18. Steinache: (1921) Arch. F. Entwickmech, XLVI 557
19. Walker, K. (1953) Practitioner, Oct. 463.