A Literature Study by Kenneth D. Reda
- Problems with the Traditional Vasectomy
- Open-Ended Vasectomy Research Results
- Open-Ended Vasectomy Technique
- A No-Scalpel Open-Ended Vasectomy
- Advantages of the Open-Ended Vasectomy
- Spermatic Granulomas
- Concerns with the Open-Ended Vasectomy
- Why Is It Not More Popular
- How You Can Get an Open-Ended Vasectomy
- If Pain Persists After Vasectomy….
- A Survey of No-Scalpel Vasectomy Doctors
- Open-ended Vasectomy Doctors
When I was considering vasectomy, I discovered that there is an option to either close both ends of the cut vas (traditional method), or leave the testicular end open (the open-ended method). If you read the relevant literature, you will find the latter procedure leaves the testicles relatively unaffected with improved reversibility and less chance of long term chronic pain. This option is seldom discussed despite a large body of strong evidence that indicates it should be the preferred technique. (Please see the American Family Physician’s July ’99 Article on Vasectomy Technique .) If you are planning to get a vasectomy, ask your doctor to do it “open-ended”.
Problems with the Traditional Vasectomy
Blocking the normal exit of sperm in a vasectomy can cause pain for a number of reasons: 1) elevated pressure within your testes, 2) swelling (i.e.dilation of seminiferous tubules) 3) thickening sperm debris and 4) interstitial fibrosis. Reversal becomes less successful with time as conditions foster potentially painful complications.
In the words of the inventor of the method, “The success rate of reversal after standard vasectomy decreases with time because the rise in pressure produces leaks of sperm in the epididymus resulting in granulomas that obstruct it so that no sperm reaches the vas.”(Dr. Edward Shapiro, personal communication, 1999) Please also see Professor Earl Owens’ Vasectomy Information page and a paper entitled Post-vasectomy pain, an underestimated side-effect. These may spur your interest as they did mine. ( Professor Earl Owen is The Vasectomy Reversal Pioneer as well as an avid open-ended vasectomy advocate.)
Open-Ended Vasectomy Research Results
These potential problems are avoided if you leave the testicular end open. (1,2,3,11,13). The sperm does not flow freely for very long into the scrotum. “A nodule i.e. a granuloma quickly forms at the cut end of the testicular end of the vas containing the sperm.” (Dr. Shapiro). This acts as a natural safety valve because it does not seal completely. Pressure cannot rise to rupture levels thus preventing the multiple tiny granulomas which look painful. Studies confirm no increase in failure due to recanalization if the closed vas end is covered by the sheath after it is cauterized. A reduced rate of painful complications is also realized.
These combined studies evaluated over 10,000 vasectomies. Another study of 100 open-ended vasectomies documented an unacceptable increase in failure rate with this technique(4), but it appears likely that study employed an improper cautery technique (5). Earlier studies failed to implement adequate sheath closure over the prostatic end of the vas (11,12), and thus were prone to recanalization / failure.
Open-Ended Vasectomy Technique
In most cases, vasectomy failures are caused by inadequate creation of a barrier of facia between the cut ends of the vas (10). An open-ended procedure should require no more work than a good traditional one, and possibly even less. Here’s a reasonable technique summary with elements from all the studies (1,2,3):
1) cut the vas. It is unnecessary to remove a segment (which can make the procedure irreversible). 2) cauterize the prostatic end – perhaps hot wire cautery is preferred for its desiccating effect(10), 3) cover the prostatic end with surrounding facia using clips (1,2) or a purse string suture(3) 4) Use a magnifier such as a 2 1/2X visor to confirm the relatively small vas is not peeking out(10).
A “No-Scalpel” Open-Ended Vasectomy
The “No-Scalpel” vasectomy uses special tools to minimize the “invasiveness” of this already simple surgery. Complications common to any surgery are reduced when cutting is minimized. Implementation of a “No-Scalpel” vasectomy with the open-ended option is an ideal combination of techniques (2,3,7).
Advantages of the Open-Ended Vasectomy
Recent articles on vasectomy technique refer to the advantages of the open-ended variation. (1,2,3,6,7): 1)Your sterility can be reversed successfully after many more years, and 2) There is less chance of chronic testicular pain from congestive epididymitis or spermatic granulomas.
Granulomas form to contain sperm leakage. The idea of the open-ended vasectomy is to reduce pressure, allow a single granuloma to form at the testicular end, and thus prevent pressure induced pain, ruptures and multiple tiny granulomas which block the epididymus. (Dr. Shapiro). Painful complications clearly occur less frequently with the open-ended technique (1,2,3,11,13)
Concerns with the Open-Ended Vasectomy
The cut vas can develop a “Medusa’s head” of ducts, each searching the lumen of the urethral end to restore continuity (8). IF the sheath is not adequately closed over the prostatic / urethral end of the vas, recanalization can occur returning sperm to semen. The prostatic end of the vas must be covered with surrounding facia to avoid this danger.
Another effect is that antibodies to sperm can develop which can interfere with sperm motility after an otherwise successful reversal (Dr. Shapiro). But 50 to 70 percent of traditionally vasectomized men have elevated serum levels of anti sperm antibodies anyway (9). The benefits of eliminating back pressure far outweigh any possible minor effect of elevated sperm antibodies with respect to reversal.
Why Is The Open-ended Vasectomy Not More Popular
Many urologists are simply unaware of this approach. Most seem more familiar with the possible dangers than they are with the documented assessments. Perhaps others are aware of early studies which documented high failure rates before the importance of the sheath barrier was understood (11,12). Others know there is a greater tendency for recanalization. Many are concerned about allowing spermatic granulomas to form. Too few are concerned with the unnatural blockage of sperm from the testicles. Many won’t perform the technique since recanalization can occur if they mistakenly leave the vas exposed. Many may consider that a vasectomy failure combined with a non-standard technique would be harder to defend in a liability suit. These are all understandable concerns. The biggest single reason is that doctors don’t have an incentive to modify a simple, inexpensive and widely accepted procedure if no one asks them to.
How You Can Get an Open-Ended Vasectomy?
Just ask. Anybody who does vasectomies can do it open-ended. Here’s a procedure you can follow to locate an appropriate vasectomologist near you: 1) Get a list of urologists in your area (yahoo). 2) Contact preferentially the offices of micro surgeons who specialize in vasovasectomy (i.e. vasectomy reversals) if possible. They have better experience to insure sheath closure over the tiny vas. 3) Send them a printout of this paper. 4) Indicate your interest in a consultation if they can perform an open-ended vasectomy. 5) Have consultations with several specialists if possible. 6)Schedule your open-ended vasectomy with confidence. You’ll have less post-surgical pain because the pressure in your testicles won’t abruptly increase. More importantly, your testicular fluids won’t stagnate and solidify and rupture over time leading to other problems. Other complications common to any surgery can of course still develop.
A Procedure to (possibly) relieve post vasectomy pain
At least 3% of vasectomized men experience painful complications. Holland reports an incidence of about 10%. Regardless of the actual statistic, it is clear that men who have had open-ended vasectomies have a far lower incidence of post vasectomy pain (PVP).
Some men have had their vasectomies reversed in hopes to relieve the pain, but reconnection is relatively expensive and offers no added benefit with respect to PVP. If you are seeking a surgical procedure for PVP, you should have your testicular vas ends snipped off effectively converting to an open-ended vasectomy.
Professor Earl Owen was kind enough to provide the following information which I quote from his email: “I have now done a further 500 Open ended Vasectomies without having ANY report back with the PAIN Syndrome that is seen in so many(I would put it higher than you do, at least 10%) from “routine” vasectomies. I have had a further 36 patients referred to me with the PAIN Syndrome who have had to have the conversion to an OPEN ENDED vasectomy, and of these only some 4 have not had a complete cure. Those unfortunate 4 men have gone on to have to have an epididymectomy which did finally relieve their pain.”
Dr. Neil Pollock from Vancouver Canada is also proactively seeking patients who might benefit from this procedure. Other urologists should be capable of this procedure as well, though surprisingly few are familiar with the advantages of the open-ended vasectomy. (A situation I hope will improve).
If you have had a vasectomy and are experiencing painful complications, maybe this conversion procedure can provide relief.
A Survey of No-Scalpel Vasectomy Doctors
While searching for a urologist to do my own vasectomy, I sent ten NSV Doctors in NJ copies of this paper and asked if they would perform open-ended vasectomies. Five said they would if asked (i.e. Drs. Fermaglich, Galdieri, Kotler, Rossman and Stulberger), three said they would not, and two did not answer.
It appears that many vasectomologists (about half) would be willing to perform an open-ended vasectomy if asked. Virtually none offer the variation in the absence of a specific request. Virtually all are genuinely skeptical that the open-ended variation can be as reliable as the traditional method. Half will concede that a patient has the right to the documented benefits of reduced pain and improved reversibility if they are aware that many doctors fear that there is a slight increase in the chance of recanalization (i.e. failure, pregnancy.)
I created this web page so that men researching their own vasectomy can benefit from my research to make an informed decision regarding technique. I of course will assume no responsibility for any vasectomy related problems construed to result from any information contained at this site. Even open-ended vasectomies can have painful complications (though less likely), and an open-ended vasectomy done wrong can be more prone to failure.
I’m a chemical engineer and I work for Merck in New Jersey. I have no medical training aside from my analysis of the relevant literature. I never did have the vasectomy I planned and researched. My wife and I lost interest when we learned that at least 20,000 men in the US suffer painful complications from vasectomy each year.
I am providing this website to summarize information which can reduce the occurance of a particularly unfortunate and avoidable pain.
Please forward this to your doctor, your urologist, and to friends who may be considering surgical sterilization.
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. Moss WM: A comparison of open-end versus closed-end vasectomies: a report on 6220 cases. Contraception 46: 521, 1992.
. Denniston GC, Kuehl L: Open-ended vasectomy: approaching the ideal technique. J Am Board Fam Pract 7:285, 1994.
. Temmerman M, Cammu H, Devroey P, Amy JJ: Evaluation of One-Hundred Open-ended Vasectomies. Contraception 33(6):529-32, 1986
. Errey BB, Edwards IS. Open-ended vasectomy (letter) Fertility and Sterility 49(2):380 1988, Feb
. Davis JE, Male Sterilization Current Opinion in Obstetrics and Gynecology 4(4):522-6, 1992 Aug.
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. Shapiro IE, Silbert SJ, Open-Ended Vasectomy, Sperm Granuloma, And Postvasectomy Orchialgia Fertility and Sterility 32:546-550 1979 Nov.
. Goldstein M, Vasectomy Failure Using an Open-Ended Technique Fertility and Sterility 40:699-700 1983 Nov.
. Horan AH, Open-Ended Vasectomy Fertility and Sterility (letter) 46(5):979-80 1986 Nov.
. Flickinger CJ, The Effects of Vasectomy on the Testis The New England Journal of Medicine V313:1283-5 1985 Nov.
Published August 27, 2001
Contact Kenneth D. Reda