Introduction:
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".
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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.)
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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.
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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).
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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).
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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.
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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)
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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.
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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.
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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.
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A Procedure to (possibly)
relieve post vasectomy pain:
At least 3% of vasecomized 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 pro actively 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.
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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. 5 said they would if asked (i.e. Drs.
Fermaglich, Galdieri, Kotler, Rossman and Stulberger), 3 said
they would not, and 2 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.)
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Open-Ended
Vasectomists:
I know that the following doctors perform
open-ended vasectomies. I'm sure that there are many more. Please
send the contact information of any doctors to add. The following
link provides additional vasectomy related information and can
help locate a suitable service provider www.VasectomyMedical.com:
California, Santa Monica-UCLA, Dr. Thomas A. Bzoskie, (310)
319-4700
California, Thousand Oaks, Dr. Barry Lefkovitch , (805)
495-1066
Florida, Tampa, Dr.
Douglas Stein, (813) 903-1902
New York, Albany, DR. Orekondy, 116 Everett Rd., (518)
437-1200
North Carolina, Raleigh, Stephen F. Shaban
Tennessee, Knoxville,Dr.Larry E.
Davis, (865)544-9352
Texas, Houston, Dr. Michael
Crouch, (713)798-7700
Texas, Round Rock, Dr.
Flint DeShazo, (512) 244-1995
Wisconsin, Milwaukee, Dr. John J.
Seidl, (414) 962-1999 or 961-1810
Wisconsin, Waukesha, Dr.
Steve Klemish, (262) 513-7555
Australia: Professor Earl
Owen (The Vasectomy Reversal Pioneer)
Canada, Alberta, Dr.
Rick Balharry , (403) 678-5511
Edmonton,Canada, Dr Mike Hancock, (780) 433-7211
Canada, Ottawa, Dr. Edward I.
Shapiro (Inventor of Open-Ended), (613) 523-1170
Canada, Ontario, Dr. P. Cragg,
1-866-GENTLE-1
Canada, Vancouver: Dr.
Neil Pollock
Canada, Vancouver, Dr. Barry
Rich
Ireland: Dr. Andrew
Rynne
UK, Dr. Andrew Dawson (Hartlepool Vasectomy
Clinic)
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Disclaimer:
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.
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Personal:
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.
References:
[1]. Errey BB, Edwards IS. Open-ended
vasectomy: an assessment. Fertil Steril 1986; 45:843-6
[2]. Moss WM: A comparison of open-end versus closed-end
vasectomies: a report on 6220 cases. Contraception 46:
521, 1992.
[3]. Denniston GC, Kuehl L: Open-ended vasectomy: approaching the
ideal technique. J Am Board Fam Pract 7:285, 1994.
[4]. Temmerman M, Cammu H, Devroey P, Amy JJ: Evaluation of
One-Hundred Open-ended Vasectomies. Contraception
33(6):529-32, 1986
[5]. Errey BB, Edwards IS. Open-ended vasectomy (letter)
Fertility and Sterility 49(2):380 1988, Feb
[6]. Davis JE, Male Sterilization Current Opinion in
Obstetrics and Gynecology 4(4):522-6, 1992 Aug.
[7]. Stockton MD, Davis LE, Bolton KM, No-Scalpel Vasectomy: A
Technique for Family Physicians American Family Physician
Vol 46 #4, 1992 Oct.
[8]. Shmidt SS, Vasectomy JAMA Vol 259 #21, June 3,
1988
[9]. Linnet L, Clinical immunology of vasectomy and vasovasectomy
Urology 1983;22:101-14
[10]. Schmidt SS, Vasectomy failure and open-ended vasectomy
(letter) Fertil Steril. 44(4):557-8 1985 Oct.
[11]. Shapiro IE, Silbert SJ, Open-Ended Vasectomy, Sperm
Granuloma, And Postvasectomy Orchialgia Fertility and
Sterility 32:546-550 1979 Nov.
[12]. Goldstein M, Vasectomy Failure Using an Open-Ended
Technique Fertility and Sterility 40:699-700 1983 Nov.
[13]. Horan AH, Open-Ended Vasectomy Fertility and Sterility
(letter) 46(5):979-80 1986 Nov.
[14]. Flickinger CJ, The Effects of Vasectomy on the Testis
The New England Journal of Medicine V313:1283-5 1985
Nov.
Aug. 27, 2001 / Kenneth D. Reda