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April 15, 2002

The unkindest cut?

By George Sirois

The magazines in the waiting room were familiar, the carpet was a little worn, and he was greeted by a receptionist rather than a nurse. All of this gave comfort to Warren Dickson as he awaited his vasectomy. He faced surgery so minor that he wasn't even at the hospital. And the operation itself was much as he expected: "Snip, snip and it was all over."

In addition to the procedure involving little pain, he was assured that it was perfectly safe and that his libido would be unaffected. As far as he knows, he hasn't suffered any side-effects at all. He has rarely, if ever, thought about it since. If he were to explore the possibility of reversing the procedure, however, he could find himself surprised at the condition of his reproductive system.

diagram of the male reproductive tract
Photo by http://www.vasectomy.ie
This is a diagram of the male reproductive tract before vasectomy.

The word vasectomy has acquired a benign and familiar tenor as the procedure has grown in popularity. Previously widespread concerns relating to impotence have dissipated as reluctance among males has gradually atrophied. The testicles, of course, are not being removed -- just disconnected.

Use of the words atrophy and testicle in the same sentence, however, can still generate discomfort among men. Perhaps that is one reason why those in favour of vasectomy, as an alternative to sterilization by tubal ligation for females, do not highlight what may be a possible side-effect: atrophy of the testicles.

The mechanics of the operation are straightforward. Under local anaesthetic, a small incision is made in the wall of the scrotum and a section of the vas deferens (the slender tube through which the sperm travel from the testicle) is removed. This prevents the sperm from reaching the ejaculatory duct, where they would normally become mixed with seminal fluids from several glands, including the prostate, and be discharged as semen. After a brief recovery period, some aspirin, and a wait of several weeks for the system to be free of those loitering in the darkest corridors, sterility has been accomplished.

One would logically conclude that such a procedure is reversible if the capacity to reconnect the vas deferens exists. It does, and the tube is restored in operating rooms around the globe by way of a procedure called vasovasostomy. But many men seeking a reversal of their vasectomy discover that, in the intervening period, their gonads have ceased to perform their most basic function: they are no longer producing sperm. The vas deferens could be opened as wide as a new four-lane highway, but the toll will never be an issue. Production of new vehicles has ceased.

Dr. F. Antoine, an urologist from Moncton, says that the testicles "in this respect, are not unlike the muscles in your arm; if you stop using them, they will eventually atrophy."

Since the most common sterilization technique for women, tubal ligation, is a much more invasive surgical procedure than is vasectomy (requiring general anaesthetic and a hospital stay), couples have increasingly made the election that the male partner be the one sterilized. In fact, the number of vasectomies performed in the United States increased from 45,000 annually in 1960 to 75,000 in 1970 and has levelled off at 500,000 in the 1990s. In Canada, two-thirds of couples between the ages of 35-44 choose sterilization as their method of birth control. Overall, amongst that same age group, the percentage choosing vasectomy rose from 8.7 per cent in 1984 to 30 per cent in 1995, while tubal ligation increased from 24 per cent to 36 per cent during the same period.

diagram of the vas deferens severed by vasectomy
Photo by http://www.vasectomy.ie
The vas deferens is severed in vasectomy.

On the basis of the surgery, the increasing popularity of vasectomy appears entirely rational. While both the female and male sterilization techniques involve relatively safe, simple procedures, and both patients are having their "tubes tied," the vasectomy is less invasive. We are left, then, with the side effects to be expected over both short and long term.

A woman can expect to be sterile subsequent to her surgery as the egg(s) released monthly during ovulation reach a dead end and dissolve. This will continue until she reaches menopause and ceases to ovulate, a natural occurrence which would have rendered her sterile if the surgery had never been done. No claims appear to advance theories of harmful side effects due to the dissolving eggs and sex drive is believed to be unaffected. Accordingly, post-menopausal women can expect to be absolutely unaffected by having had the procedure earlier, in their reproductive years.

A similar chronology cannot be constructed in the case of a man subjected to vasectomy. While no negative health effects are believed to result from sperm decomposing in the body (assuming this is not arrested by testicular atrophy), atrophy of the testicles is not a natural occurrence. And while sex drive is not affected over the short term (except as the result of psychological impact of the procedure) the long-term effects are more difficult to determine. The testicles produce a cocktail of over a dozen hormones, including testosterone. And the question of whether the atrophy associated with vasectomy causes the testicles to cease, or diminish, the production of these hormones is of concern to some physicians.

As a man ages, he can expect his testicles to produce a decreasing amount of sex hormones. Barring serious health problems, however, he can expect that the production of these chemicals, and his sex drive, will never entirely fade away. Whether atrophy of the testicles diminishes sex drive, hastens the arrival of impotence, increases sex drive, or has an altogether insignificant impact, remains unknown over the long term. This is not dissimilar from the medical community's understanding of the most common form of male infertility, low sperm count. The most common diagnosis for low sperm count remains that it is "idiopathic." Translation: we don't know.

Accordingly, unlike specific diseases or conditions such as cancer, a diminished sex drive is difficult to diagnose as resulting from a particular procedure. The Harvard University Center for Cancer Prevention reports that "men who have had vasectomies have a slightly higher risk of prostate cancer. Scientists aren't sure why." Similarly, there is no shortage of studies documenting other easily identifiable, if rare, side-effects of vasectomy such as ruptures, leaking and epididymitis (swollen testicles). But linking long-term effects on sex drive to the procedure is more difficult. Dr. Lou Zaninovich, who specializes in male health problems at his clinic in Perth, Australia, doubts physicians dealing with impotence or male reproductive illnesses even ask about vasectomy "because doctors in general don't consider it relevant." While he has not conducted a survey, Zaninovich has "a disproportionate number of problems in men who have had their vasectomy done many years ago."

Until the recent marketing bonanza related to Viagra, impotence hardly amounted to dining table conversation. Even with the massive funding associated with anti-smoking campaigns, coupled with the hostility of the medical profession towards tobacco, smoking was only recently linked to impotence. Vasectomy, of course, enjoys the enthusiastic support of most of the medical community as a safe and effective birth control method. Accordingly, although Internet forums devoted to the side effects of vasectomy are proliferating, attempts to establish a link between the procedure and diminished testosterone levels cannot expect to enjoy similar levels of enthusiasm and support.

Some doctors are unwilling to even consider that testicular atrophy occurs as a result of vasectomy. Dr. Richard Weiss, for example, is a professor at the University of Ottawa and introduced a no-scalpel vasectomy to Canada 10 years ago. He says the assertion is false and that there is "no evidence whatsoever" that vasectomy causes atrophy of the testicles or any other ill effects.

The initial procedures conducted by American surgeons who perform vasovasostomies, however, appear to contradict this view. When making their assessments of men seeking to have their vasectomies reversed, these doctors first seek to establish the continued production of sperm. Aside from presuming a possibility that sperm production has ceased, they also refer to conditions such as a "blow out" of the epididymis which could complicate or prevent successful reversal.

Others on the cutting edge, such as Dr. Malcolm Carruthers, also question whether vasectomies are always benign. The author of a book on male sexuality, he has raised concerns about the immune system's responses to vasectomy. These include the unnatural presence of sperm outside the vas deferens provoking the appearance antibodies, which, in turn, attack the testicular tissues that produce testosterone.

With the huge increase in the number of vasectomies having only occurred in the last two decades, it may be that the long-term implications are only now beginning to emerge. This, together with growing numbers of men seeking reversals of the procedure, may eventually answer new and troubling questions about this popular method of birth control.