This page examines the page entitled "Problems with the quick fix".

Quote

Analysis

"Doctors have made efforts over the years to minimize the short-term complications of vasectomy. Most guys have heard the horror stories of eggplant-like scrotums and other complications, which are the thing nightmares are made of. This has a dramatic impact on one’s enthusiasm to participate in a surgical process where such results are possible, so doctors have made many efforts to find ways to minimize such effects, even Doctors have even come up with an innocuous sounding version of the procedure called a "noscalpel vasectomy," which is advertised to have minimized complications."

Although strictly speaking this is personal opinion, it's necessary to comment on the statement that NSV is "advertised" to have minimized complications, and the general commenting on doctors motives.

Firstly, the implication that Doctors have made efforts to reduce complications is accurate in the sense that over the years the medical research has primarily been in order to make the procedure as safe as possible with the minimum of risk. That's simply being responsible. The inference that their motives have been to protect their income is frankly ludicrous. The No Scalpel procedure was not developed in the US, but in China. The purpose was to make vasectomy more acceptable to Chinese men. Far from being an "Advertised" to have minimized complications, it's an accepted fact that risks are lower with NSV than the conventional procedure.

It's long been the preferred procedure in the US based on the studies that indicate fewer short term complications with NSV. In the UK, the 2006 National Sterilisation Guidelines¹ recommendation 37 states that "Except when technical considerations dictate otherwise, a no-scalpel approach should be used to identify the vas, as this results in a lower rate of early complications.". The guidelines produced by the Royal College of Obstetricians and Gynaecologists looked at 285 studies, and formed recommendations for counselling and clinical practise of sterilisation procedures in the UK. It represents the most thorough examination of the facts currently available by a very long way.

"What doesn't get discussed very often are the long-term consequences of vasectomy and how a man’s health can be substantially affected. It’s almost like a "dirty little secret" of the urology trade. I should mention that the negative effects of tubal ligation for women and many other long-term methods of birth control used by women are well known. Unlike men, though, this has been discussed openly for many years."

Again, though this could be considered personal opinion. Saying that the medical profession covers up vasectomy complications, but openly discusses complications with female sterilisation is frankly bizarre. Statistically, female sterilisation does have more complications, and is less reliable. Therefore it's no surprise that this is discussed more - especially as the take-up rates for female sterilisation tend to be higher than vasectomy in many countries. The RCOG¹ in fact make the following statement:-

Men and women requesting sterilisation should be given information about other long-term reversible methods of contraception. This should include information on the advantages, disadvantages and relative failure rates of each method. Both vasectomy and tubal occlusion should be discussed with all men and women requesting sterilisation. Women in particular should be informed that vasectomy carries a lower failure rate in terms of post-procedure pregnancy and there is less risk related to the procedure.

"After a vasectomy, the natural duct for sperm, the vas deferens, is closed off. The testicles continue to produce sperm at a rate of about 50,000 cells per minute. These sperm cells build up pressure in the delicate epididymis portion of the testicles, which eventually ruptures from the pressure. This can occur spontaneously, or often when there is stress in the area, such as when a man is ejaculating."

There is no research to suggest that rupture of the epididymis happens during ejaculation or intercourse. Nor is the epididymis as delicate as suggested. What he doesn't tell you is that half of the sperm you produce never leaves your body anyway. The body has many self defence mechanisms to protect itself, and the one it has to break down and reabsorb sperm simply steps up a gear as described below. In fact, rupture is prevented by sperm granuloma's in the vast majority of cases. The granuloma acts as a pressure release valve to stop this happening.

"When some obstruction to sperm exiting the epididymus occurs, a "Compensatory action" happens to avoid permanent testicular dysfunction. Obstruction does not necessarily mean vasectomy - various medical conditions may cause temporary or permanent obstruction. In the case of vasectomy, initially, the diameter of the ducts increases 2 to 4 times their original size to counteract the increase in fluid pressure, and fluid absorption is increased, particularly in the efferent ducts, where 90% of excess fluid is reabsorbed. This, and other changes seem to delay significant problems, but due to the ongoing production of sperm, further alterations often take place to avoid permanent testicular dysfunction. Post-vasectomy, the level of macrophages will increase within the epididymus. Macrophage means "big eater". Macrophages are white blood cells that crawl around in the extracellular fluids of your body and gobble up microbes and other foreign material. They ingest these microbes by phagocytosis ("cell eating"). Parts of the cell surround the particle to be eaten, then the macrophage's membrane flows together and the particle ends up inside."²

Research results range from as low as 2% to as high as 33% of vasectomy patients experiencing some form of long-term post-vasectomy pain.

The 33% figure is discussed on the "Important quotes" page, and other pages of this site on the grounds that he does rather seem to love using this particular study!

It's a telephone questionnaire⁴ to a small sample of men that generated some very contradictory results. When using this study elsewhere, he deletes most of it, and uses only uses part of one sentence, and even manages to re-word that! I use the word "Discomfort", as that is the word used by study authors.

• Early complications such as infection, hematoma and orchitis (swelling) applied to 6 out of 172 patients (3.5%).

  Of the patients that answered yes to the pain question, 54% did not consider the discomfort troublesome.

  9 patients out of 172 (5%) complained of testicular discomfort related to sexual intercourse.

  9 patients (5% - and not necessarily the same 9 above) sought medical help for problems.

  2 patients (1%) required surgical intervention for Epididymectomy and 1 excision of a hydrocele.

  3 patients (1.7%) regretted vasectomy because of pain.

There are other studies that look at the incidence of chronic pain. Schwingle & Guess³ reviewed some 139 studies in their literature review. In the discussion of long term chronic pain they state that "Generally, the occurrence of epididymitis is uncommon and is reported in 0.4%–6.1% of vasectomies. Congestive epididymitis can occur sooner or later after vasectomy and linger. Typically, it lasts weeks to months, and it is extremely rare for it to last more than one year."

They go on to point out that there is a difference between infectious and non-infectious long term pain. Congestive epididymitis, and epididymitis (above) are treated with analgesics and anti-biotics. They separate off non-infectious pain and discuss it as follows:- Among the reported long-term complications of vasectomy is a syndrome of chronic noninfectious epididymal pain and induration beginning months to years after vasectomy . This syndrome has been attributed to long-standing obstruction with dilatation of the epididymal ducts, extravasation of sperm and sperm granulomas with an inflammatory reaction. The syndrome appears to be quite rare, and the attribution to vasectomy is based on case reports.

The fact that it is documented by case histories and not studies, and that there is no attempt to attribute an incidence rate indicates the rarity. it doesn't indicate that the data is "Covered up" as Hauber would like - it merely indicates that it is statistically rare. Too rare to have enough data to give an incidence rate. Nobody is saying it doesn't exist - simply that it's rare.

Schwingle & Guess³ go further than most studies do - they looked at incidence rates of post-vasectomy epididymitis-orchitis by quoting a study in which 10,590 men with vasectomies were paired with neighborhood controls without vasectomies. There was an elevated risk in the first year after vasectomy (approximately 8 cases per 1,000 person-years) that fell to 1 case per 1,000 person-years after the first year. The slight difference in figures for the vasectomised group and non-vasectomised group were not statistically significant. They conclude that "Based on these data, further study is needed to characterize this risk. However, because of the low incidence of all forms of epididymitis-orchitis, any study of a specific chronic form of epididymitis-orchitis would be difficult to conduct."

"But it is known that 75% or more of the men who have had a vasectomy will begin to produce these antisperm antibodies. Many doctors characterize this reaction as harmless. But a good deal of medical research says otherwise. "The presence of sperm antibodies correlates with nearly every pathological condition of the male reproductive tract" (Verajankorva, et al, 1999).

Well, actually most studies don't quote the antisperm antibodies rate at 75% plus!

To start with, it should be noted that:-

• Antisperm antibodies are detectable 61% of patients before vasectomy⁵

  Naturally occurring human antisperm antibodies were found to have a peak incidence of 90% in both sexes before puberty. Thereafter, the incidence declined to about 60% and persisted through life.⁶

  The men with the highest number of antisperm antibodies are naturally infertile men³

Schwingle & Guess put the rate of antisperm antibodies post vasectomy at between 52% and 68% at 6 months, and 52%–60% after 1 year, and antibodies have been found to persist in the circulation for several years. Men who have high preoperative sperm counts are likely to have sustained or early high levels of antisperm antibodies.

"The major impact of antisperm antibodies tends to be on the reduced rate of pregnancy after vasectomy reversal." There are many other studies and peer reviews that conclude similarly.

The study quoted by Hauber⁷ is actually a study in rats that was part of a study towards the goal of the "Male Pill". Specifically, it compared the antisperm antibodies in a group of rats who had a 5cm long testosterone implant, and another group with a blank implant and vasectomy. In the vasectomised rats, the antisperm antibody level rose until 66 days post-operation, and then decreased to the levels of non-vasectomised rats. They conclude that "These results suggest that the immunological conditions remain stable in the testes after vasectomy and during testosterone treatment".

Numerous studies over more than 30 years have shown correlations between vasectomy and increased incidence of many diseases. The list of the diseases studied for links includes prostate cancer, rheumatoid arthritis, erectile dysfunction, chronic testicular pain, chronic inflammation, epididymitis, Prostatitis, testicular cancer, and autoimmune orchitis.

This is my personal favourite misquotation!

In other pages he attributes the source of the quotation as a study by Raspa⁸. He refers to this study A LOT, and makes the same mistake every time he quotes it. He claims that Raspa says that all of these problems are associated with vasectomy. The part of the sentence he routinely removes is "although not substantiated by clinical studies". Raspa concludes that "Compared with tubal ligation, vasectomy has fewer serious complications and a comparable failure rate." Oddly enough, that is also removed from the Hauber version of the quote.

If that’s not enough, how about other reports of vasectomy resulting in increased incidence of recurrent serious infections, fatal scrotal gangrene, atherosclerosis, non-Hodgkin’s lymphoma and several other forms of cancer, diabetes, multiple sclerosis, migraine and other forms of headaches, liver dysfunction, generalized lymph node enlargement, and adrenal gland malfunction.

In a nutshell, the list opposite is simply made up. There is no evidence to link any of the conditions opposite to vasectomy. In fact, there is plenty of evidence that the opposite is true. Many studies are done into all sorts of potential connections in all areas of medicine. Hauber repeatedly makes the mistake of confusing the fact somebody has done a study into a possible link with proof that a link exists.

There is no evidence that vasectomy results in recurrent serious infections. In the case of Fourniere's Gangrene, two cases in Malawi doesn't really count as any proof. Heart disease has been disproved by many studies. The cancer societies, nor any other body state that there is a connection between vasectomy and NHL, and indeed any other form of cancer. The World Health Organisation (amongst others) dismiss any connection between vasectomy and the rest of the items in the list.

Many men will take months or years to manifest symptoms, which is why many doctors don’t look for the connection between vasectomy, the antibodies that result, and the diseases that occur later. Even in the case of chronic testicular pain that develops months or years following vasectomy, many doctors will diagnose what appears to them to be epididymitis, which is often from the congestive effects of the procedure.

There is a reason for this - and it's not that they don't believe patients have post vasectomy pain syndrome either.

Post vasectomy pain syndrome is not a disease or condition in it's own right. It's a collection of symptoms and causes. The most common form of it is congestive epididymitis. This is in fact a common urological problem. As stated above, the incidence is broadly similar in vasectomised and non-vasectomised men. The standard treatment for this particular form of Chronic Testicular Pain is analgesics and antibiotics, and in the vast majority of cases this resolves the problem.

Yes, some men do not respond to the conservative treatment methods, but as most men do, that is the route doctors will go in the first instance. Self diagnosis will be rightly ignored by doctors. Doctors treat the symptoms they see - not what the patient thinks he's got based on visiting websites such as dontfixit.org. It would be grossly negligent to head straight towards a surgical option based on the patient's self diagnosis - especially as the likelihood is that the conservative treatment will resolve the problem whether it was caused by the vasectomy or one of the other usual causes of the problem.

Studies show that about 60% of men will form cysts in or around their testicles following the procedure. The most commonly studied of these cysts is known as a sperm granuloma. In many cases, the cysts will need to be removed surgically in an effort to seek relief of the pain that results from their presence.

It is true that sperm granuloma's do form, and the rate quoted by most studies is approximately 60% rate. The implication of Hauber's wording is that 60% of men develop a variety of cysts including granuloma's. That simply isn't true. In the case of granuloma's they are in most cases small and the patient is unaware of their existence³. The incident rate for painful granuloma's is 2% - 3%³. In fact, granuloma's are regarded as positive. They provide a temporary expansion of the epididymis whilst the body adjusts to it's new state of sterility, and in most cases disappear of their own within 6 months and do not require surgery. It's actually rare that surgery is required.

Why aren’t these facts disclosed and discussed more openly? For one, sterilization has become a huge industry with lots of social implications and lots of dollars attached. Understandably, doctors may not want to critically examine a procedure performed so commonly in light of such evidence, since there are huge health and legal implications involved.

Doesn't this strike you as a rather bizarre, paranoid notion? How realistic is it that doctors could knowingly conceal the fact that some 33% of men have serious pain after vasectomy? After all, that is what we are asked to believe.

Think about it for a moment. He says earlier on the page that problems with female sterilisation are openly discussed, and male sterilisation is the doctor's "Dirty little secret". Why then is there a conspiracy theory on men's reproductive health only? How exactly could this be maintained if it were true? Vasectomy is a world wide procedure with millions of them being performed each year. How would anyone with a vested interest keep it quiet in one country - let alone on a worldwide basis?

How exactly would you silence the patients worldwide with problems? If the US figure of 500,000 men per year having a vasectomy is accurate, then that equates to 165,000 men per year EVERY YEAR in the US alone with serious pain issues that are being remarkably quiet. The World Health Organisation estimates that some 40,000,000 vasectomies are performed annually. That equates to 1,320,000 men with serious pain issues EVERY YEAR being silenced? Whilst it is true that many men who have a problem would not go public about it, on the other hand there are a lot that would. If the idea is to believed, there are a lot of men who are not afraid to stand on a soapbox and shout who are being unusually quiet.

Other problems with contraceptive methods over the years have become public. Take Norplant for example, and the well publicised problems with long term usage of the contraceptive pill. Vasectomy would be no different if these assertions were true.

Is there really a financial motive involved? Are they really protecting a lucrative income? Consider the fact that in the US the majority of vasectomies are performed under healthcare schemes. Patients don't have an unlimited choice of where they can go, and doctors do it on a fixed fee (and likely discounted) basis. In other countries who have a public healthcare system (the EU, UK, Australia & NZ to mention a few) the procedure is performed out of public funds, and again at fixed fees for doctors, many of whom are salaried. The take-up of vasectomy isn't really affected by any advertising that happens, as most vasectomies are not performed in a private practice of the patients choice in ANY country. The US has an average take up rate, yet most of the advertising. Other countries such as the UK and NZ have considerably higher take up rates yet very limited advertising happens.

Are there legal implications? I can't see how personally. Well, I suppose if there was a cover-up that could be proved then heads might roll, but as discussed above, that does seem just a bit unlikely! The way information dissemination is moving is towards evidence based guidelines. This is where a guideline of clinical practice and pre-procedure counselling is produced, and that protects both patients and doctors. In fact, legal cases tend to revolve mainly around technical failures where a child is produced, and the patient wasn't informed properly that like all methods of birth control there is a failure risk. I don't know of any cases whereby a doctor has been sued for post vasectomy pain. I'll gladly look at corrections to this statement if anybody can produce evidence.

Despite the fact that this might be considered a personal viewpoint, it's not an unheard on one on the web. Therefore it's fair to discuss this in the context of being a non-unique viewpoint.

A survey of 1,500 urologists in the U. S. reported that 90% of the doctors would not change their practice of performing vasectomy, despite numerous reports of vasectomy being linked to prostate cancer.

This is attributed to Sandlow, et al, 1996⁹. It's not going to come as a great surprise that Hauber's quote is selective.

The study asked doctors about their practice in light of various studies indicating a possible elevation. The response rate to the survey was only 51%.

Whilst the quote is accurate in that greater than 90% of urologists who bothered to respond wouldn't change their practice because of these studies, there is no indication implicit in the statement of what their prostate screening practice was - only that they wouldn't change it.

This study has to be looked at in the context of current thinking. The study was published in 1996. At the time, the prostate cancer/vasectomy was the subject of a certain amount of media hype. Although the available evidence at the time indicated there was no associated risk, since then there have been some large, definitive studies that disproved the link. The World Health Organisation has since decided on the basis of evidence that there isn't a link, and the American Urological Association (based on the WHO report) now recommend that vasectomised men are not screened any more frequently than unvasectomised men.

This situation is summarized well by R. F. Raspa in the Journal of the American Family Physician (1993): "Family physicians should be aware of the potential effects and complications of vasectomy so they can appropriately counsel patients seeking sterilization. Vasectomy produces anatomic, hormonal and immunologic changes and…has been reputed to be associated with atherosclerosis, prostate cancer, testicular cancer and urolithiasis. Complications of vasectomy include overt failure, occasional sperm in the ejaculate, hematoma, bleeding, infection, sperm granuloma, congestive epididymitis, antisperm antibody formation and psychogenic impotence."

Again, it's his old favourite study⁸, and again he leaves out the words "although not substantiated by clinical studies". He also leaves out the conclusion of the study that "Compared with tubal ligation, vasectomy has fewer serious complications and a comparable failure rate."