Manhood: The Rise and Fall of the Penis (41 page)

Even today forced sterilizations take place, and not only of the mentally handicapped. The following story may serve as an illustration: Patient a, a 37-year-old man of Iranian origin, came to the urology clinic after having failed for the third time to father a child. His ejaculate repeatedly contained almost no sperm cells. After some years’

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residence in the Netherlands both he and his wife wanted to extend their family. He had fled from Iran for political reasons, having endured extended periods of torture, including electric shocks to his genitalia, which had often rendered him unconscious. Echographic examination led to a diagnosis of an epididymal cyst on the right side and on the left; the head of the epididymis was irregular; the testicles themselves showed no abnormalities. At the patient’s request the diagnostic process was continued in our clinic after two years, and it was decided to perform an exploratory operation under anaesthetic. When sections of tissue from the testes were examined the pathologist found a slight disruption of sperm production on both sides, though adult sperm cells were present. After the removal of scar tissue, non-soluble green knotted stitches were observed on both sides, consistent with a post -

vasectomy condition. The loose ends were stitched back together on both sides, without any post-operative complications. When the hospital did a follow-up check, the patient indicated that he had absolutely no knowledge of the sterilization.

Sometimes men are ignorant of the fact that they have undergone sterilization. Another illustrative case history: A 47-year-old man was referred to me by a gynaecologist in relation to the patient’s involuntary childlessness with his new partner. He had two children from a previous marriage. Three examinations by the gynaecologist showed a complete absence of sperm cells. In another hospital a section of testicular tissue had been removed under local anaesthetic. The production of sperm cells, spermatogenesis, was shown to be only slightly disrupted, which suggested an obstruction, for instance a double epididymal inflammation. When asked if he had had diseases or operations in the past, the patient’s answer was negative. It was decided to explore further under anaesthetic. No obvious abnormalities were apparent to the touch, but after incision it soon became clear that he had been sterilized: the gap between the two ends of the seminal duct was so small on both sides that it had not been felt and likewise on inspection of his shaved scrotum the tiny scars were virtually invisible. The ducts were rejoined on both sides, and there were no post-operative complications.

At a follow-up check the patient mentioned that in the years before and following his divorce his alcohol intake had been very high, and that he could remember little or nothing from that time. When asked about the case the referring gynaecologist said that he had information only from the gp of the present partner. Three months after the restorative operation microscopic examination showed over 20 million spermatozoa per millilitre, and it was soon possible to fulfil the desire for children.

When divorced people enter into a new relationship, there is of course a good chance that they will not have the same gp. If the referral 216

vo l u n ta ry a n d i n vo l u n ta ry s t e r i l i t y process in relation to an unfulfilled desire for children subsequently begins with the woman, usually only her medical records are forwarded. In this case the urologist had omitted to request possibly relevant information on the man from the gp.

The World Health Organization

In the 1970s a large-scale programme was launched by the World Health Organization in India and elsewhere to combat over-population, in which millions of men were sterilized. The same happened in China under government pressure. For some decades Chinese doctors had already been using alternatives to vasectomy, including a technique requiring only three instruments (an important factor in developing countries), the so called ‘no-scalpel’ technique, that is, no scalpel but a sharp clip, a pair of scissors and another clip for fixation of the seminal ducts.

The Chinese doctors claimed that with the aid of this technique haemorrhaging was less frequent than in conventional vasectomies, an important factor in a country where at the time sterilization of men was more or less obligatory after the birth of the first child, and in addi -

tion was less time-consuming. Another Chinese technique was based on quickly pricking the outer surface of the seminal duct, after which a blunt-ended needle was inserted in the duct on both sides. On one side a blue dye (methylene blue) was injected and on the other a red one (Congo red). If after the procedure the man’s urine was red, the operation had most probably been a success! When the needles appeared to be properly in position on both sides, a caustic fluid was injected, causing a build-up of scar tissue which blocked the seminal ducts. Initially phenol was used, and later carbolic acid with cyanoacrylate. The advan tage of this method of sterilization was the speed with which it could be performed. In any case the procedure was irreversible. To this end the Chinese had started using polyurethane and later silicones, but the use of polyurethane in the seminal duct was not initially permitted by the who since there was a chance it might be carcinogenic. The use of silicones, however, was sanctioned by the who at the end of the 1980s, in the first instance for plugging the Fallopian tubes via the vagina and the uterus. When asked, the Chinese were not able to give the exact composition of their silicones, so a Dutch company and Dutch urologists were called in. A joint workshop was held, which was also attended by Indonesian urologists. Chinese men from an area in the province of Shandong were used as test subjects. This method was of great interest to the Indonesians, since many Muslims have religious objections to conventional sterilization. Basically their religion forbids 217

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Chinese instru-

ments for use in

vasectomy.

the violation of the body, and any contraceptive procedure should be reversible. The Dutch doctors were of course focused on a potentially easily reversible form of sterilization: removing a plug is much easier than a lengthy, expensive operation in which the ends have to be sewn back together.

At the workshop it soon became clear that the Chinese had not succeeded in achieving sterility in 100 per cent of the men treated with plugs, an outcome which would never be acceptable in Western culture in countries where sterilization was on a completely voluntary basis.

Failed sterilizations have sometimes led to (successful) claims for damages, though this virtually never happens today, since every doctor performing an operation will inform the patient about the impossi bility of guaranteeing absolute sterility. Carrying out a vasectomy entails an obligation to perform to the best of one’s abilities, not an obligation to guarantee a certain result: an important legal distinction.

The type of vasectomy which involves the removal of a section of seminal duct is at present considered one of the most practical ways of achieving sterility. With Nepal, the Netherlands, Yemen, Bulgaria and India, the United Kingdom is among the few countries in the world where more men than women have been sterilized. Countries where vasectomy is considered completely unacceptable include the Dominican Republic, El Salvador, Honduras, Jamaica and Tunisia. What kind of people opt for vasectomy? Mainly men over 30, with a high educa-tional level, an above-average income and a complete family. Many of them feel that it is now ‘their turn’ to contribute to contraception.

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vo l u n ta ry a n d i n vo l u n ta ry s t e r i l i t y Though the operation may be regarded as simple by some, the great variety of techniques used suggests a different picture. The great majority of surgeons use local anaesthetic, beginning with the nerves in the seminal cord. In the 1960s it was not unusual for a man to go straight back to work after the procedure, but today patients are recommended to take things easy, at least on the day itself. An experienced doctor can perform the procedure in less than fifteen minutes, though it is sometimes difficult to locate the seminal duct, particularly if the scrotum is rather compact. Matters are complicated if the man involved disregards advice and arrives by bike in winter. For reasons of temperature regulation the layer of muscle beneath the skin of the scrotum is tautened, making it more difficult for the urologist to take hold of the seminal duct.

Bearing in mind the possibility that the procedure may one day have to be reversed, it is sensible to carry out the vasectomy high in the scrotum. To check whether the operation has been successful, the ejaculate is examined under the microscope after three months for the presence of spermatozoa (there is no point in doing this any sooner). In those three months it is advisable to ejaculate as often as possible: after vasectomy the patient is not immediately sterile, since downstream from the point of ligature spermatozoa are still making their way towards the outside world. The criterion for sterility is the absence of sperm cells; according to urological guidelines it is sufficient if after three months there are only a few cells visible, provided that these are immobile. On problem is that if a patient submits ejaculate that has spent some time out of the body, the spermatozoa will invariably have failed to survive. One thing is certain: if after a vasectomy living sperm cells remain visible, alarm bells should start sounding. In 2004 the us Food and Drug Administration (fda) approved a new vasectomy Presentation of

seminal duct and

local anaesthetic.

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technique, in which the seminal ducts are not severed or cauterized but are closed off with the aid of a special clip, Vasclip. The technique is designed to make a restorative operation easier, but has not yet been approved in Europe.

Spontaneous recanalization

From the very beginning the occurrence of spontaneous recanalization, the growing together of the severed ends of the seminal ducts, has been one of the main problems associated with vasectomy. As long ago as the 1950s it became clear that if one simply tied off the seminal duct there was virtually always recanalization, and even after severing in several places there was also spontaneous recanalization. If a length of 3 cm was removed, but the sheath of the duct remained intact, the same thing happened. Recanalization did not occur if the sheath was also removed.

Recanalization is still a problem, and is found in between 1 in 1,000 and 1 in 2,000 men who have ‘had themselves fixed’. The risk is higher if after the vasectomy a spermagranuloma develops. A granuloma is created by leakage of spermatozoa on the testicle side, despite effective ligature of the end of the seminal duct. Tying off is actually not all that easy, since the seminal duct has a thick wall of muscle, so that there is a risk that the stitch will be pulled too tight and will sever the duct. Partly for this reason many urologists decide for reasons of safety to cauterize the tied-off ends. It is also a good idea to sew a section of different tissue between the two ends, preventing them from coming into contact.