Manhood: The Rise and Fall of the Penis (42 page)

The complications of vasectomy are quite often underestimated.

Whichever way you look at it, vasectomy is an odd procedure; if a surgeon were to remove a section of intestine and close off both ends, he or she would be immediately committed to a lunatic asylum, if necessary by force . . .

From puberty to death millions of sperm cells pass along these tubes that resemble liquorice shoelaces. After vasectomy the ‘little creatures’ can no longer do this. Upstream of the blockage all is woe and affliction, with dead and dying spermatozoa, and of course that can lead to ailments: a painfully swollen epididymis, pain in ejaculating, the previously mentioned spermagranuloma and tears in the wall of the extremely long tube which the epididymis in fact is. Sperm cells may leak through those tears, causing inflammation and antibody formation, since spermatozoa are regarded as basically alien, having only half the normal number of chromosomes.

In the past few decades surgeons and urologists have perhaps made things a little too easy for themselves in failing to dispense complete 220

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 information on the possible downside of vasectomy. Many men would be deterred if they were told that approximately 5 per cent of sterilized men have chronic testicular pain. Men who already suffer from testi -

cular pain should certainly not have themselves sterilized. Other reasons not to be sterilized include childlessness, a serious or chronic illness in one’s partner and the lack of a permanent relationship. In addition anyone contemplating the procedure should be warned of continued bleeding and/or haemorrhaging (10% to 20% chance) and infection (2% to 10% chance).

Restorative operations

In 1888 Bernhard Bardenheuer (1839–1913), a German surgeon who specialized in genito-urinary surgery, was the first to try to connect the seminal duct and the testicle in a man whose epipidymis had been removed because of tuberculosis, and in 1934 a thorough survey of all attempts made up to then was published by the German researcher F. Spath. Spath himself experimented on dogs: at the point where he had sewn together the two ends he left behind a soluble sewing thread made of catgut, thus preventing premature blockage by scar tissue.

His results were disappointing, especially when the ends were tied together under tension. Vaso-vasostomy – the name by which a restorative opera tion after vasectomy is known – fell into obscurity. A few Ameri can researchers, however, persisted stubbornly into the 1960s and 1970s. Dogs proved to be excellent guinea-pigs. So what were the underlying difficulties related to a restorative operation? In the first place the spot where the ends were attached must not leak, or there would be an inflammatory reaction. It also became clear that the thread must not be under tension. Too large a section of the seminal duct must not be removed in sterilization and the ends must not contain too much scar tissue. Another finding was that tension could be produced by the simple fact that dogs, like humans, have hanging testicles.

In operating on humans use is often made of a splint, which is posi tioned outside the scrotum and removed after a few days. Stitching over a splint makes it impossible to sew up everything tightly. Initially many of those carrying out the operation removed a small section of testicle before finally deciding on a restorative operation. Later this was no longer considered necessary, at least if the testicles felt normal on physical examination. It also became clear that over half the men who had had a vasectomy had developed antibodies against their own sperm. However, a high level of antibodies does not mean that a restorative operation has no chance of success.

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Vaso-vasostomy.

About 90,000 vasectomies are carried out in the uk each year.

Nearly 600 vasectomy reversals are done every year in nhs hospitals, but many more are performed privately. So, the exact number of vaso-vasostomies is not known. (In the Netherlands 2.5% of vasectomized males have reversal surgery.)

There is an 80 per cent chance of achieving adequate throughput in the seminal duct if the restorative operation takes place within ten years of sterilization. The longer the interval, the less chance of success. Incidentally, adequate throughput does not mean that it will be easy for the partner to become pregnant, since sperm quality is virtually always inferior to that of non-sterilized men, meaning that in many cases assisted reproductive methods are required. The number of men who regret undergoing a vasectomy is large, given the previously mentioned testicular pain. The chance that a patient will regret the decision increases the younger the age at which the vasectomy takes place.

In men below 25 the chance is over 11 per cent.

The reader may think: ‘Is anybody really sterilized at that age?’

Well, not in 2007, but they were in the 1970s. In those days it was quite normal for young guys to have themselves sterilized. It was an age of doom and gloom, mainly fuelled by the alarming economic and social reports of the Club of Rome, which invoked the approaching apocalypse with almost Calvinist fervour.

Deterioration in sperm quality

In the early 1990s researchers at the University of Copenhagen analysed the scientific literature that had appeared between 1938 and 1991 on 222

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 the quality of sperm, which had involved 15,000 men. They found that in 1940 the average number of spermatozoa per millilitre of seminal fluid was 116 million. By 1990 that had fallen to 66 million. The amount of semen (sperm cells and seminal fluid) produced per ejaculation had also fallen. The average for 1940 was 3.4 millilitres, for 1990 only 2.75 millilitres. These two findings pointed to a decline in male fertility. The researchers assumed that exposure to toxins like dioxins, alkylphenols, pcb and ddt played a significant part in this.

The standards for ‘normal’ sperm have been adjusted over the course of time: nowadays 20 million sperm cells per millilitre counts as the lower limit. If there is to be a chance of fertilization there must be a minimum of 5 million spermatozoa present in each millilitre of seminal fluid, but a minimum of 10 million is desirable and as was said in 2007, a minimum of 20 million was regarded as normal.

Spermatozoa are incredibly small: from the head to the tip of the tail they measure 0.05 mm with a maximum diameter of 0.0025 mm.

The sperm cells of men, horses and zebras resemble each other, having the same shape of head and a long tail. They share these characteristics with the lancelet fish, the escargot and the water flea. A rat’s sperm cells have a sickle-shaped head, while the hermit crab has beetle-like, exploding spermatozoa. If any of them touches an egg it leaps up and launches its genetic cargo into the interior of the egg.

The human male tadpole really is a miracle of design. It consists of three parts: the oval head, in which the genetic material is transported, an oblong thickened central section housing the engine room, and a tail which enables the sperm cell to steer towards the ovum. The fuel is sugar, which in the engine room is converted into adenosine phosphate. Very many spermatozoa die in the extremely acid vagina, and 40

per cent of the survivors are rejected at the entrance to the womb. Then half of the survivors swim into the wrong Fallopian tube, until finally one victor emerges in the sperm competition. Arriving at the ovum the chosen spermatozoon sheds its cap, or acrosome, which contains a special protein, releasing enzymes that enable the sperm cell to penetrate the ovum. So while a large number of sperm cells are required to make fertilization possible, quantity alone is not decisive: quality is also of great importance. This includes having a normal head and being able to swim fast in one direction, not swimming circuits but a long -

distance race. If little of the sperm is up to standard, doctors speak of
oligo-terato-asthenospermia
. ‘Oligo’ indicates an insufficient quantity,

‘terato’ an excessive number of abnormal heads and ‘astheno’ poor mobility. If no spermatozoa are found in the ejaculate, it is called
azoospermia
.

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Diagnostic methods in reduced male fertility

According to the who one can speak of reduced fertility where no conception has occurred after one year of frequent and unprotected intercourse. It is not completely clear what is meant by frequent. Eels mate once in their lives, taking a long time to become sexually mature. Many of these fish are over eighteen years old when they have sex for the first and last time somewhere in the shadowy depths of the Bermuda Triangle. After depositing their sperm or eggs, they die.

Although the vast majority of human couples see their wish for pregnancy fulfilled within a year, there remains a group with reduced fertility. The majority will eventually achieve a spontaneous pregnancy and a small percentage will remain involuntarily childless. The cause of reduced fertility may lie with the woman, the man or both simultan -

eously. A large who study showed that in 39 per cent of cases the cause of involuntary childlessness lay with the woman, in 20 per cent with the man and in 26 per cent with both partners. In 15 per cent no cause can be found.

Systematic and standardized examination of a woman with reduced fertility is carried out by a gynaecologist, and in the case of men by a urologist with a particular interest in this problem, who in most European countries is called an andrologist. Causes of reduced fertility include: inability to achieve an erection or a sufficiently hard erection, inability to ejaculate, a varicose vein, an obstruction due to sterilization or inflammation of the epididymis, absence of seminal ducts, hormonal problems, certain medications, undescended testicles and inflammation of the prostate. In many cases the cause unfortunately remains unknown.

There is no better characterization of reproductive problems than that given by the biologist Midas Dekkers:

First you have to negotiate with some woman. You have to introduce yourself, say what you earn, what your father does . . .

you can’t buy an ovum anywhere. There’s a whole tea cosy built around an ovum and the tea cosy doesn’t want me to go anywhere near her ovum with my sperm. So I have to negotiate with her, dance with her, maybe even take dance classes . . .

if that goes well and you’re allowed to get to grips with her, there are millions of sperm at the start line ready for the off.

Then we find that we as men should be ashamed of ourselves, since of all those sperm not one usually reaches its destination.

The sperm we produce is totally shit sperm.

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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 Investigation to determine the cause of male subfertility (‘shit sperm’) begins with questions about sexual development, illnesses, use of medication, smoking habits and external factors such as contact with toxic substances or frequent and protracted exposure to high temperatures. In addition attention will be paid to family illnesses and genetic disorders in the man or his partner. Various diseases are associated with fertility problems and if an unfulfilled desire for children is successfully treated they may be transmitted. Olfactory disorders and abnormalities in vision may be associated with a defect in the pineal gland (hypo physis). A number of genetic diseases are associated with a typical physical build, which will be immediately recognized by an experienced doctor. The patient will also be asked about certain personal habits: thermal underwear, use of saunas, intensive practising of sport, excessive alcohol use – all examples which may adversely affect fertility. The physical examination begins with looking at possible signs of breast formation, the pattern of hair growth and the measuring of height and weight. The examination of the groin area, penis, testicles, epididymides, seminal ducts and prostate is the counterpart of the gynaecological examination. There will also be a check for any variocele, which must be carried out with the man in standing position. Additional examination includes repeated examination of sperm – abnormalities found on one occasion need not be significant, since that could caused even by a flu bug – and hormone tests.

Closer examination

In the microscopic examination of sperm one looks, for example, at the number of sperm cells, their mobility and their shape. The volume of the sperm sample and the degree of acidity are also recorded. It is important that there should have been no ejaculation for three days: research has shown that that is when sperm quality is at its highest, and in addition different sperm samples can in that way be compared over time. We find that it is difficult for many men to produce sperm in the laboratory. However, if the sperm sample is obtained in more familiar surroundings, it is important that the sperm is delivered to the laboratory within the hour. The sperm must be collected directly into a jar provided for the purpose – the use of a patient’s own jars is not to be recommended. The same applies to catching the sperm in a condom: rubber and latex are harmful to sperm cells. Of course it is crucial that
all
the sperm ejaculated is collected. If something gets lost, there is no point in taking the rest of the sperm to the laboratory. It is much better to arrange a new date with the lab.