Clinical Studies in Men and Histological Studies in Sterilized Experimental Animals. 1952-1954
Thesis Submitted to Agra University India by Dr. P.S. Jhaver M.B. B.S.
Note: This study was conducted in the early 1950s. While some information may still be relevant today, it does not necessarily represent a modern understanding of vasectomy and should be viewed primarily as a historical reference.
Table of Contents
Experimental vasectomy dates from eighteen hundred and thirty. As a surgical procedure it came into use in the later part of the nineteenth century, as an alternative to castration, which use to be the treatment for senile enlargement of prostate. This was however too severe a measure with very little benefit.
Dr. Oschner of Chicago, one of then leading surgeons performed two successful operations in 1897. He then discussed the possibilities of the eugenic application of vasectomy, in his paper ‘Surgical treatment of habitual criminals’.
Dr. Sharp followed this up and performed the operation for eugenic purposes. Between 1899 and 1907, he had done 456 cases, including a few physicians. All his cases assured him that there was a decided improvement in muscular efficiency and nervous fatigue was delayed. (Unfortunately, all records of Dr. Sharp’s early work at the Indiana Reformatory were lost in fire, so fuller details are not available.)
Later, this operation came to be used for other purposes. It was used in the prevention of ascending and descending infections in genito-urinary tuberculosis. It was also used to prevent the spread of infection from the prostatic-bed after prostatectomy. It was then employed as a remedy for premature senility and sexual debility.
Of late, this operation is being done in normal healthy people as a conception-control measure. Various workers have claimed that this operation leads to rejuvenation and prevents premature senility, whereas many people, in the profession and outside, fear a diminution or loss of sexual capacity following this operation. The growing interest in family planning in this country, and the use of this operation as one of the methods for the same, prompted the present work.
Various conflicting results have been published regarding the effects of vasectomy and neither the experimentalists nor the surgeons have expressed a unanimous opinion.
We have made a clinical survey of the effects of vasectomy in man and attempted to correlate the observations with the histological changes observed in the rat testes, after a similar operation.
REVIEW OF LITERATURE
Work on vasectomy in its various aspects is about a century and a quarter old. Earlier work was experimental and concerned mainly with the study of the effects of vasectomy on the germinal epithelium of the seminiforous tubules. There was no unanimity in the findings of the various workers until the end of the 19th century. Meanwhile the operation came to be used clinically. First, it was used as a treatment for senile enlargement of the prostate as an alternative to castration, which used to be the then treatment. Later it was used for sterilization, of habitual criminals and mentally defectives. Its use was gradually extended, to the prevention of ascending and descending infections in genito-urinary tuberculosis. Many patients claimed improvement in their physical and sexual lives following the operation. This led to the consideration and use of this operation for rejuvenation. It also led some workers to investigate into the changes in the interstitial calls of the testis, after the operation, in an attempt to seek the cause of the reported sexual improvement. Even from this work no definite conclusions could be drawn and various workers expressed diverse opinions.
Of late, circumstances have led to investigations on the possibility of reunion of the vas with a view to re-establishing reproductive function, and this problem required further study.
One of the earliest observations on the effects of occluding the vas deferens is that of Sir Ashley Cooper (15). He ligated one vas deferens in a dog, and on the opposite side ligated the artery and vein without interfering with the vas deferens. The testis whose artery and vein were ligated “ gangrened and sloughed.” Operated in 1822 the dog was kept alive till 1889, when he was killed. During six years it was noted in coitus two separate times but no issue followed. Observed after killing, the vasectomised testis with its epididymis was notable increased in size and the latter, with the short stub of appended vas deferens, was gorged with spermatozoa. Occlusion of the duct had been complete and the two ends of the severed duct were separate. This conclusive experiment showed without doubt that merely closing the outlet duct of the testis had no effect upon the germinal portion of the organ; spermatogenesis continued for six years after operation and the epididymis became much enlarged to accommodate the products of germinal cell activity.
Gossalin (19) some years latter dissected human cadavers and noted cases in which the vas deference was entirely occluded, and had been undoubtedly so, for many years, but the enlarged epididymis, contained quantities of spermatozoa. Later Gosselin introduced the experimental study of effects of ligation and resection of the vas deferens using dogs as experimental material. He found that there was normal spermatogenesis present four to six months after such an operation.
Brissaud (13) and Griffiths (20) working rabbits and dogs respectively found that occlusion of the outlet duct had no influence on spermatogenesis. Griffiths later, however, determined that testes of the dog rapidly lost the germinal portion if blood vessels passing to the testis were injured. Simmonds (43) in human autopsies found occlusion of the vas deferens of years standing without any injury to the generative portion. Neither testicular degeneration nor loss of the germinal epithelium had occurred and the epidermis was enlarged from the immense amount of spermatozoa carried to it.
Later when results on experimental studies of the testis became more numerous contrary results began to appear. Richton and Jeandelize (36) stated that rabbit testes, whose was deferens had been experimentally occluded contained no spermatozoa, and that the seminiforous tubules were degenerated.
The extensive study of sex glands conducted by Bouin and Ancel (1) (2) (7) (8) (9) (10), however, was the chief factor in changing the tide of opinion relating to the effect of vas deferens occlusion. Summarizing many of their different studies Bouin and Ancel declare that closing the outlet from the testis, by ligation and resection of a portion of the Vas deferens, invariably leads to degeneration of the germinal tissues of the testis. They worked with guinea pigs, dogs and rabbits, young and adult. According to their account ligation of the outlet duct before the stage of puberty does not interfere with the attainment of complete germ cell differentiation, but after this attainment the seminiferous tubules rapidly lose their lining epithelium and become converted into a testis entirely similar to the cryptorchid testes found in nature, i.e. with seminal tubules reduced and having a single layer of columnar Sertoli cells prolonged into filamentous processes, and with no sperm forming cells present. They dismiss the contrary findings of the earlier writers by assuming an insufficient length of the after operation before the animals were killed.
Shattock and Seligman (42) performed double vasectomy on Herdwick rams, but despite the fact that of double, complete vas deferens occlusion for eighteen months the tests were normal in size and spermatogeneisis continued; the epididymis was much larger than normal due to the retention of the products of spermatogenesis and consequent distension of the epididymis. They note that testes may be abnormal if the blood vessels had been included in the ligature of the vas deferens.
Wallace (51) reviewed the results of vas deferens ligation in man. Sometimes before he started his work it was an accepted surgical practice, due to the suggestion of earlier workers, to ligate the sperm duct as a method of alleviating prostatic hypertrophy. Favorable results had been reported in a great number of cases, but Wallace remarks “when it is remembered how often cases of prostate enlargement are greatly improved by rest and treatment of the accompanying cystitis, it is an open question whether the results claimed were not, to a considerable measure, due to such treatment” From the literature on sex it would appear that the implication of such a statement are too infrequently considered in clinical work. Wallace performed vasectomy on the cat and dog and found that the testes in such cases were perfectly normal many months later than Bouin and Ancel would imply was a sufficient time to expect degeneration. Wallace concludes that single or double vasectomy has no effect upon the spermatogeic function of the testis; it continued to produce spermatozoa months and years after total occlusion of both the vasa deferentia.
Kuntz (24) after experiments on the dog stated that thirty days after unilateral vasectomy the testis of the same side showed degeneration; but similar degeneration was seen on the unoperated side also. He conceived of some influence operating through the nervous system that caused degeneration on the opposite side. Later experiments on both the dog and rabbit were reported by him in which practically all animals showed testicular degeneration as the result of vas ligation and resection. In control animals, however, Kuntz noted that the testes were likewise aspermatic and recognized that confinement and care of the animals was such that the unoperated tests were degenerated to about the same extent as these of experimental animals. He then withdrew his former suggestion that sympathetic nervous influences set up by one degenerating testis caused the degeneration of the opposite one, but he allowed the idea to stand that within a month after operation the degenerated testis shows the influence from ligation of the vas deferens.
The greatest impetus to the conception, of seminiferous tubule degeneration following vas deferens occlusion since Bouin and Ancel, is the striking and apparently conclusive work of Steinach (1910-1920) culminating in his suggestive work on rejuvenation. After ligation of the vas deferens in rats Steinach (44) reported degeneration of the germinal epithelium accompanied by an hypertrophy of the interstitial cells- the hormones producing tissue; secondarily this stimulating hormone causes renewed germ-cell production. This he believes that an animal so old as to have lost its germ cell production capacity is reinvigorated by a unilateral vas deferens ligation, and that the opposite testis following the stimulation begins to produce germ cells again and the animal returns to a functional condition. Steinach believes that ligation between the epididymis and the testis proper hastens the degeneration, and hypertrophy of the interstitial tissue.
Tiedje (47) follows Steinach in the belief of first a degeneration of the germinal epithelium and then regeneration after vasectomy. Wheelon (58) found that nine months after vas deferens occlusion in dogs the testis contained all elements of the germinal epithelium. He believes that either all the tubules did not degenerate or that there might possibly have been regeneration.
Sand (37), (38), (39) has studied the effects of vasectomy on the rat, guinea pig and dog, and has performed the operation in clinical, practice, reporting eighteen cases of such operations on the human individuals. In the latter, however, Sand follows Steinach’s procedure and ligates between the epididymis and testis instead of merely occluding the duct. By this method he believes that the process of destruction of the germinal tissues is hastened. Sand’s reported observations on vasectomy in rabbits, guinea pigs, and rats are summarized in his paper; out of fifteen operated cases, some of which were observed for longer than a year, two cases only showed degeneration. Despite the fact that thirteen of his own operated cases failed to show degeneration, he confirmed the work of Bouin and Ancel that vas deferens ligation causes degeneration of the germinal epithelium and employed the operation in clinical practice. Brack (11) has shown that congenital absence of the vas deferens in man is without effect on spermatogenesis.
In America, Benjamin (5) has been perhaps the chief advocate of the Steinach operation as applied to the human individual. In such cases histological studies are lacking but accepting the Steinach idea as correct and due to follow, Benjamin restricts himself to the clinical effects, which manifest in the patients.
In order to test the hypothesis of an early degeneration of the epithelium followed by regeneration in vasectomy cases, Moore and Quick (30) performed the operation on a series of rabbits, studying the testes at intervals from thirteen days to six months after operation and the retained products caused the epididymis to double or triple its size. There was no evidence that would lead one to assume an early degeneration of the germinal epithelium followed by regeneration.
Steinach and Sand ligated between the testes and the epididymis believing that by this method degeneration occurred more surely and more rapidly. Von Wagener (49) recently studied this method of blocking the testis outlet and noted degeneration of the tubules in 10 G cases in the rat. In a later paper however, she stated that her operations were followed by hardening of the testis from congestion, and that the lack of oxygen and food was undoubtedly sufficient to cause such destruction as was obtained.
Balfield (4) has stated the conditions obtained in man where the vas deferens has been totally occluded. “In a large majority of subjects sperms have been found there (epididymis) even from five to seventeen years after occluding the epididymis and in these cases, therefore, atrophy of the spermatic tubules had not occurred”.
In view of the conflicting results, Oslund (35) in America undertook a detailed study of the changes in the germinal tissue of the testis of rats and guinea pigs following vasectomy. In this paper published in 1924, describing this work, he divided the experiments into two parts. In the first no special regard was paid to the position of the testicles. Degeneration was noted to follow vasectomy in some of the cases while spermatogenesis continued in others. During one of these experiments he noted that the testis, following vasectomy, had come to occupy an intra-abdominal position as a result of an adhesion, as his operation had been done by the abdominal route. He then embarked on the second series of operations in which he controlled and observed the position of the testis. In some of the cases 30-60 days after bilateral vasectomy one of the testis was pulled into the abdomen while the other was left in the scrotum. The animals were killed 2 -3 weeks later. From the study of the changes following these various operations Oslund concludes most emphatically that vasectomy alone does not cause degeneration of the germinal epithelium. He also concludes that the degeneration, which was observed, was due to the intra abdominal position of the testis and was, therefore, in then nature of an artificial cryptorchidism.Gerden (18) refers to many cases reported by many different clinicians in which sexual precocity was associated with functioning interstitial- cell tumors of the testis. He also quotes cases in which there was testicular deficiency with an associated absence of scarcity of Leydig cells. This association of the testicular hormone with the leydig cells lends further support to the observations of Steinach. Steinach claims that vasectomy by causing backpressure in the seminiferous tubules leads to the degeneration of the germinal epithelium while there is a corresponding increase in the interstitial tissue. This proliferation of the interstitital tissue leads, according to Steinche to hypertestoidism and rejuvenation. Steinche on this theory advocated the use of vasectomy for rejuvenation. Seyle (40) and Wright (5f3) support the conclusion that sexual function is related to the activity of the interstitial Tissue.
During the late ‘nineties’ the operation of vasectomy began to be widely used by genito-urinary surgeons mainly in connection with operations on the prostate. In 1897, A. J. Oschner performed two such operations. He stated that the operations had been entirely successful and the patients reported no change whatsoever in their sex lives. This led Oschner to consider the eugenic application of vasectomy and he published a paper entitled “Surgical treatment of Habitual Criminals”(34)
In 1899, Harry Sharp (41) the physician in the Penal Institution, Jeffersonevillo, Indiana, had a patient, a young man, who complained of excessive masturbation and insisted upon castration. Sharp advised him not to undergo that mutilating operation and instead advised vasectomy. The patient agreed and it was performed. Six months after the operation the patient reported that he had sopped masturbating and felt very little desire to do so. This encouraged Sharp to carry out further work on these lines. In 10 year’s time he did 456 operations and reported that he has seen no unfavorable results, and he has also commented that voluntary sterilization among professional men was already on the way. Another outstanding clinical worker in America has been Benjamin (5) who published a very favorable report on the subject. Sand and Steinache did important clinical work and the later inaugurated his new technique of dividing the vas deferens between the testis and epididymis as he considered this to be the most effective method of hastening the degeneration of the seminiferous tubules and regeneration of the interstitial cells leading to rejuvenation. He had a large following who came to be known as “rejuvenators”.
Clifford Morson (31) describes the operation, the technique and its complications. The latter were due to failure to maintain perfect asepsis, imperfect haemostasis and mistaken cutting of the wrong structure thus leaving the vas intact.
Testicular atrophy following cutting of the artery, intractable pain due to cutting of the nerves, and a case of pulmonary embolism have been among the complications reported. Morison concludes that there have been no bad effects due to duct division itself but due to faults in the technique.
Dickinson (16) has given a brief resume of the facts and uses of the operation as known at present.
In India Mathews (28) did vasectomy in 106 cases for rejuvenation purposes between 1932 and 1946. He published the figures and commented on the usefulness of the operation.
Unheard of (c)
Partial Impotence (b)
(a) slimy, sticky discharge from urethra at slightest sexual stimulus of any kind
(b) sexual weakness
(c)Those who never reported back to the author
Kenneth Walker (50) in answering a query has stated: “It can be said with confidence that vasectomy has no adverse effects on the physical or mental welfare of the patient. This being so I see no reasons why it should not be used on large scale in India or in any other country in which the increasing population has become a National Problem. The technique is an easy one and can be carried out under local analgesia. Cases which have been treated by this method have now been watched for a period of 30 years and no delayed adverse results have been noted”.
It used to be the belief that vasectomy once done was irrevocable Cameron (14). An accidental vasectomy during a herniorraphy led Parlavechio to attempt the first vas deferens anastomosis. Bickham (6) describe this as one of the use of vasorraphy. Twyman and Nelson (48) Freiberg and Lepsky (17), Barker (3) and Nelson (32) reported cases of Vasorraphy following vasectomy for contraception. The operation was done four to seven years after vasectomy. R.S. Handly (22) also reports a case where vasorraphy was done ten years after vasectomy with complete recovery of function so that the patient’s wife became pregnant about 6 months after the operation. This shows definitely that rejoining the cut ends of a severed vas deferens can restore function. O’Conner (33) has described the technique of vasorraphy in detail in Medical Annual 1954.
In finally reviewing the whole subject a few important facts stand out. The first is that right from 1880, when the subject first began to interest investigators, until to day the experimental results dealing with both the germinal epithelium and the interstitial tissue changes have been contradictory and inconclusive. Against this stand the unquestioned clinical observation that there has been no bad effects, while most of the cases have been immeasurably benefited. Further it is now known that the operation is most irrevocable and it is these heartening clinical observations that encourage us to delve further and further into the question.
ANATOMY AND STRUCTURE OF THE MALE GENITALIA
The Testes, the reproductive glands in the male are suspended in the scrotum by the spermatic cords. The anterior border is convex, the posterior border nearly straight, to which the spermatic cord is attached. The epididymis lies along with the lateral part of the posterior border. It is invested by three tunics. The tunica vaginalis has visceral and a parietal layer. The tunica albuginea is the fibrous covering for the testis. It is applied to the tunica vasculosa and at the posterior border of the testis is projected into the interior of the gland and is know as the mediastinum testis. The tunica vasculesa is the vascular layer of the testis consisting of blood vessels held together by the delicate areolar tissue.
The Epididymis consists essentially of a tortuous canal, which forms the first part of the efferent duct of the testis. Its control portion is called the body, the upper enlarged end the head, and the lower pointed and the tail. The head is intimately connected with the upper end of the testis by means of the efferent ductules of the gland, and from it the tail of the vas deferens emerges.
The Vas Deferens is the continuation of the canal of the epididymis and commences at its tail. It is at first very tortuous, gradually becomes straight and ascends along the posterior border of the testis medial to the epididymis. From the upper pole of the testis it ascends in the posterior part of the spermatic cord and traverses the inguinal canal to the deep ring. From here the vas runs a course in the pelvis and reaches the base of the prostate. Malformation of Vas deferens consists in absence of one or both vasa, or, duplication, usually on one side (26).
The Spermatic cord, by which the Testis is suspended in the scrotum, extends from the deep inguinal ring to the posterior border of the testes. The left spermatic cord is a little longer than the right. It is composed of arteries, veins, lymph vessels, nerves, and the vas deferens connected together by areolar tissue, and covered from within outwards by the internal spermatic, cremasteric and external spermatic fascia.
The arteries of the spermatic cord are:
The Testicular artery, a branch of the abdominal aorta, the artery to the cremaster, a branch of the inferior epigastric, the artery of the vas deferens, a branch of the inferior or superior vesical artery.
The testicular veins emerge from the back of testis and unite to form the pampaniform plexus, which constitutes the chief mass of the cord and ascends in front of the vas deferens.
The nerves are the genital branch of the genito-femoral and the testicular plexus of the sympathetic, joined by filaments from the pelvic plexus.
Four to eight collecting lymphatic vessels ascend in the spermatic cord accompanying the testicular artery.
The scrotum is a coetaneous pouch containing the testis and the lower parts of the spermatic cords. It is divided into a right and left portion by a ridge or raphe. The left portion hangs lower than the right due to the greater length of the left cord.
Its external appearance varies under the influence of circumstances. In warmth and in old and debilitated people the scrotum is elongated and flaccid. In cold and in the young and robust it is short, corrugated and closely applied to the testis. It consists of skin, dartos muscle, the external spermatic, cremastric and the internal spermatic fascia whose inner surface is in contact with the parietal layer of the tunica vaginalis.
The testicular artery, a branch of the abdominal aorta, supplies the testis. It divides into several branches some of which ramify in the tunica vasculosa, while others traverse the mediastinum testis, and after dividing on the septa testis supply the seminiferous tubules. Twigs are also given to the epididymis and anastamosis with the artery of the vas deferens.
The veins emerge from the back of the testis after receiving tributaries from the epididymis, unite to form the pampaniform plexus, which on the right side leads to inferior vena cava and on the left side the left renal vein.
The artery to the vas deferens is a branch of either the inferior or superior vesical artery. It ramifies upon the coats of the vas deferens and anastamosis with the testicular artery.
The arteries supplying the scrotum are the external pudendal branches of the femoral artery, scrotal branches of the internal pudendal, and the cremasteric branch from the inferior epigastric. The veins follow the course of the corresponding arteries.
The Nerves to the testis are derived from the 10th thoracic segment of the spinal cord through the renal and the pelvic plexuses.
The nerves to the seminal vesicles are derived from the pelvic plexus.
Nerves to the scrotum are the olio-inguinal and the genital branch of the genito-femoral nerve, two scrotal branches of the perineal nerve and the perineal branch of the posterior-femoral -subcutaneous nerve.
Lymphatics from the testes go to the lateral and pre-aortic lymph glands.
Lymphdatics from the scrotum end in the inguinal lymph glands.
STRUCTURE AND HISTOLOGY:
The testicles are enclosed by a strong fibrous capsule the tunica albuginea. From its inner surface there proceed fibrous processes or trabeculae, which imperfectly subdivide the organ into lobules. Posteriorly the capsule is prolonged into the interior of the gland and is know as the mediastinum testis. The glandular substance of the testicle is made up of convoluted seminiferous tubules. Each seminiferous tubule commences near the tunica albuginea and after many windings terminates usually joining one or two others in a straight tubule. The straight tubules pass into the mediastinum and their form a network of intercommunicating vessels of varying size, which is known as the rete-testis. From the rate-testes a limited number of tubules, called the vasa efferntia arise, which pass into the tube of the epididymis at its upper end.
The seminiferous tubules are formed of connective tissue membrane, which has lamellar structure. The lamellae are covered by flattened cell fibers. Chiefly elastic, occupy the substance of each lamelia. Of the layers seen in the tubules of the adult testicle the one next to the basement membrane is a stratum of clear cubicle cells, “spermatogenia”, the nuclei of which, for the most part, exhibit the irregular network which is characteristic of the resting condition, but in some tubules show indication of division.
Here and there between the spermatogenia some of the living epithelium cells are enlarged and project between the more internal layers being eventually connected with groups of developing spermatozoa. These enlarged cells are the “cells of sertoli” and are nutritive in function. These are easily distinguished from the spermatogenia by their nucleolus and relative paucity of chromatin. Next to this later is a zone of larger cells, “spermatocytes, the nuclei of which are usually in mitotic division. Next to this layer and most internal are to be seen as the result of this division, large number of small calls with simple spherical nuclei, Spermatids”. From some of these a tail filament is beginning to sprout. In other parts the spermatids are becoming elongated with the nucleus at one end. These elongated cells are gradually converted into spermatozoa. They lay in groups their heads projecting between the deeper cells and are connected with one of the Sertoli cells of the living epithelium, their tails projecting into lumen of the tubule. When they become mature they become free from the Sertoli cells and shift towards the lumen.
The intertubular tissue is connective tissue of very loose texture and contains numerous lymphatic clefts. Lying in this tissue are strands of polyhedral epithelium like cells known as the interstitial cells, which are yellow in color. They accompany the blood vessels before these break up to form the capillary network, which covers the walls of the seminiferous tubules.
The histocytes are also intermingled with the interstitial cells of the testis.
Activity of the intertubular tissue is under the control of the luteinising hormone of the pituitary whereas spermatogenesis is controlled by the follicle-stimulating hormone.
The Epdidymis is composed of a single convoluted tube 6-8 meters long, which receives the vasa effer entia above, and below, is continued into the vas deferens.
The tube is lined by long columnar cells which are provided with bunches of cilia projecting into the lumen of the tube.
The vas deferens is a thick walled tube having an outer layer formed of longitudinal bundles of the same tissue in between the muscle bundles. The tube is lined by mucus membrane, the inner surface of which is covered by columnar non-ciliated epithelium. Numerous leucocytes may be seen in the lumen. They destroy degenerating spermatozoa.
METHODS OF STUDY
The clinical work consisted of vasectomy in 51 men, between the ages of 24-50 years, performed for birth control, or rejuvenation or both, and a follow-up from two months to three years later to assess the physical, mental and sexual reactions to the operation. The operative technique was the same in all the cases but the site of the operation varied according to the condition of the scrotum and the purpose for which the operation was performed. The patients came from all strata’s of life.
Patients usually came desiring to undergo the operation, as they had been too many children. They were called on the morning of the operation with the instructions to get the inguino-scrotal and public region, shaved and washed thoroughly with soap and water. They were asked to have a good breakfast, before coming to the Hospital.
In the operation theatre the parts were sterilized surgically, and sterilized towels spread round. The exact site of the operation was selected according to the condition of the scrotal sac and the purpose of the operation. In young and robust individuals the scrotal skin is short and corrugated and closely applied to the testes. Most of these patients wanted sterilization for only conception-control. For these reasons an inguino -scrotal operation was found to be the best. In debilitated patients the scrotum is elongated and flaccid. These people are sexually weak or come specifically for rejuvenation. Therefore in these scrotal approach was adopted, as the “rejuvenators”, proceeding on Stein ache’s backpressure theory, advocate cutting the vas near the testes for rejuvenation.
(a) Inguino-scrotal approach:
In doing the inguino-scrotal operation an area of about two inches on each side of the root of the penis and one inch away from it was infiltrated with Novocain 2 %. A vertical skin incision one inch in length over the external inguinal ring was made. The cut edges of the skin were picked up with Allis forceps. The spermatic cord was caught and brought out by another Allis forceps through this incision. The spermatic cord was then rolled between the left forefinger and thumb to feel the vas deferens with an Allis forceps in the right hand. The vessels and other structures were stripped from the vas deferens for a length of about an inch. Care was taken to see that even the artery to the vas not injured. Two artery forceps were then applied to it at a distance of an inch from each other. The vas deferens was crushed at these spots, the intervening length was excised, and the ends tied with chromic catgut No. O. Oozing was searched for, the ends of the vas deferens were dropped back and the skin apposed with two s in stitches. The wound was sealed with tincture benzoin; a pad and T. Bandage were applied, and the patient was sent home. He was advised no strenuous work for that day though normal duties were permitted. Stitches were removed on the 3rd day. Sexual abstinence was advised for a fortnight.
(b) Scrotal Approach:
After the preliminaries previously mentioned up to the spreading of towels, the spermatic cord was held between the index fingers and thumbs of both hands as near to the testis as possible. The vas deferens was identified by rolling and brought immediately below the skin. Retaining the grip with the left hand, the over-lying skin was infiltrated with 2 % Novocain. A skin incision of 1/2 to 1 inch in length, and immediately above and parallel to the vas was made. The assistance picked up the skin edges with an Allis’s forceps and the surgeon then picked up the vas deferens with another Allis’s forceps. The operation then proceeded as in the previous description. A follow-up of these cases was done by getting their answers to the set questionnaire.
OBSERVATION AND DISCUSSIONS
Of the total 51 vasectomies done and reported 27 were for conception control, 21 were for conception control and rejuvenation and 2 for rejuvenation only. A bachelor has been operated to serve later as a volunteer for vasorraphy.
The ages of the patients varied between 24 to 50 years, the distribution being as shown in Chart I, where the purpose of operation has also been indicated.
In this whole series of cases every individual came voluntarily asking to have the operation done.
All the cases were operated under local infiltration anesthesia with 2% Procaine with adrenaline.
No one complained of pain during or after the operation except that all of them had a momentary sensation of dragging on the testis while the vas was being handled. All of them could go back on their normal duties within 24 hours of the operation some doing so immediately and some after a rest of 8 to 12 hours.
Dressings were changed the next day to see if there any hemorrhage but none was noticed. Stitches were removed on the 3rd day.
In none of the cases was any sepsis noticed nor did we have any other complications.
The reactions of the patients 2 months to 3 years after the operation have been attached to the case sheets and have been tabulated as in Chart II.
This study was undertaken to assess the advantages, and ill effects of the operation of vasectomy. The numerous operative complications that have been described in the literature on the subject have mainly centered on minor technical surgical errors for which we took great pains to avoid. Thus we maintained perfect surgical asepsis, took great care to see that the structure ligated was the vas only, and that none of the vessels were in any way damaged. These extra precautions against known defects in technique hardly increased the time of the operation and produced most encouraging results. In the whole reported series of 51 cases, and in numerous other cases, which could not be included here due to incompleteness of the date, we did not have a single mishap. Almost every authority has commented in the singular freedom from complications of the procedure in the past and we hope that our concurrence in this observation will increase the popularity of the operation.
It was long ago observed that many patients felt an increase in sexual capacity after the operation. Indeed this observation formed the basis of Stein ache’s work on rejuvenation. Our observation in this series of 51 cases was that one man complained of diminution in sexual capacity. Twenty-five cases reported an increased sexual strength and desire and twenty for maintained that their sexual capacity remained as before. That one man, who complained of a diminution in sexual capacity, explained in a covering letter, that before the operation, he had been suffering from liver disease, and debility, and felt that he was aging fast. He was given to understand by his Doctor, that the operation, apart from birth control would stabilize both his physical and sexual health. But even after the operation his health continues to deteriorate steadily. He feels that his subnormal sex urge due to his liver disease and advancing age. His unhappiness, he writes is due to having expected too much from this operation. Following the scrotal and inguinal-scrotal technique we cannot claim that there is a definite rejuvenation but we begin to feel confident that while assuring patients most categorically that their sexual capacity will not diminish we can offer them a good hope that it may be increased; which, as most of our patients undergo the operation mainly/ for the purpose of Birth control, they find very encouraging.
Twenty-five patients reported an improvement in the sense of general physical well being, and the rest felt no difference. Not one complained of any deterioration of his health though two had indeed lost weight. Inspire of this they felt better. Twenty of the patients put on weight after the operation.
Relief from the anxiety of further additions to the family has probably been the cause of the over-whelming pleasant mental reactions to the operations. Thus without having sacrificed anything they feel an increased sense of security. To a certain extent this pleasure has been associated with the increase of sexual capacity felt by some especially the older men who feared senility. While one patient was unhappy mentioned previously; one felt that he was indifferent and wrote to us in an accompanying letter in which he said that his nocturnal omissions had become less frequent but his threadworm disease which is 10 years old still persists and sought advice for the same. Though he has gained 4 lbs. in weight and his frequency of nocturnal emissions has become less, he has not expressed satisfaction because he himself ascribes his dissatisfaction to the threadworm disease, which causes him great annoyance. Forty-eight have felt pleased and many have been lavish in their praise of the operation. Theirs is the most eloquent testimony in support of vasectomy for Birth Control.
An increase in capacity for concentration and work has seen reported by only a few and is probably a result of lessening of anxiety and greater sense of security.
The reaction of the wives of the patients has been varying. About twenty-four feel happy, probably also because of the security from further childbearing. Twenty-three, however, have not recorded any particular reaction. There have not been any striking reports about improvement in the wives’ health. This is because the follow up has been quite early after the operation, As the improvement in the health of their wives would result mainly from freedom from child bearing it would take at least a couple of years for the difference to be felt. This is a study, which we hope to do in future.
The species Ratus Ratus was selected for this series as it is easy to obtain and also as most of the previous work has been done in rodents i.e. rabbits, guinea pigs and mice. Further, the normal life span of Rattus Rattus is 2 1/2 to 3 years and its reproductive period begins at about the age of 6 months. The advantage in the choice of this animal is that the study of the progressive testicular changes after vasectomy over a period of 6 months, which represents a quarter of its sex life, it would therefore correspond to a study of about 10 years duration in man.
In the control experiment, orchidectomy was done on rats of the same age both before and at the end of the experiment. The histology showed normal testicular tissue with active spermatogenesis both before and after experiment. This shows with active spermatogenesis both before and after experiment. This shows that the operation of vasectomy was done after the commencement of spermatogenesis and that within the course of the experiment there were no changes due to aging of the rats, nor due to confinement and care. Any changes that were noticed following vasectomy could, therefore, be rightly considered to result from that operation.
A study of the histology shows that within 2 weeks following the operation the seminiferous tubules began to show degenerative changes accompanied by congestion of the stroma. This degree of degeneration seemed to increase during the first 8 weeks. This is explained by the fact that sudden blockage of the outlet inhibits the activity of the testis. Subsequently however spermatogenesis was seen. There appear to be two possible explanations) a) that the degeneration induced by the operation is temporary or (b) that it is incomplete. Previous workers have also made this observation and explained it as a temporary degeneration followed by renewal of the function of at least some of the seminiferous tubules.
In sections of the testes removed eight weeks after vasectomy, the appearance was very striking, consisting of islands of normal somniferous tubules surrounded by degenerated tubules and vice-versa. This appearance seems to be the result of active regeneration of a focal type contrasting with the surrounding features of degeneration.
The interstitial tissue shows hardly any change immediately following the operation. From the tenth week onwards it is more noticeable than it usually is in a normal unvasectamised rat. The interstitial tissue proliferation is quite striking towards the end of the experiment. This observation though not exactly in accordance with that of the former workers is in keeping with the generally observed increase of interstitial tissue following vasectomy, and may well is a factor conducive to hypertestoidisam. A simultaneous histological study of the testes and biochemical estimation of androgens in the blood of unvasectomised animals would possibly throw more light on the subject.
The whole course of the experiment was uneventful except for 4 rats dying suddenly on May 16th, 1954, within half an hour, of heat stroke. The rest were active and healthy till the end and suffered from no illness whatsoever.In none was there any postoperative complication. It was observed that in every case the testis had maintained its intra-scrotal position after the operation.
No macroscopical changes were evident in any of the testis. The results have been tabulated in Chart III.
On the basis of this work, we have arrived at the following conclusions:
Vasectomy as a measure for conception-control and for other purposes has no untoward effects, on the physical, mental and sexual faculties. It is a safe, sure and convenient method for conception-control.
Bad effects reported so far are never due to the operation itself, but to technical errors namely sepsis, injury to vessels and nerves of the spermatic cord, or to accidental cutting of the structures other than the vas deferens.
There is a definite improvement in the sexual, and physical health of most of the cases, and a great mental relief.
Vasectomy is followed by a definite degeneration of the seminiferous tubules, but this degeneration is either incomplete or temporary. Rejoining of the vas would therefore offer every hope of spermatogenesis restarting and consequent restoration to the individual of his reproductive function.
Following vasectomy there is definite proliferation of the interstitial tissue.
There appears to be a Correlation between the rejuvenation affect of clinical vasectomy and the experimentally observed interstitial tissue proliferation. To establish the similarity or otherwise of the two processes, simultaneous biochemical study would be required.
The aim of this work was to study the clinical effects of vasectomy done for birth control, to dispel unfounded fear from the minds of people. We were especially interested in verifying the claim of Steinche and others that this operation leads to. Interstitial tissue proliferation, hypertestoidism and rejuvenation.
The earliest workers focused their attention on the tubular changes only. Sir Ashley Cooper, Gosselin, Brissaud, Griffiths, and Simmods all reported that spermatogenesis continued even after vasectomy, and there were no degenerative changes found in the Seminiferous tubules, by them. Later Richton and Jeandelize, Ancel & Bouin, Sterinache and Tiedje reported definite degenerative changes in the seminiferous tubules after vasectomy. The latest workers like Shattock and Soligman, Wallace and Oslund have however reported normal spermatogenesis after the vasectomy. Oslund state that the degeneration in the tubules occurred in vasectomised as well as non-vasectomised rats when the testis was maintained. In the intra-abdominal position.
Steinache and others have observed interstitial tissue proliferation following vasectomy which according to them led to hyper testoidisam and rejuvenation.
Vasectomy was first used as a treatment for senile enlargement of the prostate. Oschner suggested its use for eugenic purposes. Sharon followed up this and carried out work on this line. Many others including Clifford-Morson, followed up this work, and the use of the operation was extended to sterilization. None of the workers have reported any ill effects; on the contrary some have reported physical, sexual and various other improvements following the vasectomy. Mathews in our country has done this operation of rejuvenation, in 106 cases, and has observed very good results.
Recently vasorraphy has excited much interest. Bickham, Twyman and Nelson, Friberge & Lepsky, Berker, Methoson and O’Conor have reported many cases and methods of vasorraphy. Handley has very recently reported a case in which vasorraphy was done after ten years and reproduction started after the operation.
The anatomy, structure and histology of the male genital have been described going on to the description of the methods of study.
Vasectomy was done in fifty-one men for the purposes of sterilization, rejuvenation or both. In one of these it has to be done to attempt vasorraphy later. The operation was performed by the Scrotal and inguino-scrotal approach. Great care was taken that no other structure was included with the vas-deferns and the artery to the vas and all the coverings of the vas were separated before crushing or cutting the vas.
Young rats were vasectomised and after the operation. Even two weeks, orchidectomy was done in one of them, and the testis sections studied histological. Similar histological studies were done on the testes of unvasectomised rats from the same age group to serve as controls.
The ages of the patients varied between 24 and 50 years. Forty-eight of them had come primarily for sterilization; twenty-eight of them had come primarily for sterilization; twenty -one out of these were also interested in rejuvenation. Two were operated only for rejuvenation and one was a human volunteer to help us to attempt vasorraphy later.
Follow up of from 2 months to 2 years revealed that except one all were happy ever their operation for having been operated. Twenty-eight reported improvement in physical health, twenty-one reported improvement sexually, and a few reported increased capacity for work and concentration. The wives of these persons were happy and few had noticeably improved in health.
Histological studies showed that there was an early degeneration in the tubules. Later spermatogenesis was seen. The interstitial tissue changes were obvious only after ten weeks, where proliferation of Leydig cells was seen. This was maintained and marked proliferation was observed after sixteen weeks, and was seen till the experiment terminated.
It is concluded that the operation of vasectomy is a safe method for sterilization. Bad results may only be due to the fault in the technique and not due to any other reasons. It has a beneficial effect on the physical and sexual faculties of the persons and it gives a great relief to the people who otherwise feel completely lost due to having no control on the number of children.
From the experimental studies it is concluded that spermatogenesis is temporarily and incompletely depressed. Interstitial tissue shows definite proliferation. This is one of the factors for the reported physical, sexual and other improvements in the clinical cases.
At the conclusion of this work, we feel that the following new problems require study.
Estimation of the androgens before and after vasectomy.
A lengthier follow-up to study the results on the female partners.
As vasectomy continues to increase in popularity the need for vasorraphy may also rise some time. This has been done by a few workers abroad and will be pursued by us.
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