Re: No-scalpel vasectomy

There are, I believe, some erroneous assertions and important omissions in Dr Barry Rich’s article “Male contraception and no-scalpel vasectomy” (BCMJ 2001;43(10):560).

Dr Rich is concerned about truancy rates, the proportion of men who do not return for semen analysis, and whose failures may therefore remain unreported. He affirms that such rates are never mentioned in the medical literature. Not so. My 1988 JAMA paper describes a total group of 8879 consecutive vasectomies, from which a study group of 5331 men who had at least two semen tests was used to establish failure classifications and rates.[1] But this is largely a non-issue as, in my experience, truants whose vasectomies fail will unhesitatingly report the matter to the surgeon, who would, presumably, add it to his register of failures.

Under “Risks and complications after vasectomy”… I was disappointed to find no mention of vasovagal reactions, which may be frighteningly manifest by syncope, apnoea, and convulsions during a vasectomy. Nor are rates of failure given as reported in the literature, or, for that matter, in Dr Rich’s own experience. Such comparative data is useful in evaluating techniques, methods, and, perhaps, practitioners.

“Few studies,” Dr Rich declares, “define exactly what is meant by vasectomy failure in terms of sperm counts plus or minus motility and at what point in time.”… [In my 1988 paper] I described and classified… early, late, overt, and technical failures in terms of sperm counts, time, and motility.[1]…

As Dr Rich acknowledges, no-scalpel vasectomy (NSV) is only a method of accessing the vas, implying—quite correctly—that the more challenging issues of how to treat the open ends of the vas are unrelated to the method of accessing it. What, then, is all the hullabaloo about NSV?

For some 15 years the Association for Voluntary Surgical Contraception (now renamed Engender Health) and no-scalpel promoters have claimed fewer hematomas, less bleeding, fewer infections, shorter operating times, less pain, and an enhanced acceptance of vasectomy.[2]

In his article, Dr Rich mentions only two studies that directly compare the complication rates of NSV and standard incision techniques. The first, a 1990 paper by Nirapathpongporn et al. describes a series of 1203 vasectomies performed by 28 physicians during a festival in Thailand.[3] While the reported results favored NSV, no definitions of complications were given. In any event, there were 11 instances of hemorrhage, of which nine (0.75% of the 1203) occurred with standard technique, including two requiring admission to hospital for surgical drainage of large hematomas. This compares with an incidence of 0.33% for minor hemorrhages and 0% for any requiring hospitalization or drainage in a series of 1224 standard incision vasectomies I reported in 1991.[4] It seems curious that Nirapathpongporn’s “experienced vasectomists” had such unfortunate results with standard incisions.

Dr Rich asserts that “subsequent studies [to Nirapathpongporn’s] have shown similar results, though one 1999 study showed little difference.” I was not surprised to see that no such subsequent studies were actually referenced by Dr Rich because, to my knowledge, no such comparative studies exist, although many articles can be found in the literature that describe the NSV technique or are laudatory testimonials by its practitioners.[5,6] The 1999 study Dr Rich refers to was authored by Dr Gary E.C. Morrison and myself.[7] This paper reported a series of 619 consecutive vasectomies performed…by the same surgeon using both no-scalpel and standard incision techniques. We found no evidence for shorter operating times, less pain, or enhanced acceptance of vasectomy because of NSV, and virtually identical (and very low) complication rates for both techniques. We concluded that:

• A satisfactory vasectomy can be achieved when either technique is meticulously executed by an experienced physician

• The claims made for the advantages of no-scalpel vasectomy remain unsubstantiated.

—Philip M. Alderman, MD 
West Vancouver

References

1.  Alderman PM. The lurking sperm: A review of failures in 8879 vasectomies performed by one physician. JAMA 1988;259:3142-3144. PubMed Abstract 
2.  Li S, Goldstein M, Zhu J, et al. The no-scalpel vasectomy. J Urol 1991;145:341-344. PubMed Abstract 
3.  Nirapathpongporn A, Huber DH, Krieger JN. No-scalpel vasectomy at the King’s birthday vasectomy festival. Lancet 1990;335:894-895. PubMed Abstract 
4.  Alderman PM. Complications in a series of 1224 vasectomies. J Fam Pract 1991;33:579-584. PubMed Abstract 
5.  Davis LE, Stockton MD. No scalpel vasectomy. Prim Care 1997;24:433-461. PubMed Abstract 
6.  Filshie M. No scalpel technique for vasectomy. Eur J Contracept Reprod Health Care 1996;1:231-235. PubMed Abstract 
7.  Alderman PM, Morrison GE. Standard incision or no-scalpel vasectomy? J Fam Pract 1999;48:719-721. PubMed Abstract