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 addi­tion 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 advantage 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

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 ioo 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 impossibility 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 educa­tional level, an above-average income and a complete family. Many of them feel that it is now ‘their turn’ to contribute to contraception.

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

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.