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Open-ended vasectomy: an assessment
FERTILITY AND STERILITY
VoL 45, No.6, June 1986 Printed in U.S.A.
Copyright ", 1986 The American Fertility Society
Open-ended vasectomy: an assessment
Bruce B, Errey, M,B.*t Ian S. Edwards, M.B.:J: Fertility Control Clinic, Brisbane, and Cronulla Private Medical Clinic, Sydney, Australia
Leaving open the testicular end of vas at vasectomy could reduce symptoms of epididymal congestion and improve the success rate of vasovasostomy but might have the disadvantage of increasing the incidence of painful sperm granulomas and spontaneous recanalization. In 4330 open-ended vasectomies the rate of epididymal congestion was significantly less than in 3867 standard vasectomies. The rate of painful sperm granulomas was not increased: it was significantly reduced. Spontaneous recanalization was rare in both groups. Whether or not open-ended vasectomy improves the success rate of vasovasostomy, it represents an improvement in technique because it reduces the rate of complications after vasectomy. Closure of the sheath over the prostatic end of vas is essential if recanalization is to be prevented. Fertil Steril45:843, 1986
The idea of leaving open the testicular end of the vas at the time of vasectomy is not new. In 1909 Sharpi thought it important to leave it open so that "the economy receives the tonic effect of the secretion." In 1966 Schmide noted that "some authors advocate leaving the proximal end open," and in 1971 Livingstone3 said that "it was formerly a common practice to omit ligation of the proximal end." By 1948, however, surgeons became aware of cases of spontaneous recanalization of the vas, 4 and closing both ends has become standard technique. A disadvantage of closing the testicular end has been that a few men suffer discomforts apparently because of back pressure: orchialgia, epididymitis, and epididymal granulomas. If observed at vasovasostomy, the testicular end of the vas and the epididymis are typically found to be grossly dilated, and minor trauma may have rup-
Received November 18, 1985; revised and accepted February 13, 1986. *Reprint requests: Dr. B. B. Errey, 687 Logan Road, Greenslopes, Q 4120, Australia. tFertility Control Clinic. :j:Cronulla Private Medical Clinic. Vol. 45, No.6, June 1986
tured dilated tubules, resulting in a sperm granuloma of the epididymis. 2 Another cause of discomfort, sperm granuloma at the site of vasectomy, apparently results from ineffective occlusion of the vas, with leakage of sperm into the surrounding tissues. 2 It might be expected that deliberately leaving open the testicular end of the vas could increase the incidence of this complication. Granulomas sometimes lead to spontaneous recanalization of the vas or to a vas-cutaneous fistula, 2 so that the rate of these complications might also be increased. On balance, the occasional and usually mild complications of vas occlusion seemed preferable to the risks of sperm granuloma and spontaneous recanalization. This assumption was questioned in 1977 by Silber,5 who reported that the presence of sperm granulomas in men presenting for vasovasostomy increased the success rate of that operation. Pressure in the epididymis appeared to impair its function, and he suggested that granulomas might act as safety valves and that perhaps their formation should be encouraged. Schmidt,6 while not disputing these observations, noted that granulomas can occasionally be very painful and questioned the wisdom of deliberately enErrey and Edwards Open-ended vasectomy
843
couraging them. Further doubt was cast on the idea of open-ended vasectomy by Shapiro and Silber 7 and by Goldstein 8 when the method appeared to result in increased rates of spontaneous recanalization. One of us (B. E.) has since 1979 modified his method of vasectomy by leaving open the testicular end of vas. Clinical impressions have been that the postoperative complications of painful epididymal congestion and orchialgia are reduced, while those of sperm granuloma and spontaneous recanalization are not increased. 9 To test these impressions, we have reviewed the records of 3867 men whose vasectomies were done with the testicular end of vas occluded, and compared them with those of 4330 done by an open-ended technique. MATERIALS AND METHODS VASECTOMY TECHNIQUE
All vasectomies were performed at one location by one of us (B. E.), who had performed 6000 vasectomies before 1976. Those by the standard technique were done from 1976, when closure of the sheath over the prostatic end of vas was introduced, until 1979. Those by the open-ended modification were done between 1979 and June 1984. All vasectomies were done with the patient under local anesthesia as outpatient procedures. The standard technique was to excise 2 to 5 mm of vas, irrigate the lumen of the prostatic end with 5 mIl % lidocaine, treat that end with high frequency diathermy to the cut surface, ligate it with 3-0 nylon, turn it back without anchoring it, and close the sheath over it with a continuous suture of 3-0 nylon. The testicular end was treated with diathermy, ligated with 3-0 nylon, turned back, and anchored to the outside of the sheath by means of the ligating suture. The wound was closed with 3-0 nylon, and the procedure was repeated through a separate incision on the other side. The open-ended technique was similar, except that diathermy was not performed on the testicular end, nor was it ligated; instead, it was left open. An attempt was made to retain it in a turned back position by means of a loop of 3-0 nylon sutured to the outside of the sheath. Patients were routinely seen 4 days after vasectomy for postoperative review and removal of 844
Errey and Edwards Open-ended vasectomy
skin sutures. The men were urged to return for treatment, which would be free of charge, should they later have any complications. It is these patient-initiated return visits which are the subject of this study. COUNT AND CLASSIFICATION OF COMPLICATIONS
After June 1985 we searched consecutive case histories of 3867 standard technique vasectomies and 4330 open-ended vasectomies, and counted all return visits made within 1 year of vasectomy because of pain or swelling, after the routine postoperative visit. Tender swelling occurring within 2 weeks of vasectomy was regarded as being caused by postoperative infection or hematoma, and return visits made during that time were excluded from the count. It was noted whether visits were made during the first 2 months after vasectomy, or later in the year. An attempt was made to quantify the severity of the complications by noting whether one, or more than one, visit was made for each episode. A few men made visits for both granuloma and epididymal congestion, usually on separate occasions, or for more than one episode of either complication. In these cases each complication was counted separately. The visits were classified under the categories below.
Epididymal Congestion Tender swelling of all or part of the epididymis, tender lumps in it, whether solid or cystic, or complaints of orchialgia in the absence of any detectable abnormality were included in this category.
Granuloma We used Schmidt's definition 2 , 6 of symptomatic sperm granuloma of the vas: a nodule or cyst at the point of interruption of the vas after the immediate postoperative tenderness had subsided, painful to pressure or during ejaculation.
RESULTS
The diagnosis could usually be clearly identified as either "epididymal congestion" or "granuloma." It was noteworthy that in most cases the return visit had been occasioned by a sudden discomfort, often attributed by the patient to a recent episode of minor trauma or sexual interFertility and Sterility
Table 1. Epididymal Congestion Visits in first 2 Visits in first year Rate months
%of total
More than one %of .total visit
%
Closed series (3867) Open series (4330)
106
2.7
54
51
41
39
64
1.5
30
47
22
34
course. Most had been treated simply by explanation, reassurance,andenteric-coated aspirin; and about half required no further visit. Change to the open-ended technique significantlyreduced the rate of epididymal congestion, .as measured by the number of return visits during the first year after vasectomy (P < 0.001). There is some indication that the decrease was more marked for visits within the first 2 months after vasectomy, and that when it occurred, this complication was less severe in the open-ended series, as shown by a reduction in the proportion of men making more than one return visit; however, these reductions fall short of being statistically significant (Table 1). Change to the open-ended technique did not increase the rate of sperm granuloma. On the contrary, there was a significant decrease in the number of return visits during the first year for this complication (P < 0.001). In the rate of return visits for sperm granuloma the reduction on changing to the open-ended technique was particularly noticeable in visits made during the first 2 months after vasectomy, the difference being statistically significant (P < 0.001). There was also some indication that the complication was less severe in the open-ended series, as shown by a reduction in the proportion of men making more than one return visit; but the reduction falls short of being statistically significant (Table 2). Spontaneous recanalization occurred in three cases in the standard technique series (0.08%). There was one case in the open-ended series (0.02%). The difference is not statistically significant. Vas-cutaneous fistula occurred in one case in each series. DISCUSSION
The rate of spontaneous recanalization remained very low when the open-ended modi ficaVol. 45, No.6, June 1986
tion was used. It is of interest to compare this low rate with the reported experience of others who have been careful to close the sheath over one end of the vas. Some who have done so, whether treating the testicular end with diathermylO or with ligation,ll have reported large series without any cases of recanalization. In contrast, those who have reported an unacceptable rate of spontaneous recanalization after open-ended vasectomy 7, 8 have not included fascial separation in their techniques. It would appear that fascial separation of the two ends of the vas is, of itself, the most effective means of preventing spontaneous recanalization. In the rate of complications attributable to epididymal congestion, the reduction which had been hoped for did in fact occur, suggesting that symptoms of congestion are indeed attributable to occlusion of the vas. It might be asked, however, why these complications continued to appear at all in the open-ended series. Perhaps in some cases the open end of the vas later became occluded by scarring. Another possibility is that the rate of such complications depends not solely on whether the testicular end of the vas is left open or closed, but partly on other more subtle variations in operative technique. This would be consistent with the results of others,10 who changed to an apparently more effective means of occluding the vas and yet found that this resulted not in an increase, but rather a reduction in the rate of congestive epididymitis. It is not clear why open-ended vasectomy does not usually result in painful granulomas forming postoperatively, or why there should be a decrease, rather than an increase, in the rate at which they form during the following year, particularly during the first 2 months after vasectomy. The explanation may lie in the pathogenesis of sperm granuloma, as yet not fully understood, but possibly attributable to the release of acid-fast lipids from sperm. 12 It may be that the Table 2. Sperm Granuloma Visits in first year Rate
Visits in first 2 months
% of total
More than one visit
% of total
%
Closed series (3867) Open series (4330)
122
3.2
68
56
60
49
66
1.5
15
23
28
42
Errey and Edwards Open-ended vasectomy
845
factor inducing granuloma formation is more abundantly produced by dead or degenerating sperm than by normal sperm emerging from a vas deliberately left open. In studies of tissue excised at vasovasectomy, asymptomatic sperm granulomas have been found in as many as 39%.13 There is as yet no reported histologic evidence of the incidence of asymptomatic granulomas after open-ended vasectomy. We do not know, then, what proportion of those in the open-ended series might have developed an asymptomatic sperm granuloma. If asymptomatic granulomas are often the outcome of all techniques, minor trauma might cause the sudden release of an irritating substance, causing the granuloma to become symptomatic. A lower rate of painful granuloma after open-ended vasectomy could then reflect a lower rate of asymptomatic granuloma formation with this technique, rather than the higher rate reported by Shapiro and Silber. 7 Instead of being attributable to a "safety valve" effect, the reduction in symptoms of congestion might simply be the result of the testicular end of the vas being unoccluded. A retrospective study comparing series which follow each other is open to the criticism that improved results may be attributable to increasing experience of the operator. A prospective study of alternating cases would be methodologically preferable. 14 We have compared two series of vasectomies all performed in one location by the same experienced operator, and the numbers are sufficient for statistically significant conclusions to be drawn about a reduction in complication rates which were already at a low level. The reduction in complications has been small in percentage terms, but should be related to the millions of vasectomies being performed worldwide each year. 14 Whether or not the open-ended modification of vasectomy is eventually shown to improve the success rate of vasovasostomy, it represents a worthwhile improvement in technique because it
846
Errey and Edwards Open-ended vasectomy
reduces the rate of complications from epididymal congestion and from sperm granuloma. It is emphasized that the technique must include closure of the sheath over the prostatic end of the vas. If this is done, the rate of spontaneous recanalization does not increase. Acknowledgment. We thank Mr. Alan E. Stark of the School of Community Medicine, The University of New South Wales, for his invaluable statistical advice. REFERENCES 1. Sharp HC: Vasectomy as a means of preventing procreation in defectives. JAMA 53:1897,1909. Cited by HJ Klapproth, IS Young; Vasectomy, vas ligation and vas occlusion. Urology 1:292, 1973 2. Schmidt SS: Technics and complications of elective vasectomy: the role of spermatic granuloma in spontaneous recanalization. Fertil Steril 17:467, 1966 3. Livingstone ES: Vasectomy: a review of 3200 operations. Can Med Assoc J 105:1065, 1971 4. O'Conor VJ: Anastomosis of vas deferens after purposeful division for sterility. JAMA 136:162, 1948 5. Silber SJ: Microscopic vasectomy reversal. Fertil Steril 28:1191, 1977 6. Schmidt SS: Spermatic granuloma: an often painful lesion. Fertil Steril 31:178, 1979 7. Shapiro EI, Silber SJ: Open-ended vasectomy, sperm granuloma, and postvasectomy orchialgia. Fertil Steril 32:546, 1979 8. Goldstein M: Vasectomy failure using an open-ended technique. Fertil Steril 40:699, 1983 9. Errey B: Open-ended vasectomy. (Letter) Fertil Steril 41:164, 1984 10. Schmidt SS, Free MJ: The bipolar needle for vasectomy. I. Experience with the first 1000 cases. Fertil Steril 29:676, 1978 11. Yeates WK: Delayed spontaneous recanalization of the vas deferens. (Letter) Br J Surg 71:914, 1984 12. Glassy FJ, Mostofi FK: Spermatic granulomas of the epididymis. Am J Clin Path 26:1303, 1956 13. Alexander NJ, Schmidt SS: Incidence of antisperm antibody levels and granulomas in men. Fertil Steril 28:655, 1977 14. Population Information Program, The Johns Hopkins University, Baltimore: Vasectomy-safe and simple. Population Reports, Series D, Number 4, 1983
Fertility and Sterility
VoL 45, No.6, June 1986 Printed in U.S.A.
Copyright ", 1986 The American Fertility Society
Open-ended vasectomy: an assessment
Bruce B, Errey, M,B.*t Ian S. Edwards, M.B.:J: Fertility Control Clinic, Brisbane, and Cronulla Private Medical Clinic, Sydney, Australia
Leaving open the testicular end of vas at vasectomy could reduce symptoms of epididymal congestion and improve the success rate of vasovasostomy but might have the disadvantage of increasing the incidence of painful sperm granulomas and spontaneous recanalization. In 4330 open-ended vasectomies the rate of epididymal congestion was significantly less than in 3867 standard vasectomies. The rate of painful sperm granulomas was not increased: it was significantly reduced. Spontaneous recanalization was rare in both groups. Whether or not open-ended vasectomy improves the success rate of vasovasostomy, it represents an improvement in technique because it reduces the rate of complications after vasectomy. Closure of the sheath over the prostatic end of vas is essential if recanalization is to be prevented. Fertil Steril45:843, 1986
The idea of leaving open the testicular end of the vas at the time of vasectomy is not new. In 1909 Sharpi thought it important to leave it open so that "the economy receives the tonic effect of the secretion." In 1966 Schmide noted that "some authors advocate leaving the proximal end open," and in 1971 Livingstone3 said that "it was formerly a common practice to omit ligation of the proximal end." By 1948, however, surgeons became aware of cases of spontaneous recanalization of the vas, 4 and closing both ends has become standard technique. A disadvantage of closing the testicular end has been that a few men suffer discomforts apparently because of back pressure: orchialgia, epididymitis, and epididymal granulomas. If observed at vasovasostomy, the testicular end of the vas and the epididymis are typically found to be grossly dilated, and minor trauma may have rup-
Received November 18, 1985; revised and accepted February 13, 1986. *Reprint requests: Dr. B. B. Errey, 687 Logan Road, Greenslopes, Q 4120, Australia. tFertility Control Clinic. :j:Cronulla Private Medical Clinic. Vol. 45, No.6, June 1986
tured dilated tubules, resulting in a sperm granuloma of the epididymis. 2 Another cause of discomfort, sperm granuloma at the site of vasectomy, apparently results from ineffective occlusion of the vas, with leakage of sperm into the surrounding tissues. 2 It might be expected that deliberately leaving open the testicular end of the vas could increase the incidence of this complication. Granulomas sometimes lead to spontaneous recanalization of the vas or to a vas-cutaneous fistula, 2 so that the rate of these complications might also be increased. On balance, the occasional and usually mild complications of vas occlusion seemed preferable to the risks of sperm granuloma and spontaneous recanalization. This assumption was questioned in 1977 by Silber,5 who reported that the presence of sperm granulomas in men presenting for vasovasostomy increased the success rate of that operation. Pressure in the epididymis appeared to impair its function, and he suggested that granulomas might act as safety valves and that perhaps their formation should be encouraged. Schmidt,6 while not disputing these observations, noted that granulomas can occasionally be very painful and questioned the wisdom of deliberately enErrey and Edwards Open-ended vasectomy
843
couraging them. Further doubt was cast on the idea of open-ended vasectomy by Shapiro and Silber 7 and by Goldstein 8 when the method appeared to result in increased rates of spontaneous recanalization. One of us (B. E.) has since 1979 modified his method of vasectomy by leaving open the testicular end of vas. Clinical impressions have been that the postoperative complications of painful epididymal congestion and orchialgia are reduced, while those of sperm granuloma and spontaneous recanalization are not increased. 9 To test these impressions, we have reviewed the records of 3867 men whose vasectomies were done with the testicular end of vas occluded, and compared them with those of 4330 done by an open-ended technique. MATERIALS AND METHODS VASECTOMY TECHNIQUE
All vasectomies were performed at one location by one of us (B. E.), who had performed 6000 vasectomies before 1976. Those by the standard technique were done from 1976, when closure of the sheath over the prostatic end of vas was introduced, until 1979. Those by the open-ended modification were done between 1979 and June 1984. All vasectomies were done with the patient under local anesthesia as outpatient procedures. The standard technique was to excise 2 to 5 mm of vas, irrigate the lumen of the prostatic end with 5 mIl % lidocaine, treat that end with high frequency diathermy to the cut surface, ligate it with 3-0 nylon, turn it back without anchoring it, and close the sheath over it with a continuous suture of 3-0 nylon. The testicular end was treated with diathermy, ligated with 3-0 nylon, turned back, and anchored to the outside of the sheath by means of the ligating suture. The wound was closed with 3-0 nylon, and the procedure was repeated through a separate incision on the other side. The open-ended technique was similar, except that diathermy was not performed on the testicular end, nor was it ligated; instead, it was left open. An attempt was made to retain it in a turned back position by means of a loop of 3-0 nylon sutured to the outside of the sheath. Patients were routinely seen 4 days after vasectomy for postoperative review and removal of 844
Errey and Edwards Open-ended vasectomy
skin sutures. The men were urged to return for treatment, which would be free of charge, should they later have any complications. It is these patient-initiated return visits which are the subject of this study. COUNT AND CLASSIFICATION OF COMPLICATIONS
After June 1985 we searched consecutive case histories of 3867 standard technique vasectomies and 4330 open-ended vasectomies, and counted all return visits made within 1 year of vasectomy because of pain or swelling, after the routine postoperative visit. Tender swelling occurring within 2 weeks of vasectomy was regarded as being caused by postoperative infection or hematoma, and return visits made during that time were excluded from the count. It was noted whether visits were made during the first 2 months after vasectomy, or later in the year. An attempt was made to quantify the severity of the complications by noting whether one, or more than one, visit was made for each episode. A few men made visits for both granuloma and epididymal congestion, usually on separate occasions, or for more than one episode of either complication. In these cases each complication was counted separately. The visits were classified under the categories below.
Epididymal Congestion Tender swelling of all or part of the epididymis, tender lumps in it, whether solid or cystic, or complaints of orchialgia in the absence of any detectable abnormality were included in this category.
Granuloma We used Schmidt's definition 2 , 6 of symptomatic sperm granuloma of the vas: a nodule or cyst at the point of interruption of the vas after the immediate postoperative tenderness had subsided, painful to pressure or during ejaculation.
RESULTS
The diagnosis could usually be clearly identified as either "epididymal congestion" or "granuloma." It was noteworthy that in most cases the return visit had been occasioned by a sudden discomfort, often attributed by the patient to a recent episode of minor trauma or sexual interFertility and Sterility
Table 1. Epididymal Congestion Visits in first 2 Visits in first year Rate months
%of total
More than one %of .total visit
%
Closed series (3867) Open series (4330)
106
2.7
54
51
41
39
64
1.5
30
47
22
34
course. Most had been treated simply by explanation, reassurance,andenteric-coated aspirin; and about half required no further visit. Change to the open-ended technique significantlyreduced the rate of epididymal congestion, .as measured by the number of return visits during the first year after vasectomy (P < 0.001). There is some indication that the decrease was more marked for visits within the first 2 months after vasectomy, and that when it occurred, this complication was less severe in the open-ended series, as shown by a reduction in the proportion of men making more than one return visit; however, these reductions fall short of being statistically significant (Table 1). Change to the open-ended technique did not increase the rate of sperm granuloma. On the contrary, there was a significant decrease in the number of return visits during the first year for this complication (P < 0.001). In the rate of return visits for sperm granuloma the reduction on changing to the open-ended technique was particularly noticeable in visits made during the first 2 months after vasectomy, the difference being statistically significant (P < 0.001). There was also some indication that the complication was less severe in the open-ended series, as shown by a reduction in the proportion of men making more than one return visit; but the reduction falls short of being statistically significant (Table 2). Spontaneous recanalization occurred in three cases in the standard technique series (0.08%). There was one case in the open-ended series (0.02%). The difference is not statistically significant. Vas-cutaneous fistula occurred in one case in each series. DISCUSSION
The rate of spontaneous recanalization remained very low when the open-ended modi ficaVol. 45, No.6, June 1986
tion was used. It is of interest to compare this low rate with the reported experience of others who have been careful to close the sheath over one end of the vas. Some who have done so, whether treating the testicular end with diathermylO or with ligation,ll have reported large series without any cases of recanalization. In contrast, those who have reported an unacceptable rate of spontaneous recanalization after open-ended vasectomy 7, 8 have not included fascial separation in their techniques. It would appear that fascial separation of the two ends of the vas is, of itself, the most effective means of preventing spontaneous recanalization. In the rate of complications attributable to epididymal congestion, the reduction which had been hoped for did in fact occur, suggesting that symptoms of congestion are indeed attributable to occlusion of the vas. It might be asked, however, why these complications continued to appear at all in the open-ended series. Perhaps in some cases the open end of the vas later became occluded by scarring. Another possibility is that the rate of such complications depends not solely on whether the testicular end of the vas is left open or closed, but partly on other more subtle variations in operative technique. This would be consistent with the results of others,10 who changed to an apparently more effective means of occluding the vas and yet found that this resulted not in an increase, but rather a reduction in the rate of congestive epididymitis. It is not clear why open-ended vasectomy does not usually result in painful granulomas forming postoperatively, or why there should be a decrease, rather than an increase, in the rate at which they form during the following year, particularly during the first 2 months after vasectomy. The explanation may lie in the pathogenesis of sperm granuloma, as yet not fully understood, but possibly attributable to the release of acid-fast lipids from sperm. 12 It may be that the Table 2. Sperm Granuloma Visits in first year Rate
Visits in first 2 months
% of total
More than one visit
% of total
%
Closed series (3867) Open series (4330)
122
3.2
68
56
60
49
66
1.5
15
23
28
42
Errey and Edwards Open-ended vasectomy
845
factor inducing granuloma formation is more abundantly produced by dead or degenerating sperm than by normal sperm emerging from a vas deliberately left open. In studies of tissue excised at vasovasectomy, asymptomatic sperm granulomas have been found in as many as 39%.13 There is as yet no reported histologic evidence of the incidence of asymptomatic granulomas after open-ended vasectomy. We do not know, then, what proportion of those in the open-ended series might have developed an asymptomatic sperm granuloma. If asymptomatic granulomas are often the outcome of all techniques, minor trauma might cause the sudden release of an irritating substance, causing the granuloma to become symptomatic. A lower rate of painful granuloma after open-ended vasectomy could then reflect a lower rate of asymptomatic granuloma formation with this technique, rather than the higher rate reported by Shapiro and Silber. 7 Instead of being attributable to a "safety valve" effect, the reduction in symptoms of congestion might simply be the result of the testicular end of the vas being unoccluded. A retrospective study comparing series which follow each other is open to the criticism that improved results may be attributable to increasing experience of the operator. A prospective study of alternating cases would be methodologically preferable. 14 We have compared two series of vasectomies all performed in one location by the same experienced operator, and the numbers are sufficient for statistically significant conclusions to be drawn about a reduction in complication rates which were already at a low level. The reduction in complications has been small in percentage terms, but should be related to the millions of vasectomies being performed worldwide each year. 14 Whether or not the open-ended modification of vasectomy is eventually shown to improve the success rate of vasovasostomy, it represents a worthwhile improvement in technique because it
846
Errey and Edwards Open-ended vasectomy
reduces the rate of complications from epididymal congestion and from sperm granuloma. It is emphasized that the technique must include closure of the sheath over the prostatic end of the vas. If this is done, the rate of spontaneous recanalization does not increase. Acknowledgment. We thank Mr. Alan E. Stark of the School of Community Medicine, The University of New South Wales, for his invaluable statistical advice. REFERENCES 1. Sharp HC: Vasectomy as a means of preventing procreation in defectives. JAMA 53:1897,1909. Cited by HJ Klapproth, IS Young; Vasectomy, vas ligation and vas occlusion. Urology 1:292, 1973 2. Schmidt SS: Technics and complications of elective vasectomy: the role of spermatic granuloma in spontaneous recanalization. Fertil Steril 17:467, 1966 3. Livingstone ES: Vasectomy: a review of 3200 operations. Can Med Assoc J 105:1065, 1971 4. O'Conor VJ: Anastomosis of vas deferens after purposeful division for sterility. JAMA 136:162, 1948 5. Silber SJ: Microscopic vasectomy reversal. Fertil Steril 28:1191, 1977 6. Schmidt SS: Spermatic granuloma: an often painful lesion. Fertil Steril 31:178, 1979 7. Shapiro EI, Silber SJ: Open-ended vasectomy, sperm granuloma, and postvasectomy orchialgia. Fertil Steril 32:546, 1979 8. Goldstein M: Vasectomy failure using an open-ended technique. Fertil Steril 40:699, 1983 9. Errey B: Open-ended vasectomy. (Letter) Fertil Steril 41:164, 1984 10. Schmidt SS, Free MJ: The bipolar needle for vasectomy. I. Experience with the first 1000 cases. Fertil Steril 29:676, 1978 11. Yeates WK: Delayed spontaneous recanalization of the vas deferens. (Letter) Br J Surg 71:914, 1984 12. Glassy FJ, Mostofi FK: Spermatic granulomas of the epididymis. Am J Clin Path 26:1303, 1956 13. Alexander NJ, Schmidt SS: Incidence of antisperm antibody levels and granulomas in men. Fertil Steril 28:655, 1977 14. Population Information Program, The Johns Hopkins University, Baltimore: Vasectomy-safe and simple. Population Reports, Series D, Number 4, 1983
Fertility and Sterility