IN 1890, VASECTOMY was first suggested as an alternative to castration for men with enlarged prostates. In the early 1890’s, it was also suggested as a ‘treatment’ for certain criminals and undesirables, and for a time, enforced sterilisation was legal for some. It wasn’t until 1948 that vasectomy came into common use as a form of permanent contraception. At this time, the operation was performed through an incision on each side of the scrotum, a loop of vas deferens would be brought through the incision, a segment removed and the ends tied off. In 1974, no-scalpel vasectomy (NSV) was pioneered by Dr Li Shunquang in China, carried out through a single mid-line incision or puncture wound under local anaesthetic and is now the recommended method of vasectomy in Britain.
More than 65,000 vasectomies are done each year in the UK – in hospitals, clinics and, increasingly, in GP surgeries. There is a recognised programme (via the Faculty of Sexual and Reproductive Health) for training in NSV and the faculty has a list of 24 registered trainers throughout the country. Surgeons are encouraged to undertake a minimum of 50 operations each year, to conduct regular audits of their work and attend regular courses to keep up-to-date.
Vasectomy is now commonly carried out in GP surgeries and clinics and has a very low, rarely severe, complication rate (perhaps <2% risk of infection, excessive swelling or bruising). A more serious complication of vasectomy is development of a chronic pain syndrome (PVPS), which can occur many months or even years after a vasectomy. This is one of the two commonest reasons for litigation, as it can be difficult to treat and occasionally become quite disabling. Published papers quote anything from 5-30%. However, there is a large variation in defining PVPS and within my organisation, British Association of No-Scalpel Vasectomists (BANSV, affiliated with ASPC-Association of Surgeons in Primary Care) we believe the incidence is lower, perhaps below 5%.
The other common reason for litigation is failure of the operation. Failure is well-recognised, and a rate of 1:2000 (after ‘confirmation’ of sterility) is generally quoted. Failure does not imply sub-standard care, although, of course, sub-standard care can result in failure but is extremely difficult to ‘prove’. Early failure, recognised when initial post-vasectomy semen tests still show live sperm, is slightly greater than 1:2000
Litigation often arises because informed consent has not been obtained. ‘Informed’ means that the patient has been advised of the actual procedure, how it will be done, irreversibility (having the operation reversed is not always successful) as well as recognised risk and complications and failure. In addition, alternative methods of contraception should also have been discussed, in particular, long-acting reversible contraceptives (LARCs). All this means that the patient should be made aware of alternatives to vasectomy, as well as risk of: excessive swelling, bruising, infection, chronic testicular pain and even testicular atrophy (where the blood supply to a testicle is inadvertently cut off during the operation, resulting in the testicle ‘dying’ on that side, and eventually needing to be removed; when this happens, it can be due to sub-standard care during the operation, but not necessarily). These issues should be written on the consent form which the patient signs, or at least in an information leaflet that the patient has had a chance to study beforehand.
On the day of operation, the patient should be encouraged to ask questions, and steps should be taken to ensure that the patient understands the nature and implications of the operation, and that it is the right method of permanent contraception for him and his partner, as well as the risks and failure rates listed above.
It goes without saying that all the above should be properly documented in the patient’s medical record, as well as a proper record of the operation itself, including any problems or difficulties encountered either before the operation, during or after. Appropriate information should be provided regarding post-operative care, in particular what the patient should do, and whom to contact, if any concerns arise. Lack of proper records makes it more difficult for a surgeon to defend him/herself when a complaint arises.
Finally, it should be stressed that sterility cannot be confirmed until appropriate semen tests have been carried out and an additional method of contraception should still be used until sterility is confirmed. Traditionally, two consecutive clear tests were required. However, it is now recognised that one completely clear sample at least four months after the vasectomy is sufficient to confirm sterility, as evidence shows that the risk of pregnancy after one clear sample is the same as after two. Also, ‘special clearance’ can sometimes be given if there are still only a small number of non-motile sperm present at least seven months after the operation.
Complaints still arise when the partner becomes pregnant say 12 months later, but he has not done any semen tests and just ‘assumed’ he would be OK! You can’t blame the surgeon for that, assuming that proper advice and information have been given, including reminder letters when sperm tests are not received back at the expected times.