Abstract :

Vasectomy was in the National family welfare programme of India which was started in the 1950's. However, because of various socio-cultural reasons, faulty approach and lack of proper motivation, vasectomy did not get the acceptance it deserved. India's population grew unabated and reached the one billion mark it may, 2000. It is expected to rise above two billions within the next 20 years, which will negate all the progress and development in India. However, in China , where vasectomy is well-accepted as one of the means for permanent contraception, birthrate came down from 33.34 per thousand population in 1970 to 15.23 in 1999 with about million births evaded during the period. Dr. Li Shunqiang of Sichuan Reproductive Health Institute, Chengdu (China) introduced No Scalpel Vasectomy (NSV) - vasectomy without knife - in 1974. It is an improved minimal access version of the conventional vasectomy. It allays the fear of incision with knife as in conventional vasectomy. Complications are rare and mild. Contrary to the fears of some people, there is nothing to show any causal relationship between vasectomy and development of coronary heart disease or prostatic and testicular cancer. NSV is a very simple and safe procedure which can be performed almost anywhere by any doctor with a little training. It does not require a costly set up or instruments. It can be safely implemented as an essential component of population control programmes. Widespread publicity to remove misconceptions and ignorance among the masses combined with continued training of NSV service providers to expand the provider pool will bring the number of NSV acceptors to a significant level meaningful for a stable population.

Introduction :

Independent India was one of the earliest nations to start a national family welfare programme in 1950's. Vasectomy was included in the programme. However, because of various reasons - cultural and social aspects, health and sexual misconceptions, a rather aggressive approach and an unprepared and unmotivated community - the response to vasectomy dwindled. Vasectomy, which should have been a boon for India, became a bad word.

Vasectomy was the method of choice for the provider, which not necessarily that of the client. In 1977, men expressed their dissatisfaction through the ballot box.

All the hard work on vasectomy in India was wasted; India announced its one billion mark in population on May 11, 2000. Like a monster it is trying to gulp down all the progress in developmental works. Indeed, today India is a billion-monster. With only 2.5% of global land area, India supports 17% of the world's population. Every year 15 million children are born here to an "uncertain future".

The population of India is projected to rise above two billions within the next twenty years (www.fpindia.com) with its attended problems. If the average children per couple are restricted to two, the population of India will stabilise at 1.7 billion. However, under the present prevailing situation, the population is unlikely to stabilise until 2060 and the legitimate requirements of basic amenities will remain a distant dream.

During the time vasectomy was suffering a set back in India, neighbouring China scored a remarkable achievement in population control. Men have been encouraged to take more responsibility in family planning and choose vasectomy as permanent contraception. China 's birthrate came down from 33.43 per thousand population in 1970 to 15.23 in 1999. Since 1955 the total fertility rate has stabilized at the replacement level of 2 births per women. About 338 million births were evaded in 28 years (1971-98). This delayed the world's 6 billion population day by nearly four years. During the period, more than 30 million vasectomies were performed in China.

Compared to the number of users of other contraceptive means, vasectomy looks insignificant but if the "Goliath" of population monster has to be dealt with, vasectomy could be the "David".

No Scalpel Vasectomy :

As an outcome of reproductive health research, Dr. Li Shunqiang (1974) in Sichuan Reproductive Health Institute, Chengdu (China) introduced No Scalpel Vasectomy (NSV) - vasectomy without knife.

Technique of NSV:

No Scalpel Vasectomy is an improved minimal access version of the conventional vasectomy. Here the anatomical fascial distribution separating the vas from the rest of the spermatic cord structures is taken advantage of. The vas only is identified, fixed between the thumb, index and middle fingers (the three-finger technique) in the midline half-way between the root of penis and top of testis.

A local anaesthetic agent (2% Xylocaine injection without Adrenaline) is injected perivasally within the external spermatic fascia. The vas is grasped with the ringed clamp (3-4mm diameter ringed forceps) extracutaneously. The overlying scrotal skin, fascia and anterior wall of the vas are punctured with the pinpointed tip of the dissecting forceps; the skin and fascia are stretched out and the vas delivered through the hole. The dissecting forceps are used again to isolate the vas away from accompanying vessels.

The vas is dealt with (tied and about 1 cm of it excised) and the cut ends returned inside the scrotum. The procedure is repeated on the opposite vas through the same skin puncture site.

The puncture hole is hardly visible after the procedure which usually takes less than 10 minutes. The client is allowed to return home after 30 minutes of rest. The client is allowed normal activities and sexual intercourse with temporary contraception within 2-3 days if he feels comfortable. (The ringed forceps and dissecting forceps have been specially designed by Dr. Li Shunquang). *For more details of the NSV technique, readers may refer to "No-Scalpel Vasectomy - An Illustrated Guide for Surgeons" published by AVSC International, 79 Madison Avenue, New York, NY 10016, USA.

Advantages :

NSV allays the fear of incision with a knife as in conventional vasectomy. No-incision and no-stitch is a popular option. It is a simple, effective and minimal-access precision procedure. Compared to the female tubectomy which is intra-abdominal, NSV complications, so far reported, are simple to deal with and are of milder form. This simplified technique of access to vas deferens used in NSV has also become the stepping stone for other procedures on the vas, contraception or otherwise, e.g. chemical vasal occlusion, threading of vas, vasography and patency test for vas.

By late 1980's, NSV technique has been widely used outside China. The prevalence of this technique has increased the acceptability of male sterilization in many parts of the world. More than 5,000 physicians in 25 developing countries have been trained in NSV technique. In the USA, in 1995 this technique was employed in nearly one third of vasectomies. In the whole of North America, a total of 1100 doctors have been trained.

Complications and long term safety:

The Chinese had 0.09% haematoma and 0.91 % infection rate in 179,741 cases of NSV in 8 provinces while in a New York hospital - Cornel Medical Center - 238 NSV procedures were performed in the 1980's with no complications.

In India, Kumar V and Kaza RM et al performed 4253 NSV procedures with a mean procedural time of 9.5 minutes and evaluated the complication rate which was found to be extremely low - haematoma (0.047%), wound infection (0.07%), painful nodule (0.07%).

During the king's Birthday Vasectomy Festival in Thailand, NSV technique was compared with conventional vasectomy in 1203 clients. An average of 57 procedures of NSV could be done per day by each physician compared with 33 conventional vasectomies. The complication rate was 0.4 per 100 procedures for NSV and 3.1 per 100 procedures for conventional vasectomy. NSV is a rapid and economic alternative to conventional vasectomy with fewer complications and better client acceptance.

We, at Imphal, India, encountered a case of haematoma which required surgical drainage under local anaesthesia in our 509th case of NSV in our training-cum-service camps. (Unpublished).

Long term safety after vasectomy has also been another concern for the policy makers. The Sichuan Province studies-(1) comparing 12,501 vasectomised and 11,265 non-vasectomised men for 10.05 years and (2) comparing 4590 vasectomised and 4340 non-vasectomised men for 14.05 years-showed that men with vasectomy were not at greater risk of coronary heart disease (CHD), hypertension, hyperlipidaemia or diabetes than those who had not undergone vasectomy. Sperm antibodies developed within 6 months postvasectomy and persisted for more than 20 years. But no evidence was provided that the sperm autoimmunity after vasectomy increased the incidence of atherosclerosis or other cardiovascular diseases except for the uncertain influence on subsequent restoration of fertility after vasovasostomy. Two epidemiological studies conducted in the U.S. suggested that vasectomy might be associated with an increase risk of pro static cancer. But a specially convened group of experts at a WHO consultation in 1991, after reviewing all the available biologic and epidemiologic evidence linking vasectomy to prostatic and testicular cancer, concluded that any causal relationship between vasectomy and the risk of prostate or testicular cancer was unlikely, and no changes in family planning policies concerning vasectomy were warranted.

Acceptability:

The acceptance rate of vasectomy is quite low compared to other contraceptive methods. Among the correctable causes of law acceptance, one is non-availability of easily accessible and reliable centre for vasectomy. The availability of reversal facility may add colour to these centres. Further, a centre for only male service may attract more male clients who usually shy away from the centres entertaining both sexes. A free and fair consultation should be made possible to help the client take a decision for the future of his family. Inadequate counselling, lack of publicity and educational materials are other stumbling blocks. These have been mentioned as reasons for non-performance of NSV services in La Paz, Bolivia where only one NSV was performed over a course of two years.

With the technique of male sterilization gradually reaching a favourable accepted level, the role of awareness has become an important one. Mehta and McKenzie M focused the advertising strategies which can bring clients in overwhelming numbers. We also share the same feeling that advertising in the media brings in a number of NSV clients, if not overwhelming.

Persistent efforts and continued training of NSV service providers will contribute to the success of population control. Expanding the provider pool to increase access to the services has been tried. In the USA, mid level health care personnel, such as nurse practitioners and physician assistants, are trained to provide services. In a project in Alaska, Idaho, Oregon and Washington, these nurse practitioners and physician assistants were trained to perform NSV. This project had very positive response.

NSV is a very simple and safe procedure which can be performed by any doctor with a little training. It does not require a costly set up or expensive and cumbersome instruments as in laparoscopic tubal ligation, and can be performed almost anywhere -health centres, health camps and even in very remote villages. It can be safely implemented as an essential component of population control programmes. If only we could remove cultural misconceptions and ignorance among the masses, there would be no hindrance for NSV to become the most important tool for population control.

Conclusion :