An Ottawa architect in his late 20s breezed into Dr. Edward Shapiro’s office a while back, his 18year-old lady friend in tow. He wanted a vasectomy, he explained, so there would be no chance of getting the young woman—or the young women who might succeed her—pregnant. “Certainly, I was willing to do it to protect her and the others like her,” recalls Shapiro. “It’s his lifestyle and he’s entitled to it. I don’t have the right to impose my values.”
But what if the young man discovers Ms. Right in the future and wants a family? Preliminary scientific data confirms the possible return of fertility for men who no longer want the ties that bind them.
As sterilization has gained in popularity, and as a younger population has come to regard it as an easily obtainable birth control option, physicians have acknowledged that the demand for reversals will undoubtedly increase.
A decade ago, it would have taken some shopping around to find a doctor or hospital morals committee prepared to sterilize anyone under the age of 30. Today, doctors are far more willing to consider each case on its own merits, regardless of age, marital status or size of family.
Last year, more than 148,000 Canadians—107,500 women and 40,900 men—chose to undergo this ultimate form of birth control, according to federal health figures made available last month. The World Health Organization reported last year that sterilization is now the leading form of birth control worldwide, and Canadian officials say it ranks as the third most popular contraceptive choice here, trailing only the pill and IUD (intrauterine device).
Vasectomy in men and tubal ligation in women have long been the contraceptive measures of choice for couples who have finished their families or who, for medical reasons, should avoid pregnancy. But within the statistics is a somewhat smaller population of young couples who have decided to forgo the rites of parenting entirely.
London, Ontario, obstetrician and gynecologist Dr. Earl Plunkett, chairman of the Canadian Committee for Fertility Research, believes the large number of sterilizations performed in recent years might represent a backlog which will subside. But the high figures also
reflect a change in social attitudes toward family life. “I think young women are under far less pressure to have children today,” Dr. Plunkett says. Dr. James Henderson, a Mississauga, Ontario, physician who has performed hundreds of vasectomies, remarks:
“Some mature couples are deciding before marriage that they just don’t want children. Usually, they wait a year or two to reinforce their viewpoint before the husband comes in. They like their lifestyle and they don’t want to be tied down.” And, an interesting sidelight: “We are finding that with a number of couples who come to us for counselling, both decide they want to be sterilized, to show their commitment,” says Dallas Petroff, executive director of Planned Parenthood of Toronto.
Yet an increasing number of patients are returning to doctors’ offices asking that the irreversible be reversed. Remarriage, the death of a child, or even an improvement in the family fortunes, are all offered as reasons. In a study of 100 women who requested a reversal of tubal sterilization, Dr. Victor Gomel, head of obstetrics and gynecology at the University of British Columbia, found that 52 had been under the age of 25, and 89 under the age of 30 at the time of sterilization. Sixty-three wanted reversal because of a change in marital status, 21 because a child had died, 10 decided they wanted more children and six had experienced adverse psychological reactions to sterilization.
Microsurgical techniques now hold some promise for couples who experience a change of heart. But the procedures are time-consuming, expensive, and hold no guarantee of success.
Restoring fertility to women is primarily dependent on the degree of damage the fallopian tubes underwent when they were sealed off to prevent the egg from travelling from the ovary to the uterus. Cauterization of the tubes, for example, tends to leave considerable scarring. Gomel recommends the use of tiny plastic clips on younger women undergoing sterilization; it has a slightly higher failure rate, but offers the best chance for reversal. In a followup study of patients whose tubes were in good enough condition to attempt reversal and who otherwise had nothing impeding pregnancy, 80 per cent became pregnant after 18 months or longer.
If the microsurgical procedure is performed within three years of sterilization, the success rate is between 85 and 90 per cent. As time goes by, the likelihood of successful recovery of sperm production decreases (50 per cent after 10 years). The time interval between vasectomy and reversal is one of the most important factors determining whether the testes will still produce healthy sperm in sufficient numbers.
Ottawa surgeon Shapiro believes he has overcome these problems through his open-ended technique, which he has performed on more than 500 patients.
A vasectomy usually involves cutting and sealing both severed ends of each vas deferens, the two tiny tubes which carry sperm from the testicles to the penis. After a vasectomy, the sperm continues to be produced but, unable to proceed beyond the barrier, it disintegrates and is absorbed by the body.
What was considered a common “complication” of vasectomy is the formation of a tiny nodule of cells called a sperm granuloma, which allows a continual leakage of sperm. This leakage acts like a safety valve, preventing a buildup of pressure in the vas that could damage the system of ducts within the testes. A recently published study by St. Louis, Missouri, urologist Dr. Sherman Silber indicates that in men who have a sperm granuloma, reversibility stays at 95 per cent, no matter how long the interval.
Shapiro has been sealing only one end of the vas to allow the deliberate formation of this granuloma. He believes his patients, should they ever want reversal (to date, none have) will stand an excellent chance.
“You still have to accept vasectomy as a permanent and irreversible procedure,” says Shapiro. “But the results with the open-ended vasectomy have been ideal. The granuloma is small, it’s completely harmless. All patients have expressed complete satisfaction, and I think one reason is their feeling of security. They haven’t burned their bridges behind them.” Sarah Henry
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