Letters to the Editor

Evaluating Vasal Occlusion Methods for Vasectomy

TO THE EDITOR: The review article on vasectomy discusses the relative failure rates with various methods of occluding the vas deferens. Figure 1 illustrates how the vasal occlusion methods for vasectomy are performed. Careful examination of the ligation and fascial interposition method in this figure shows that the suture placed to do the fascial interposition forms a pursestring around the vas deferens itself. In practice, this will likely be tied too loosely and allow the vasal end to slip back inside the sheath, or tied too tightly and strangulate the vasal end, with both resulting in lack of fascial interposition. I suspect this accounts for the extraordinarily high rate of failure with this method. No vasectomist should accept a 16.7 percent failure rate. All vasal occlusion methods that place a ligature around the vas deferens will cause necrosis of the end, leading to a failure of occlusion and an unacceptably high rate of failure.

Many years ago, the late Stan Schmidt developed the intraluminal thermal cautery and fascial interposition method of vasal occlusion.1 This method of vasal occlusion had a 0 percent failure rate when he performed it;2 other authors have reported a less than 1 percent failure rate with this method.3 This is the preferred method of vasal occlusion, and I have reported details of how to incorporate this into No-scalpel vasectomy.4 I cannot fathom why a vasectomist would use any other method of vasal occlusion.

Ronald D. Reynolds, MD

New Richmond, Ohio; E-mail: ron.reynolds@uc.edu

Author disclosure: Nothing to disclose.

REFERENCES

1. Schmidt SS. Prevention of failure in vasectomy. J Urol. 1973;109(2):296-297.

2. Schmidt SS. Vasectomy. JAMA. 1988;259(21):3176.

3. Esho JO, Cass AS. Recanalization rate following methods of vasectomy using interposition of fascial sheath of vas deferens. J Urol. 1978;120(2):178-179.

4. Reynolds RD. Vas deferens occlusion during no-scalpel vasectomy. J Fam Pract. 1994;39(6):577-582.

editor's note: This letter was sent to the authors of "Vasectomy: An Update," who declined to reply.

Clavicle Fractures During Birth

TO THE EDITOR: The article on clavicle fractures by Drs. Pecci and Kreher is interesting. I would like to add an important cause of clavicle fracture in newborns that was not mentioned in the article. Clavicle fractures sometimes occur during childbirth, especially during a difficult cephalic vaginal delivery or following a breech delivery.1,2 These fractures still occur in developing countries, where such deliveries are more common. The child usually presents up to a few weeks after delivery with a palpable swelling on the mid-shaft location of the clavicle.3 There are usually no other symptoms. Plain radiography of the clavicle confirms the diagnosis with callous formation visible in the second or third week after birth.

Emmanuel Monjok, MD, MPH, FRIPH

Houston, Tex.; E-mail: emonjok@uh.edu

Author disclosure: Nothing to disclose.

REFERENCES

1. Kaplan B, Rabinerson D, Avrech OM, Carmi N, Steinberg DM, Merlob P. Fracture of the clavicle in the newborn following normal labor and delivery. Int J Gynaecol Obstet. 1998;63(1):15-20.

2. Turnpenny PD, Nimmo A. Fractured clavicle of the newborn in a population with a high prevalence of grand-multiparity: analysis of 78 consecutive cases. Br J Obstet Gynaecol. 1993;100(4):338-341.

3. Reiners CH, Souid AK, Oliphant M, Newman N. Palpable spongy mass over the clavicle, an underutilized sign of clavicular fracture in the newborn. Clin Pediatr (Phila). 2000;39(12):695-698.

Send letters to Kenny Lin, MD, Assistant Editor, American Family Physician, e-mail: afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680.

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