Citation Nr: 1318153 Decision Date: 06/04/13 Archive Date: 06/11/13 DOCKET NO. 06-15 885 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for adenocarcinoma of the colon, to include as secondary to exposure to herbicides. 2. Entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as secondary to exposure to herbicides. 3. Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as secondary to exposure to herbicides. 4. Entitlement to service connection for multiple myeloma, to include as secondary to exposure to herbicides. 5. Entitlement to compensation under 38 U.S.C.A. § 1151 for retrograde ejaculation due to VA medical treatment. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his Spouse ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION The Veteran served on active duty from July 1970 to July 1971. His awards and decorations for service in the Republic of Vietnam include the Purple Heart Medal and the Combat Infantryman Badge. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a rating decision in June 2004 by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, that denied service connection for adenocarcinoma of the colon and for peripheral neuropathy of the right and left upper extremities. Also on appeal is a January 2006 RO rating decision that denied compensation under 38 U.S.C.A. § 1151 for retrograde ejaculation and an October 2008 RO rating decision that denied service connection for multiple myeloma. In January 2011 the Veteran and his spouse testified before the undersigned Veterans Law Judge (VLJ) in a videoconference hearing from the RO. The Board remanded the issues on appeal to the Originating Agency in August 2012 for additional development. The file has now been returned to the Board for additional appellate review. This appeal has been advanced on the Board's docket pursuant to 38 U.S.C.A. § 7107(a)(2) (West 2002) and 38 C.F.R. § 20.900(c) (2012). FINDINGS OF FACT 1. The Veteran served in the Republic of Vietnam during a period in which exposure to herbicides is presumed. 2. Adenocarcinoma of the colon is not etiologically related to service, to include as secondary to exposure to herbicides. 3. Peripheral neuropathy of the right and left upper extremities is not etiologically related to service, to include as secondary to exposure to herbicides. 4. The Veteran is not diagnosed with multiple myeloma. 5. The Veteran underwent laparoscopic colectomy at a VA medical center in March 2004, as a consequence of which he has additional disability manifested by retrograde ejaculation that is at least as likely as not due to fault on the part of VA in furnishing the surgical treatment, or to an event not reasonably foreseeable. CONCLUSIONS OF LAW 1. Adenocarcinoma of the colon is not due to or aggravated by service. 38 U.S.C.A. §§ 1101, 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). 2. Peripheral neuropathy of the right upper extremity is not due to or aggravated by service. 38 U.S.C.A. §§ 1101, 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). 3. Peripheral neuropathy of the left upper extremity is not due to or aggravated by service. 38 U.S.C.A. §§ 1101, 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). 4. Multiple myeloma is not due to or aggravated by service. 38 U.S.C.A. §§ 1101, 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). 5. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for retrograde ejaculation are met. 38 U.S.C.A. §§ 1151, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.361 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Before addressing the merits of the Veteran's claims on appeal, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The VA is required to assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. The VA is required to notify a claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, the VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, the VA will attempt to obtain on behalf of the claimant. In addition, the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant be provided "at the time" of, or "immediately after," the VA's receipt of a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). Complete notification in this case was not provided to the Veteran prior to the June 2004 rating decision on appeal, in that he was not notified of the disability-rating and effective-date elements of a claim for service connection. However, complete notice was provided to the Veteran by a letter in June 2006, and the Veteran had ample opportunity before the Originating Agency readjudicated the appeal in October 2007. Where there is a timing defect in a case (i.e., where the appealed rating action precedes VCAA notice) VA may cure the timing defect through compliance via proper remedial measures, such as the issuance of compliant VCAA notice followed by readjudication of the claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Complete notice was provided to the Veteran prior to issuance of the January 2006 rating decision (compensation under 38 U.S.C.A. § 1151) and the October 2008 rating decision (service connection for multiple myeloma). In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing an error is harmful or prejudicial normally falls upon the party attacking the agency's determination). The RO also provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. The Veteran's service treatment record (STRs) have been obtained, as have the Veteran's post-service Social Security Administration (SSA) disability file and treatment records from those VA and non-VA medical providers identified by the Veteran as having afforded relevant treatment. The Veteran's representative asserted during the hearing before the Board, and in an Informal Hearing Presentation submitted in April 2013, that Quality Assurance (QA) records relating to the Veteran's surgery in August 2004 should be obtained in support of his claim for compensation under 38 U.S.C.A. § 1151 as well as his claim for entitlement to service connection for colon cancer. The duty to assist requires the Originating Agency or the Board to request QA records from the Veterans Health Administration (VHA) and, if VHA denies access, to appeal such denial to the VA Office of General Counsel (OGC). See VAOPGCPREC 1-2011 (April 19, 2011); Hood v. Shinseki, 23 Vet App (2009). However, it is VA's policy to destroy quality assurance records after three years unless needed for research or legal purposes. See Norvell v. Peake, 22 Vet. App. 194, 200 (2008) (citing VHA Records Control Schedule 10-1, at XXXIII-2 (Aug. 1, 2009)); see also VHA Records Control Schedule 10-1 (Mar. 1, 2011). Accordingly, there is no reasonable possibility that QA records, if indeed they were ever produced, would still be retained. VA has no duty to seek to obtain that which does not exist. Counts v. Brown, 6 Vet. App. 473, 477 (1994); Porter v. Brown, 5 Vet. App. 233, 237 (1993). In sum, the Board is aware of no existing outstanding evidence that should be obtained before the appeal is adjudicated. The Veteran has been afforded appropriate medical examinations. In that regard, the Board reviewed the file in August 2012 and determined the medical opinion of record was insufficient in regard to the issue of service connection for peripheral neuropathy, and remanded the case for an addendum opinion. The requested addendum opinion was issued in September 2012. The Board has reviewed that opinion and finds the Originating Agency substantially complied with the requirements articulated in the Board's remand. See D'Aries v. Peake, 22 Vet. App. 97 (2008), citing Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that in the context of medical examinations/opinions only substantial compliance, not strict compliance, with the terms of the Board's opinion request is necessary). Finally, the Veteran was afforded a hearing before the Board. There are two duties imposed on the person who presides at a hearing: (1) the duty to fully explain the issues, and (2) the duty to suggest the submission of evidence that may have been overlooked; these duties are not impacted by the Veteran's receipt of a VCAA-compliant notice letter. 38 C.F.R. § 3.103(c)(2); Bryant v. Shinseki, 23 Vet. App. 488, 493-94 (2010). Here, during the hearing, the presiding VLJ did not explicitly cite the bases for the prior determinations and did not list the elements that were required to substantiate the claims on appeal. However, the Veteran's representative demonstrated actual knowledge of this information and elicited testimony from the Veteran regarding the circumstances of his service and the etiology of each claimed disability on appeal; he also elicited the reasons the Veteran contends service connection is warranted for each claimed disability. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (explaining that actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what is necessary to substantiate the claim). Further, during the hearing both the representative and the VLJ elicited testimony from the Veteran regarding any existing outstanding evidence that should be pursued prior to adjudication of the appeal. The Board accordingly finds the Veteran is not prejudiced by any error associated with the hearing. Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issues to be decided herein is available and not part of the claims file. See Mayfield, 499 F.3d 1317. Therefore, the Board finds that duty to notify and duty to assist have been satisfied and will proceed to the merits of the Veteran's appeal. Entitlement to Service Connection Applicable Legal Principles Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). In cases where a Veteran asserts service connection for injuries or disease incurred or aggravated in combat, 38 U.S.C.A. § 1154(b) (West 2002) and its implementing regulation, 38 C.F.R. § 3.304(d) (2011), are applicable. This statute and regulation ease the evidentiary burden of a combat Veteran by permitting the use, under certain circumstances, of lay evidence. If the Veteran was engaged in combat with the enemy, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that in the case of a combat Veteran not only is the combat injury presumed, but so is the disability due to the in-service combat injury. Reeves v. Shinseki, 682 F.3d 988, 998-99 (Fed. Cir. 2012). To establish service connection, however, there must be the evidence of a current disability and a causal relationship between the current disability and the combat injury. Id. (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A veteran who, during active military, naval or air service served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent unless there is affirmative evidence to establish the veteran was not exposed to an herbicide agent during such service. The last date on which the veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. Service in the Republic of Vietnam includes service in the waters offshore or service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii). The Secretary of Veterans Affairs has determined there is no presumptive positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-346 (1994); see also Notice, 61 Fed. Reg. 41, 442-449 and 61 Fed. Reg. 57, 586-89 (1996); Notice, 64 Fed. Reg. 59, 232-243 (Nov. 2, 1999). The Agent Orange Act of 1991 requires that when the Secretary determines that a presumption of service connection based on herbicide exposure is not warranted for health outcomes, he must publish a notice of that determination, including an explanation of the scientific basis for the decision. The Secretary's determination must be based on consideration of reports of the National Academy of Sciences (NAS) and all other sound medical and scientific information and analysis available to the Secretary. 38 U.S.C.A. § 1116 (b) and (c). The availability of presumptive service connection for a disability based on exposure to herbicides does not preclude a Veteran from establishing service connection with proof of direct causation. Stefl v. Nicholson, 21 Vet. App. 120 (2007); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d 1313, 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, id. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, and consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, 7 Vet. App. 498, 511. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.") Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Evidence and Analysis Service connection for adenocarcinoma of the colon Service treatment records (STRs) show no indication of adenocarcinoma of the colon, or any other cancer of the colon, during service. The Veteran submitted a statement to VA in February 2004 asserting he had been advised to have 1.5 feet of his colon removed, as well as 30 lymph nodes. He subsequently underwent sigmoid colectomy surgery by VA in March 2004. The Veteran's spouse submitted a statement dated in April 2006 (received in May 2006) stating she understood that colon cancer is not a disease presumptively associated with Agent Orange exposure but expressing her belief that it should be. The Veteran testified before the Board in January 2011 that colon cancer was initially diagnosed in 2003 or early 2004. He has been essentially cancer-free since the surgery in 2004. The Veteran argued that service connection for colon cancer should be presumptively associated with herbicide exposure; he also argued that an adenocarcinoma should be considered a "soft tissue sarcoma" within the definition of the presumption. The Veteran had a VA examination in May 2011, performed by a physician who reviewed the claims file. The examiner noted the Veteran had no indication of digestive problems during service; the Veteran had been diagnosed with colon cancer in 2004, but this was corrected by laparoscopic colectomy the same year. Subsequent colonoscopies were all normal. The examiner performed a clinical examination and noted observations in detail. The examiner diagnosed sigmoid colon adenocarcinoma in situ, status post laparoscopic sigmoid colectomy. The examiner stated that adenocarcinoma of the colon is not a "soft tissue carcinoma" and that the preponderance of medical evidence does not show herbicide exposure to be an etiologic cause of sigmoid colon cancer. Review of the evidence shows the Veteran was diagnosed with colon cancer. Although he is currently free of the disease, the requirement of a "current disability" is satisfied when the claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim; thus, service connection may be granted even though the disability resolves prior to the Secretary's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. The Veteran does not contend, and the evidence of record does not show, that the Veteran had colon cancer during service. Instead, the Veteran asserts he developed colon cancer due to herbicide exposure. In September 2011 the NAS issued "Veterans and Agent Orange: Update 2010" (Update 2010). The notice explained a determination made by the Secretary, based upon Update 2010 and prior NAS reports, that a presumption of service connection based on exposure to herbicides in the Republic of Vietnam is not warranted for health outcomes including colorectal cancer. The Veteran argues that adenocarcinoma constitutes "soft tissue sarcoma" and is thus presumptively related to herbicide exposure under 38 C.F.R. § 3.309(e). However, the VA examiner in May 2011 clarified that adenocarcinoma of the colon is not a soft tissue sarcoma; this determination is consistent with the Update 2010 finding cited above. Regardless of the presumption, service connection as due to herbicide exposure may be granted if there is proof of direct causation. Combee, 34 F.3d 1039, 1042. Here, there is no medical evidence supporting such a relationship, and in fact the competent and uncontroverted medical evidence, in the form of the May 2011 VA examination report, states the preponderance of medical evidence does not show herbicide exposure to be an etiologic cause of sigmoid colon cancer. The findings of a physician are medical conclusions that the Board cannot ignore or disregard. The Veteran and his spouse have both a personal belief that there is direct relationship between herbicide exposure and colon cancer. However, the etiology of cancer is a complex medical question that is not within the competence of a layperson. Kahana, 24 Vet. App. 428. It is the province of trained health care professionals to enter conclusions that require medical expertise, such as opinions as to diagnosis and causation. Jones v. Brown, 7 Vet. App. 134, 137 (1994). As explained above, the VA examiner in May 2011 stated an opinion, uncontroverted by any other medical opinion, to the effect that colon cancer is not due to herbicide exposure. In relying on this opinion, the Board finds the record shows the opinion meets the criteria for probative opinion as articulated in Nieves-Rodriguez in that the examiner demonstrably was fully informed of the pertinent factual premises and provided a fully-articulated opinion that was supported by a reasoned analysis. In sum, the Board finds the Veteran has not had colon cancer this was incurred in or aggravated by active service, to include herbicide exposure during service. Accordingly, the criteria for service connection are not met and the claim must be denied. Because the weight of the evidence is against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. Service connection for peripheral neuropathy of the upper extremities The Veteran has been granted service connection for peripheral neuropathy of the bilateral lower extremities as secondary to the service-connected low back disability. Service connection is not in effect for cervical spine disability, and the Board notes that although the Veteran reports receiving low back trauma during combat, he does not report in-service, combat related neck trauma. STRs show no indication of peripheral neuropathy of the extremities during service. The Veteran presented to the VA outpatient clinic in September 2003 for an initial visit. He complained of numbness to both legs, but apparently had no complaint of numbness in the upper extremities. On examination the extremities had full range of motion, deep tendon reflexes (DTRs) were positive and symmetrical, cranial nerves were intact and motor examination was non-focal. The clinical assessment is silent in regard to any abnormality of the upper extremities. The Veteran submitted a statement in support of claim in October 2003 in which he added service connection for peripheral neuropathy of the upper and lower extremities to his current ongoing claims. He asserted that neuropathy of the lower extremities was probably associated with physical trauma (specifically, an explosion in Vietnam during which he was wounded) but that neuropathy of the upper extremities could be early signs of herbicide exposure. The Veteran had a VA neurological examination in February 2004 in which he reported tingling in the right hand and numbness in the right arm, beginning at least a year prior to the examination. He reported having difficulty writing and in picking up boxes and endorsed some subjective weakness. Motor examination showed no significant involuntary movements, no muscle atrophy and power 5/5 in all extremities. Deep tendon reflexes (DTRs) were "somewhat brisk." Muscle tone was normal, and sensory was normal in the upper extremities except for some decreased pinprick on the palmar sides of the hands. Diagnosis was numbness in the right hand that was nonspecific and questionable for neuropathy. The Veteran had a VA rheumatology clinic consult in January 2008 to follow up complaint of joint pain. He reported tingling in the arms "for years." Neurological examination showed strength to be normal and symmetrical in the upper extremities; sensory was not recorded. Magnetic resonance imaging (MRI) of the right wrist showed possible synovial chondromatosis. The Veteran had a VA orthopedic clinic consult in February 2008 in which he complained of numbness and severe pain in both hands. He reported severe pain radiating up to the elbow, as well as a feeling that his hands were constantly cold. Physical examination showed sensation in the hands to be intact. The clinician noted that radiographic studies were suggestive of osteoarthritis of the wrists. The clinical impression was bilateral wrist and hand pain and temperature complaints. The Veteran presented again to the VA rheumatology clinic in April 2008 complaining that his hands were sensitive to cold temperatures. The hands were normal on inspection other than mild swelling of the bilateral middle fingers at the proximal interphalangeal (PIP) joints. Color was normal and symmetrical. The Veteran had a VA hematology examination in July 2008 in response to his claim for service connection for multiple myeloma. Examination of the upper extremities showed DTRs to be +2/4 and equal bilaterally for biceps and brachioradialis reflexes. There was no atrophy of hypertrophy. Strength testing to gravity and resistance was within normal limits for his age and bilaterally equal. Grip strength was +5/5. Sensation was normal and equal bilaterally to pinprick and light touch. There was no radiculopathy. Finger-to-nose was normal. The Veteran had a VA neurology consult in August 2008 in which he complained of numbness in the bilateral upper and bilateral lower extremities, worse on the right but also present on the left. The neurologist stated an impression that considering the very gradual onset of symptoms, along with the history of moderate improvement with B12 therapy, the symptoms were most likely a B12 deficiency. The Veteran presented to the VA neurology clinic in November 2008 for follow-up. The neurologist noted that recent MRI of the cervical spine showed a C5-6 displacement of the cord, mainly on the left, but cord signal was normal. The clinician entered an impression of bilateral sensory loss of uncertain etiology. The clinician stated it seemed unlikely that the condition was related to the cervical spine but a second opinion would be sought. It was still possible that the symptoms were related to B12 deficiency as previously believed. The Veteran had a VA neurology outpatient consult in December 2008 in which he complained of back and neck pain and paresthesias to all extremities. Clinical examination was grossly normal. The clinical impression in relevant part was neck pain and numbness to the upper extremities; the etiology of the pain and sensory deficits was unknown but differential diagnoses (DD) included cervical radiculopathy and distal symetric polyneuropathy. VA neurology clinic note in February 2009 showed continued complaint of numbness, worse on the right; he also reported recent onset of neck pain. The clinical impression was bilateral sensory loss, partly related to prior B12 deficiency and partly related to cervical spine disease, and cervical spine disease with possible left-side radiculopathy. VA electromyography (EMG) study in March 2009 showed an impression of normal study. Thereafter, he presented to the VA neurology clinic the same month complaining primarily of intermittent paresthesias and hypoesthesia in the bilateral upper extremities. Clinical neurological examination was grossly normal. The clinical impression was possible radiculopathy. VA neurology clinic notes in July 2009 were consistent with those of March 2009, with essentially normal neurological examination. The clinical impression was neck and lower back pain with cervical disc disease and no evidence on EMG of radiculopathy and no specific myelopathy on MRI. The Veteran testified before the Board in January 2011. Although he was pressed by his representative to state when he first began to experience symptoms of peripheral neuropathy of the upper extremities, the Veteran did not provide a cogent response. The Veteran had a VA examination in May 2011, performed by a physician who reviewed the claims file. The examiner noted the Veteran had no indication of neuropathy during service. The Veteran had been treated for B12 deficiency since 2005, and cervical disease with left side neuropathy was diagnosed in 2009. The Veteran complained of daily neck pain with intermittent numbness, radiating down both arms to the wrists and fingers. The examiner performed a musculoskeletal and neurological examination and noted observations in detail. The examiner's diagnosis was B12 deficiency (claimed as peripheral neuropathy of the upper extremities) and not likely due to or aggravated by the service-connected lumbar spine disability. The VA examiner cited above issued an addendum opinion in May 2012 stating that peripheral neuropathy of the upper extremities is less likely than not related to or having onset during service. Rather, it was more likely due to B12 deficiency with concomitant cervical degenerative disc disease (DDD) with radiculopathy. The Board subsequently remanded the case back to the VA examiner cited above for further amplification of the opinion, which was rendered in September 2012. The examiner stated it is at least as likely as not that the Veteran's claimed peripheral neuropathy of the upper extremities is aggravated by cervical spine DDD, but it is less likely than not that the underlying cervical spine DDD is related to service; likewise, it is less likely than not that the cervical spine DDD is caused or aggravated by the service-connected lumbosacral spine disability. The examiner noted as rationale that the Veteran had a low back injury in service, whereas cervical spine disability was reported in 2006, 38 years after the reported in-service back injury. The preponderance of medical evidence shows that multilevel (diffuse) degenerative changes normally occur between ages 40 to 60; per guidelines of the American Medical Association (AMA) such changes are due to age, genetics and intrinsic disc loading. Review of the file shows the Veteran has upper extremity radiculopathy consequent to cervical spine disease as well as paresthesias consequent to B12 deficiency. Accordingly, the first element of service connection - medical evidence of a disability - is shown. However, evidence of a present condition is generally not relevant to a claim for service connection, absent some competent linkage to military service. Mingo v. Derwinski, 2 Vet. App. 51, 53 (1992). Update 2010, cited above, states that a presumption of service connection based on exposure to herbicides in the Republic of Vietnam is not warranted for health outcomes including chronic peripheral nervous system disorders other than early-onset peripheral neuropathy. As there is no medical or lay evidence of peripheral neuropathy of the upper extremities until 2003, more than 30 years after discharge from service, the Board cannot find the Veteran has "early onset" peripheral neuropathy within the clear meaning of the presumption. Turning to whether direct linkage between herbicide exposure and the claimed peripheral neuropathy and herbicide exposure is shown per Combee, there is no medical evidence whatsoever supporting such an etiology. Although the Veteran may believe his symptoms are related to remote exposure to herbicides, such etiology is a complex medical question beyond the competence of a layperson. Kahana, 24 Vet. App. 428. The Veteran's symptoms are shown by medical evidence to be multifactoral and related to B12 deficiency and to cervical spine disability; neither of these underlying disorders is a service-connected disability. The Veteran has been granted service connection for peripheral neuropathy of the lower extremities as secondary to the service-connected lumbosacral spine disability, but there is no evidence of record showing a relationship between these service-connected disabilities, and in fact the September 2012 VA medical opinion constitutes competent and uncontroverted medical evidence against such a relationship. In relying on the September 2012 opinion (reviewed in conjunction with the earlier examinations and opinions by the same examiner in May 2011 and May 2012), the Board finds the record shows the opinion meets the criteria for probative opinion as articulated in Nieves-Rodriguez in that the examiner demonstrably was fully informed of the pertinent factual premises and provided a fully-articulated opinion that was supported by a reasoned analysis. In sum, the Board finds the Veteran does not have peripheral neuropathy of the upper extremities that was incurred in or aggravated by active service, to include herbicide exposure during service. Accordingly, the criteria for service connection are not met and the claim must be denied. Because the weight of the evidence is against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. Service connection for multiple myeloma STRs show no indication of multiple myeloma during service. Multiple myeloma is listed in 38 C.F.R. § 3.309(e) as a disease that is presumptive associated with exposure to herbicides. Although the Veteran is shown to have been exposed to herbicides, the RO has denied service connection based on a determination that multiple myeloma has not been diagnosed. The Veteran presented to the VA primary care clinic in October 2007 requesting a 24-hour urine and vitamin B-12 level because he "knew" he had multiple myeloma. In December 2007 he was referred to the VA hematology clinic at his request for evaluation to rule out multiple myeloma. The Veteran had a VA rheumatology consult in January 2008 in which he reported a belief that he had multiple myeloma, although he had never been so diagnosed by a physician. The clinician noted the Veteran's medications, subjective symptoms and subjective medical history. The clinician made no impression of myeloma but stated the Veteran had been scheduled to see a VA hematologist to rule out such disease. The Veteran presented again to the VA rheumatology clinic in April 2008 insisting on seeing a hematologist because he was certain he had multiple myeloma, based on laboratory results in August 2007 that had shown serum protein electrophoresis (SPEP) and urine immunoelectrophoresis showing hypogammaglobulinemia (the Veteran's concerns were apparently based on a laboratory textbook discussing such results as indicative of multiple myeloma). The Veteran was again referred for hematology consult to rule out myeloma. The Veteran had a VA hematology/oncology consult in May 2008 in which the clinician stated he had done his best to assure the Veteran he did not have myeloma. The clinician diagnosed hypogammaglobulinemia, which in the vast majority (99.9 percent) of cases is a benign finding not associated with secretory myeloma. However, because of the Veteran's current debilitating anguish over the possibility of having myeloma, he underwent a bone marrow aspiration and biopsy. Per an addendum, the bone marrow showed no evidence of plasma cell disorder; the clinician stated, "I do not know how else to tell [the Veteran] that he has no alarming findings on diagnosis of bone marrow. I do not have any answers for him. There is no pathologic diagnosis on bone marrow." The clinician also stated, "if he has any risk factors for HIV [human immunodeficiency virus], would test for this, otherwise no further testing that I could see would help." The file contains a May 2008 bone marrow scan by the University of South Alabama, performed on behalf of VA to rule out any chromosomal changes associated with myeloma. The resultant clinical impression states that no consistent structural or numerical chromosomal anomalies had been detected. The Veteran had a VA hematology examination in July 2008 in response to his claim for service connection for multiple myeloma. He reported a history of general weakness and fatigue; he admitted he had never been diagnosed with multiple myeloma but challenged VA to prove he did not have it. The examiner noted medical history significant for B12 deficiency and hypercholesterolemia; the examiner also noted that bone marrow biopsy in August 2007 had shown hypogammaglobulinemia but was essentially normal for his age. The examiner performed a clinical examination and noted observations in detail. The examiner diagnosed B12 deficiency with mild macrocytic anemia and hypogammaglobulinemia of natural aging. The examiner specifically diagnosed no objective evidence of multiple myeloma. A VA PCC note in July 2008 shows an impression that the Veteran was convinced he had a problem with his blood levels even though the hematology clinic had done a bone marrow biopsy that was normal for the Veteran's age. The PCC provider stated there was nothing in the Veteran's laboratory values to contradict the assessment of the hematology clinic. The Veteran presented to the VA PCC in October 2008 asserting he wanted a second opinion as to whether he actually had multiple myeloma. His request was placed as a consult to a different VA medical facility. Thereafter, the Chief Medical Officer reviewed the request in March 2009 and stated the Veteran had already had a complete workup including bone marrow biopsy that showed no evidence of dyscrasia; accordingly, it was not valid to enter another consult to hematology. The Veteran presented to the VA neurology clinic in August 2009 expressing concern that a large spondylitic cyst in the cervical spine could be myelopathic. The clinician stated he had previously found it not to be myelopathic, and that the same conclusion had been reached by another facility, but the Veteran remained focused on the issue; he remained vehement that he could possibly have myelopathy based on the marker that was found, and he was concerned the bone marrow biopsy was too narrow and might have missed something. The clinician noted the Veteran was very fixated on details of studies he did not fully understand. The clinician stated he would attempt to obtain a hematology second opinion. The Veteran had a second opinion by a VA hematologist in September 2009 that continued to show no myeloma; the only hematologic deficiency observed was iron deficiency in the bone marrow, and the clinician could not attribute abnormal laboratory findings to myeloma based on the absence of diagnostic criteria for a monoclonal process. There was no evidence of myeloma or leukemia in the bone marrow, and the Veteran did not have lesions suspicious for myeloma in the skeletal survey although some abnormalities were found. The Veteran's mild macrocytosis was attributable to B12 deficiency. The disease process was extensively explained to the Veteran, but he refused to believe that had did not have multiple myeloma, based on his multiple medical complaints and internet research. The Veteran's attending VA neurologist spoke to the Veteran in January 2010 and again informed him that there was no indication of any hematologic malignancy. The Veteran was not satisfied with the explanation and stated he would soon have a hearing regarding myeloma at which the clinician would be summoned as an expert witness. The clinician stated that a thorough workup had already been performed for myeloma, but that the file would be submitted for supervisory review for the sake of thoroughness. Subsequently in January 2010 the file was reviewed by the Chief of VA's Hematology-Oncology Section, who stated that review of the file, including all laboratory findings, showed no documentation supporting a diagnosis of any current hematologic malignancy. In July 2010 the Veteran submitted his substantive appeal, in which he asserted the July 2008 examination cited above was inadequate because the examiner was allegedly incompetent, allegedly had not reviewed the claims file and allegedly refused to order the tests the Veteran considered to be appropriate. The Veteran enclosed several medical articles discussing the traits of multiple myeloma (focusing on laboratory abnormalities) and he enclosed several pages of VA and private medical records (primarily laboratory tests and bone marrow scans) showing he had manifested the same abnormalities. The Veteran's apparent intention was to demonstrate that he did, indeed, have multiple myeloma despite the negative medical opinions cited above. (The Board notes at this point that none of the medical documents enclosed by the Veteran show diagnosis of multiple myeloma.) The Veteran testified before the Board in January 2011 that he has had a constellation of symptoms indicative of multiple myeloma, such as respiratory problems, anemia and peripheral neuropathy. The Veteran cited medical studies showing that multiple myeloma is difficult to diagnose and the chance of misdiagnosis is large. The Veteran asserted that multiple test results of record are essentially meaningless because the appropriate tests to rule out myeloma had never been performed. "Congress specifically limits entitlement to service-connected disease or injury where such cases have resulted in a disability ... in the absence of a proof of present disability there can be no claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Review of the file shows the Veteran is not diagnosed with multiple myeloma. Accordingly, he has not shown a disability for which service connection may be considered. Lay evidence can be competent and sufficient evidence of a diagnosis if the layperson is competent to identify the medical condition; the layperson is reporting a contemporaneous medical diagnosis; or, lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1376-77. However, the Veteran has presented articles showing that diagnosis of multiple myeloma is a complex medical question, and the Board finds that it is beyond the competence of a layperson to self-diagnose such a disease. Kahana, 24 Vet. App. 428 (2011). The Veteran was not reporting a contemporaneous diagnosis of multiple myeloma, and there is no later diagnosis of record. Accordingly, none of the circumstances cited in Jandreau apply. The Veteran has complained that he was not afforded diagnostic workup that he believes are appropriate to rule out multiple myeloma. The Board disagrees. Review of the file shows the Veteran has in fact been afforded numerous examinations and diagnostics, and his attending VA neurologist specifically stated appropriate tests and diagnostics had been performed. The Veteran was also afforded a second opinion when he objected to the original diagnosis, and this second opinion also found no diagnosed multiple myeloma. While the Veteran has some symptoms that are consistent with multiple myeloma, numerous medical providers have demonstrated that the Veteran's overall constellation of symptoms disproves he has the disease. In sum, the Board finds the Veteran is not shown by medical evidence to have multiple myeloma. Accordingly, the criteria for service connection are not met and the claim must be denied. Because the weight of the evidence is against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. Entitlement to Compensation under 38 U.S.C.A. § 1151 Applicable Legal Principles A veteran may be awarded compensation for additional disability, not the result of his willful misconduct, if the disability was caused by hospital care, medical or surgical treatment, or examination furnished the veteran under any law administered by VA, either by a VA employee or in a VA facility as defined in 38 U.S.C.A. § 1701(3)(A), and the proximate cause of the disability was (1) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination, or (2) an event not reasonably foreseeable. 38 U.S.C.A. § 1151; 38 C.F.R. § 3.361. To establish causation, the evidence must show that the hospital care, medical or surgical treatment or examination resulted in the veteran's additional disability or death. Merely showing that a veteran received care, treatment or examination and that the veteran has an additional disability or died does not establish cause. 38 C.F.R. § 3.361(c)(1). Hospital care, medical or surgical treatment, or examination cannot cause the continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuation or natural progress. 38 C.F.R. § 3.361(c)(2). Additional disability or death caused by a veteran's failure to follow properly given medical instructions is not caused by hospital care, medical or surgical treatment or examination. 38 C.F.R. § 3.361(c)(3). The proximate cause of disability or death is the action or event that directly caused the disability or death, as distinguished from a remote contributing cause. 38 C.F.R. § 3.361(d). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a veteran's additional disability, it must be shown that the hospital care, medical or surgical treatment, or examination caused the veteran's additional disability and (1) VA failed to exercise the degree of care that would be expected of a reasonable health care provider, or (2) VA furnished the hospital care, medical or surgical treatment, or examination without the veteran's or, in appropriate cases, the veteran's representative's informed consent. 38 C.F.R. § 3.361(d)(1). Whether the proximate cause of a veteran's additional disability was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2). Evidence and Analysis The Veteran asserts entitlement for compensation under 38 U.S.C.A. § 1151 for retrograde ejaculation that is residual to his March 2004 sigmoid colectomy performed by VA. The Veteran had a colonoscopy at VA in February 2004 that revealed sigmoid cancer in a large 3-4 cm. polyp at 20 cm. The impression was that the Veteran would need sigmoid resection. A March 2004 pre-surgery note by Dr. HL states the Veteran requested a laparoscopic colectomy because he was self-employed and wanted to return to work quickly. The Veteran was informed of options, risks, benefits and outcomes including but not limited to bleeding; infection; damage to bowel, bladder or ureters; ostomy; conversion to open surgery; need for further procedures; recurrence; and, anesthetic risk. The Veteran stated his understanding and agreed to the procedure. In a separate informed consent note also dated in March 2004, Dr. HL stated he had discussed proposed laparoscopic sigmoid colectomy with the Veteran and had advised him of possible risks and complications including bleeding; infection; damage to bowel, bladder or ureters; permanent or temporary ostomy; conversion to open surgery; anesthetic complications; deep vein thrombosis (DVT); peripheral edema (PE); death; disability; stroke; and, myocardial infarction (MI). The Veteran was informed there were no suitable alternatives other than surgical. The Veteran agreed to the treatment plan and freely consented to the proposed treatment without duress or coercion. Surgical consent was thereupon scanned into the Veterans Health Information Systems and Technology Architecture (VISTA). The Veteran thereupon underwent laparoscopic sigmoid colectomy. Per the operative note, the surgery was performed by Dr. JCM, a surgical resident; attending surgeon Dr. HL is listed as assistant surgeon and attending staff. A surgical follow-up note in April 2004 states the Veteran was doing well status post colon resection. Final pathology showed well-differentiated adenocarcinoma that had penetrated into the superficial submucosa but no muscular invasion and no positive lymph nodes. The Veteran had minimal-to-no pain and no current complaints. The Veteran submitted a letter to the RO in April 2004 reporting that a major complication of his surgery was that he had no secretion of seminal fluid and no ejaculation during intercourse even though climax was attained. The Veteran complained that he was now sterile, which greatly diminished his sexual enjoyment. In July 2004 the Veteran presented to the VA surgical clinic for postoperative follow-up. He reported a concern of continued dry ejaculations since surgery. He was referred to the urology clinic for consult. In an August 2004 VA outpatient treatment note the Veteran complained he had been sterile since his March 2004 surgery, indicating he did not ejaculate with intercourse. The Veteran had a VA urology clinic consult in September 2004 in which he complained of "dry orgasm." He reported having no problem achieving and maintaining erections or experiencing the sensation of orgasm, but he complained that no ejaculate was produced; he also complained that the orgasm experience was less intense than it had been pre-operatively. Clinical examination was grossly normal. The clinical impression was retrograde ejaculation secondary to sigmoid colectomy. The clinician discussed retrograde ejaculation with the Veteran and explained it is an occasional complication of colon surgery, as well as the mechanism of ejaculation and the reason the surgery had caused the condition. The Veteran expressed his understanding and agreement. In January 2005 the Veteran submitted a Statement in Support of Claim asserting that he and his wife had been counseled on the possible side effects of surgery and were told at the time that potency should not be affected. A VA neurology consult in April 2005 shows the Veteran was seen for complaint of impotence. The Veteran complained of dry climax or retrograde ejaculation (not erectile dysfunction) since laparoscopic colectomy the previous March; he had been advised by the urology clinic that the nerve controlling the valve had been damaged and advised that there was a 90 percent chance the deficit would be permanent. The neurologist stated he did not disagree that the time course of the Veteran's complaint seemed to indicate that surgery was pertinent to the problem, but also admitted he was not knowledgeable about the relationship of surgery to this complaint and had little else to offer. The neurologist advised the Veteran to talk to his surgeons about his concerns. In June 2005 the Veteran submitted handwritten notes regarding the questions he had asked pre-operatively. The notes show the Veteran specifically asked if the surgery had an associated risk of sterility or impotence; the noted response to both these questions is "no." Also in June 2005, the Veteran submitted excerpts from an American Cancer Society booklet titled Colon and Rectal Cancer: Treatment Guidelines for Patients. The Veteran highlighted a section titled "sexual impact of colorectal surgery" that states an abdominal perineal resection can cause either "dry orgasm" or "retrograde ejaculation." The Veteran indicated by marginal note that he had not had perineal resection. The booklet also stated that laparoscopic surgery was considered experimental and was not recommended by the American Cancer Society for colon cancer. The Veteran submitted a Statement in Support of Claim in June 2005 asserting he had specifically asked prior to surgery in March 2004 whether there was any risk of impotence or sterility but was assured there was not because the procedure would be far away from any nerves associated with that kind of problem. Also, surgery was supposed to last 3 hours but instead lasted 6 hours. The Veteran believed the surgery would be performed by Dr. HL, who had performed many such procedures, but the surgery was actually performed by a surgical resident, Dr. JCM, with Dr. HL assisting and attending. The Veteran stated he felt he had been used as a training tool by the VA medical staff. The Veteran's spouse submitted a statement in June 2005 asserting her belief that laparoscopic surgery should not have been performed, and that lack of proper skill in performing such laparoscopic surgery has caused the Veteran's disorder. She also stated the Veteran did not have the problem prior to surgery and that the problem had forever changes their lives. The Veteran's spouse submitted a statement in May 2006 asserting that during surgery the Veteran lost a massive amount of blood; in her presence a group of physicians stated that such bleeding should not be happening and there should not be blood in the colon. She also complained that the surgeons were switched without their knowledge, and that a resident performed the operation. She stated that she was informed by a nurse during the operation that the reason it was taking so long was that the surgical team was having a hard time finding the tumor, but this should not have happened since the tumor should have been readily visible on previous CT scan and colonoscopy. In May 2006 the Veteran submitted a note stating his surgical team had been switched at the last minute without his approval. He also referenced the September 2004 VA urology treatment note cited above in which a VA physician had informed him that colon surgery had caused his retrograde ejaculation. The Veteran testified before the Board in January 2011 that Dr. HL, who was supposed to have performed the surgery, specifically told the Veteran prior to surgery that there was no risk of retrograde ejaculation because the surgery would not be anywhere near the associated nerves. The Veteran asserted he has been informed that his retrograde ejaculation cannot be cured, and that the condition has ruined his life because he is now unable to father any children. The Veteran had a VA examination in May 2011, performed by a physician who reviewed the claims file and diagnosed retrograde ejaculation likely due to colon resection. The examiner noted that a VA urologist had stated retrograde ejaculation is an "occasional complication" of colon surgery and stated an opinion that there is no evidence showing that this complication was proximately caused by carelessness, negligence, lack of proper skill, error in judgment or similar instance of fault on the part of VA in furnishing the surgical treatment. On review, the file clearly shows the Veteran has retrograde ejaculation that is consequent to the laparoscopic colectomy performed by VA. The remaining question is whether such disability is due to fault on the part of VA in furnishing the care, or to an event not reasonably foreseeable. The Veteran's primary assertion of fault is that he contends he did not provide informed consent. In that regard, he asserts that he was specifically advised that the procedure would not go near the nerves controlling ejaculation; thus, he was misinformed of the risk associated with the surgery. He also variously asserts that the laparoscopic surgery is an experimental procedure that should not have been performed, that he did not consent to have the operation performed by any surgeon other than Dr. HL, and that the procedure was in any event not done competently. "Informed consent" is defined as the freely given consent that follows a careful explanation by the practitioner to the patient of the proposed diagnostic or therapeutic procedure or course of treatment. The practitioner who has primary responsibility for the patient or who will perform the particular procedure or provide treatment must explain in language understandable to the patient the nature of a proposed procedure or treatment; the expected benefits; reasonably foreseeable associated risks, complications or side effects; reasonable and available alternatives; and, anticipated results if nothing is done. The patient must be given the opportunity to ask questions, to indicate comprehension of the information provided, and to grant permission freely and without coercion. The practitioner must advise the patient if the proposed procedure is novel or unorthodox, and the patient may withhold or revoke his or her consent at any time. 38 C.F.R. § 17.32(c). The Board finds the Veteran did not provide informed consent, in that the surgeon pre-operatively denied the surgery presented a risk of sterility or impotence. The VA operative notes are silent in regard to whether this specific risk was discussed with the Veteran, but the Veteran is competent to report what was said; further, his assertion is supported by his contemporaneous notes. The Board concludes that the Veteran was misinformed of the risk and thus did not provide informed consent. The Board also finds that even if arguendo the Veteran was found to have provided informed consent to the risks generally associated with surgery, the resultant injury was not reasonably foreseeable. Although the VA examination in May 2007 provided the ambiguous opinion that retrograde ejaculation is an "occasional complication" of colectomy, the fact that the surgeon had advised the Veteran pre-operatively that there was no risk of impotence or sterility associated with the procedure causes the Board to conclude that such injury was in fact not reasonably foreseeable to the surgeon. Accordingly, it is at least as likely as not that the Veteran's additional disability manifested by retrograde ejaculation was incurred as a result of negligence or other fault on the part of VA in providing surgical treatment or to an event not reasonably foreseeable. With resolution of the doubt in the Veteran's favor, the criteria for compensation under 38 U.S.C.A. § 1151 are met and the claim must be granted. ORDER Service connection for adenocarcinoma of the colon is denied. Service connection for peripheral neuropathy of the right upper extremity is denied. Service connection for peripheral neuropathy of the left upper extremity is denied. Entitlement to service connection for multiple myeloma is denied. Subject to the law and regulations governing payment of monetary benefits, entitlement to compensation under 38 U.S.C.A. § 1151 for retrograde ejaculation due to VA medical treatment is granted. ____________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs