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- Professor 1
Objective – To insure safe motherhood & child survival Article XV, Section 3.1 – The state shall defend the right of the spouses to found a family in accordance w/ their religious convictions and demands of responsible parenthood. Goal – to improve the quality of life; directed
birth spacing, in order to allow mothers to rest & regain their health before the next pregnancy Birth limitation, when desire number had reached Helping infertile couples to have children
FAMILY PLANNING METHODS
Temporary methods – Traditional – coitus interruptus Natural family planning (NFP) – Cervical mucous (Billing’s method) Basal body temperature (BBT) Sympto-thermal Lactation amenorrhea (LAM) Rhythm method
FAMILY PLANNING METHODS
Temporary methods – Artificial methods:
Pills – combined & progestin only Injectables – DMPA, megestron, noresterat Implants - noresterat
Mechanical – condoms, diaphragms Chemical – vag. tabs; gels; cream; vag. sponge
FAMILY PLANNING METHODS
Permanent methods – Female sterilization – bilateral tubal ligation Mini-laparotomy Laparoscopy Culdoscopy Colpotomy Male sterilization - vasectomy
Sterilization is the most effective method of contraception
– up to 99.97% by most investigators Offers distinct advantage over artificial methods Eliminated fear of systemic & local side effects from use of drugs & gadgets Dispenses long & regular follow-up (drop-out)
Often called voluntary surgical contraception (VSC); distinguished from castration (removal of gonads); sterilization is prevention of union of egg & sperm by occluding the tubes & deferens
Policy of VSC –
these methods do not consist of abortions (termination of pregnancy prior to 20 wks AOG) That the client is thoroughly informed of the medical implications of the procedure; regarding the irreversibility of the procedure That other methods of contraception have been explained, that that it is taken on a voluntary basis That written consent of spouse is obtained That the procedure is performed by a duly trained & accredited physician
Mechanism of action – Female – by obstructing the continuity of the tube Older method – mutilating surgical methods & use of radiation for castration (Not use anymore) Accepted methods – is tubal ligation or occlusion Tying & cutting Applying clips or rings Cauterization of tubes Tubectomy Hysterectomy – only when there is pathology in uterus Male – vasectomy (occlusion of vas deferens) 8
Tubal ligation methods:
1. Pinching off the tube in a loop with a band 2. Cutting and electro-cauterizing the tube ends 3. Cutting and tying off the tube ends
Methods of Tubal Ligation
Partial salpingectomy, being the most common occlusion method. The fallopian tubes are cut and realigned by suture in a way not allowing free passage. The Pomeroy technique, is a widely used version of partial salpingectomy, involving tying a small loop of the tube by suture and cutting off the top segment of the loop. It can easily be applied via laparoscopy. Partial salpingectomy is considered safe, effective and easy to learn. It does not require any special equipment to perform; it can be done with only scissors and suture. Partial salpingectomy is not generally used with laparoscopy. Clips: Clips clamp the tubes and inhibits blood flow to the portion, causing a small amount of scarring or fibrosis, in turn, preventing fertilization. The most commonly used clips are the Filshie clip, made of titanium, and the Wolf clip (or "Hulka clip"), made of plastic. Clips are simple to insert, but require a special tool to put in place
Methods of Tubal Ligation
Silicone rings: Tubal rings, similarly to clips, block the tubes mechanically. It encircles a small loop of the fallopian tube, blocking blood supply to that small loop, resulting in scarring that blocks passage of the sperm or egg. A commonly used type of ring is the Yoon Ring, made of silicone Electrocoagulation or cauterization: Electric current coagulates or burns a small portion of each fallopian tube. It mostly uses bipolar coagulation, where electric current enters and leaves through two ends of a forceps applied to the tubes. Bipolar coagulation is safer, but slightly less effective than unipolar coagulation, which involves the current leaving through an electrode placed under the thigh. It is usually done via laparoscopy.
Methods of Tubal Ligation
COAGULATION METHODS Bipolar Coagulation - is the most
popular method of laparoscopic female sterilization. With this method of tubal ligation, the fallopian tube is grasped between two poles of electrical conducting forceps, and electrical current passes through the tube between the two ends of the forceps. Damage to the tube is limited to the segment between the forceps. Often, two or three adjacent sites are coagulated resulting in loss of approximately 2-3 cm of fallopian tube. Bipolar tubal coagulation is a good method of female sterilization for women who decide to have a tubal reversal procedure. Pregnancy rates after reversal of bipolar tubal coagulation are approximately 60%.
Monopolar coagulation of the fallopian tubes is less common than bipolar coagulation tubal ligation. The electrical current spreads outward from the coagulating forceps, so monopolar coagulation damages more of the fallopian tube than bipolar coagulation. In most cases, the tube is also cut after it has been coagulated
Female sterilization – when done:
she is not pregnant Just after delivery (post-partum) After abortion (post-abortion) At the time of other pelvic or abdominal surgery
Sterilization can be done any time & often done during caesarean section Who delivered vaginally – early puerperium is convenient; Oviducts are accessible at the navel directly beneath the abdominal wall for several days after delivery
Advantage – technically simple; hospitalization need not be prolonged; & less dangerous technic
Others, in immediate puerperium
Has disadvantage Prefer to wait 12 – 21 hrs (Parkland, AM after delivery; post-partum bleeding in multis subsides remarkably 12 hours after delivery
Tubal ligation (also commonly referred to as having your tubes tied) is surgery that closes off a woman's fallopian tubes. Once the tubes are closed or "tied," sperm will not be able to reach an egg, so pregnancy cannot take place. Also Known As: Tying the tubes, tubal sterilization, female sterilization, having your tubes tied, sterilization surgery – female, tube tying, and permanent infertility. o A tubal ligation procedure results in permanently sterile This procedure is usually recommended for adult women who are certain that they do not want to get pregnant in the future.
Tubal ligation is considered a permanent birth control method It tends to be a popular choice because women realize that this method can offer extremely effective pregnancy protection for the rest of their reproductive years. Women tend to prefer tubal ligation because of its convenience and lack of side effects that are associated with temporary birth control methods.
Tubal ligation (also commonly referred to as having your tubes tied) is surgery that closes off a woman's fallopian tubes. Once the tubes are closed or "tied," sperm will not be able to reach an egg, so pregnancy cannot take place. o A tubal ligation procedure results in permanently sterile This procedure is usually recommended for adult women who are certain that they do not want to get pregnant in the future. It tends to be a popular choice because women realize that this method can offer extremely effective pregnancy protection for the rest of their reproductive years. Women tend to prefer tubal ligation because of its convenience and lack of side effects that are associated with temporary birth control methods. 18
The Tubal Ligation Procedure: A tubal ligation occurs in a hospital or outpatient clinic. It can be performed with: Conscious sedation - woman is awake, relaxed, and drowsy Deep sedation - woman is asleep Anesthesia - local (woman is awake), regional (body is numb from the navel down), or general (woman is asleep) During the procedure, the fallopian tubes are closed. Some may require a few small incisions made in the abdomen; in these procedures, the tubes are clipped, cut and/or cauterized (sealed shut). Another option, known as Essure, doesn't require an incision and uses micro-inserts to stimulate blocking of the tubes.
After a Tubal Ligation Procedure:
Most women can return to work within a few days after having a tubal ligation. Pain medication can help to relieve any discomfort. It is recommended that women avoid strenuous exercise for several days. In general, most women feel ready to have sex again within a week. The majority of women recover from this procedure with no problems. Unlike with male sterilization (vasectomy), no tests are required to check for sterility. A tubal ligation does not decrease a woman's sexual pleasure and doesn't affect her femininity. Since no glands or organs are removed or changed and all hormones will still be produced, a tubal ligation should not change sexuality or interfere with the functioning of a woman's sexual organs.
Tubal ligation is more than 99 percent effective in the first year. This means that that out of every 100 women who have this procedure done, less than one will become pregnant during the first year of use. Up to one out of every 100 women will become pregnant in each subsequent year following the first year (when the procedure was done). This is due to a slight possibility that fallopian tubes may reconnect by themselves. Of every 1,000 women who have undergone tubal ligation, approximately 18.5 will become pregnant within 10 years. These statistics were concluded by the U.S. Collaborative Review of Sterilization in their hallmark Crest study. However, depending on the method used and the age of the woman when she has the procedure done, this rate might be higher or lower. If a pregnancy does occur after a tubal ligation, there is a 33% chance of it being an ectopic pregnancy. However, the overall rate of pregnancy is so low, that a woman’s chance of having an ectopic pregnancy is much lower than it would be provided she did not have the tubal ligation done in the first place.
Permanent birth control. Immediately effective. Allows sexual spontaneity. Requires no daily attention. Not messy. Cost-effective in the long run. Does not protect against sexually transmitted infections, including HIV/AIDS. Requires surgery. Has risks associated with surgery. More complicated than male sterilization. May not be reversible. Possible regret. 26 Possibililty of Post Tubal Ligation Syndrome
Risk associated w/ ligation –
Due to actual procedure – include incomplete closure of tubes (becoming preg.- approximately 1 out of 200 women); injury to near-by organs or structures caused by surgical instruments; increased possibility of ectopic if pregnancy occurs after ligation Stemming from use of anesthesia – includes reactions to drugs & breathing problems Risks of surgery in general w.c includes infection & bleeding
Method-associated sterilization failure – some methods are associated w/ lower failure rate
Puerperal sterilization & interval uni-polar coagulation appear to have the lowest rate 1/2 of pregnancy occurring after failed electrocoagulation is ectopic preg. w/c is 10% compared to ring, clip or tubal resection; compared to nonsterilized, 1%
Any symptoms of pregnancy after sterilization must be investigated & ectopic must be ruled out
Post-tubal ligation syndrome – characterized by pelvic discomfort, ovarian cysts formation; esp. menorrhagia 28
FEMALE STERILZATION Failures – reasons:
Surgical errors account for 30 – 50% She was already pregnant Due to fistula formation from cauterization; faulty clips (not occlusive enough); or tube undergo re-anastomosis Equipment failure as in electro-cautery
Puerperal sterilization failure –
Surgical errors Formation of fistula tract of cut tubes or re29 anastomosis
Type of tubal ligation procedure use –
Status of women’s health will signify w/c tubal lig. option is best suited; 2 factors when deciding – Safest procedure & include body weight Whether she had or not previous surgery More than half are done right after NSD thru a small incision near navel; during C.S. or abortion Essure (no incision) can’t be done until at least 6 wks after giving birth; had abortion; or miscarriage 30
Female sterilization can be done either by – 1) Surgery or 2) Non-surgical methods Accepted female sterilization is tubal ligation or occlusion – done either by abdominal or vaginal route Abdominal route – mini-laparotomy and laparoscopic sterilization Vaginal route includes – colpotomy (trans-V); coldoscopic sterilization; & trans-cervical route by hysteroscopic sterilization
METHODS of sterilization
TYPES OF OPERATIONS
Laparoscopy: Laparoscopic sterilization is one of the two most common methods of sterilization. Typically, given general or regional anesthesia. He will make a small incision, about half an inch long, in or bellow the belly button. A harmless carbon dioxide gas is injected into the abdomen, elevating the abdominal wall off of the pelvic organs and allowing your surgeon to get an unobstructed view as well as room to operate Next, a laparoscope (a small, telescope-like instrument with a light) is inserted through the incision to view the tubes. The surgeon then inserts a smaller device used to move, hold, and close off the fallopian tubes. This device could be inserted either through the laparoscope or through a second, tiny cut made just above the pubic hairline. The surgeon closes the fallopian tubes by using rings, clamps, clips, or by sealing them shut with an electric current (electrocautery). The laparoscope is withdrawn, and the surgeon will then suture the incision(s) closed. 32
Mini-laparotomy (mini-lap) – small supra-pubic or infra-umbillcal incision thru w/c the tubes can be approached Not dependent on complicated, sophisticated instruments; hence widely used Not new but later introduction of uterine elevator made it popular w/c bring the tubes closer to the incision Criteria to be called mini-lap – length of incision is 2 cm or less
TYPES OF OPERATIONS
– 2.5 – 3 cm vertical or transverse incision about 2 fb above the upper borer of s.pubis 35
Mini-laparotomy (mini-lap) –
TYPES OF OPERATIONS
Interval mini-lap is done w/in the 1st 7 days of menstrual cycle or any time during the cycle if she is taking pill properly or has IUD & menstruating regularly Can also be done during interval period following vag. delivery or abortion – Pomeroy method is preferred Immediate post-partum – w/in the 1st 48 hrs following vaginal delivery – uterus is enlarged, so tubes are higher in location & incision is just below the umbilicus Others prefer to do right after delivery (4th stage) when still under OB anesthesia But some prefer to wait longer; done only when secure that severe post-partum bleeding necessary 36 for hysterectomy will no longer occur
A postpartum tubal ligation is done to permanently prevent a woman from getting pregnant. During this procedure, the doctor makes a cut (incision) near the belly button (navel) rather than in the pubic area. This is because the uterus is enlarged from the pregnancy, and the fallopian tubes are located higher in the abdomen. The dotted line on the figure shows where the cut is made below the belly button. The dotted lines on the fallopian tubes show where they are closed. Postpartum tubal ligation is usually done as a minilaparotomy after childbirth. The fallopian tubes are higher in the abdomen right after pregnancy, so the incision is made below the belly button (navel). The procedure is often done within 24 to 36 hours after the 38 baby is delivered.
Laparoscopic – laparoscopy is used to visualized the organs thru the anterior abdominal wall Tubal occlusion is done by – electro-cautery; application of silastic rings or clips Culdoscopic – culdoscopy is used to see pelvic organs thru the posterior vagaginal fornix Tubes are grasped, brought to vagina then do tubal oclusion currently acceptable Commonly done is Pomeroy’s method Colpotomy – same as above Transvaginal approach – those who wish no visible scar
TYPES OF OPERATIONS
Culdoscope is an instrument, a kind of endoscope, used to visualize female pelvic organs, introduced through the vagina into the cul-de-sac (which is also called the rectouterine pouch or the pouch of Douglas). The procedure of inserting the culdoscope into the rectouterine pouch is termed culdoscopy The word culdoscope (and culdoscopy) is derived from the phrase cul-de-sac, which in French literally means "bottom of a sac", here referring to a blind pouch or cavity in the female body that is closed at one end, that is the rectouterine pouch. As early as the 13th century, a cul-desac was a dead-end street (or a dead-end way), a blind alley
Culdoscopy and culpotomy are two types of vaginal sterilization approaches. The vaginal method of tubal ligation was once the preferred technique. However, since it is associated with higher risks than laparoscopic surgery, surgeons have been favoring the abdominal approach to transvaginal procedures. These procedures each take about 15 to 30 minutes, and women are able to go home the
Hysteroscopy – an instrument to visualize uterine cavity thru cervical canal
ID of cornual opening of tubes & occluding them either by electro-cautery, chemicals or mechanical plugs In Phil – did not gain ground; reserved for well staffed & equipped medical centers Latest methods – Essure methods Adiana’s method
A tubal implant is a small metal spring that is placed in each of the two fallopian tubes without using surgery. It is guided through the vagina, cervix, and uterus and lodged in a fallopian tube. Over time, scar tissue grows around the two implants and permanently blocks the tubes. This stops eggs from traveling from the ovaries and down the fallopian tubes, where eggs are normally fertilized by sperm.
IMPLANTS ESSURE METHOD
Essure is a permanent birth control procedure that works with your body to create a natural barrier against pregnancy Advantages:
No cutting No going under general anesthesia No slowing down to recover No hormones No guessing for birth control Short procedure time - only takes about 13 minutes to perform
Disadvantages of Hysteroscopic Tubal Ligation
The need to use an alternative birth control method for three months until scar tissue forms and blocks the fallopian tubs. Additionally, the Essure hysteroscopic sterilization procedure is not reversible. Because the fallopian tube tissue and coil implants grow together to create a closed passage, the micro-inserts cannot be surgically removed without damaging the fallopian tubes. A tubal implant can also be difficult to insert, so a second procedure is sometimes necessary to completely block both tubes. In clinical studies, approximately 1 out of every 7 women were not able to have the coil-implants placed in both fallopian tubes during the first placement procedure.
Two years after the Essure procedure indicate these potential risks:
The micro-inserts may have been expelled out of the fallopian tubes. The coil implants may have been inserted too far, or not far enough, into the fallopian tubes. The micro-inserts may have been pushed through the uterus or fallopian tube wall (perforation). Should this occur, surgery may be needed to repair the situation. The coil implants could become damaged during other medical procedures, such as endometrial biopsy, dilation and curettage (D&C), or procedures that require the use of radio frequency
complications that could occur during the insertion of the Essure implants include:
to moderate pain Nausea and/or vomiting Fainting following the procedure Infection Undiagnosed pregnancy
The procedure can be performed in the comfort of a doctor’s office without general anesthesia, and most women resume their normal activities within one day. 3 months following the procedure, your body and the micro-inserts work together to form a natural barrier that prevents sperm from reaching the egg. During this period, you must continue using another form of birth control (other than an IUD or IUS). Three months after the Essure procedure, a doctor will perform an Essure Confirmation Test, to confirm that the tubes are fully blocked and that the women can rely on Essure for permanent birth control. Essure does not contain hormones to interfere with your natural menstrual cycle. Your periods should more or less continue in their natural state.
Hysterosalpingogram (HSG) Test Essure Scar Tissue - 3 Months
ADIANA TUBAL STERILIZATION
Adiana is another new hysteroscopic sterilization procedure Adiana uses radio frequency energy and a polymer microsinsert that together result in tubal blockage in the interstitial segment of the fallopian tube that is within the uterine muscle. With the Adiana procedure, a catheter is positioned immediately inside the opening of the patient's fallopian tube using a hysteroscope. The catheter applies low-level radiofrequency (RF) energy to remove the thin layer of cells that line a 1 cm section of the inside of the fallopian tube. A soft polymer matrix implant, that is smaller than a grain of rice, is then inserted into the tubal opening. As scar tissue grows into the inplant, tubal blockage occurs. The area of the tube that is affected is smaller than with the Essure device. The portion of the tube outside the uterus is not affected. Similar to Essure, a confirmatory hystero-salpingogram (HSG) is performed three months later to ensure the fallopian tubes are completely blocked and that the woman can begin relying on Adiana for permanent contraception. Adiana reversal is also performed by the technique of tubouterine implantation.
TYPES OF OPERATIONS
A laparotomy procedure (open tubal ligation) is considered to be major surgery, so it is less commonly used than laparoscopy and minilaparotomy. This procedure requires general or regional anesthesia. Your surgeon will make a larger incision (2 to 5 inches) in the abdomen. The fallopian tubes will then be pulled up into or out of the incision, closed off (tied, clipped, or sealed shut) with a device, and put back into place. The incision will be stitched shut. A woman may need to be hospitalized for 2 to 4 days, and it could take several weeks to fully recover. If the procedure is done after delivery, a woman's hospital stay may be extended by 1 or 2 days. n open tubal ligation is usually performed right before or after some other type of unrelated abdominal surgery, such as a Cesarean section . If you are having a c-section delivery, your surgeon can perform the laparotomy in just a few extra minutes while you are still under anesthesia and your abdomen is still open. In addition to having abdominal surgery for other reasons, an open tubal ligation may be recommended if you have or have had pelvic inflammatory disease (PID), endometriosis, or previous abdominal or pelvic surgery. These conditions can often cause abdominal tissue and organs to scar or stick together (adhesion).
TYPES OF OPERATIONS
A laparotomy procedure (open tubal ligation) is considered to be In addition to having abdominal surgery for other reasons, an open tubal ligation may be recommended if you have or have had pelvic inflammatory disease (PID), endometriosis, or previous abdominal or pelvic surgery. These conditions can often cause abdominal tissue and organs to scar or stick together (adhesion). A laparotomy tubal ligation may also be necessary if a woman: has had prior abdominal surgery is significantly overweight has had infections that have left adhesions or scar tissue in the abdomen has had certain medical or gynecological problems
Restoration of fertility – One should be sterilized believing that her fertility can be restored either by surgery or assisted reproductive technic (in-vitro; ovum transfer) These procedures are costly, difficult & uncertain Success rates vary upon age & technology used
Tube can be occluded by surgical, electrical, mechanical or chemical Electro-coagulation – is applied & tubes are cut; current is applied to grasping forceps either by mono-polar or bipolar system; bipolar is safer Mechanical – rings or clips are applied Chemical – Quinacrine is delivered to tubes via the cervix using the IUD applicator; 3 monthly use is needed
Types of tubal sterilization done –
Puerperal tubal ligation Irving procedure Pomeroy procedure Parkland procedure Madlener procedure Fimbriectomy
Failure of puerperal sterilization – most sterilization
failures were not preventable Surgical errors – includes transection of the round ligament instead of oviduct or partial transection of oviduct Formation of fistula tract bet.severed tubal stumps or spontaneous re-anastomosis
TECHNICS of FEMALE STERILZATION
Pomeroy’s method Irving’s Aldridge Madlener Uchida Parkland’s method Kroner Modified Pomeroy’s method
A. A loop of the proximal portion of the tubal ampulla is elevated to reveal the vascular supply of the mesosalpinx B. A strand of absorbable suture material is used to bilaterally ligate the tube and simultaneously provide hemostasis. C. A hemostat is placed on the suture strands immediately distal to the knot to prevent the tube from retracting into the abdomen. The open blade of the Metzenbaum scissors is used to pierce the mesosalpinx and approximately 1 cm of the tube is excised. D. The end result following dissolution of the absorbable suture material is return of the proximal and distal portions of the tube to their normal anatomic position. 65
Parkland procedure involves tying two non-absorbable ligatures around the fallopian tube in its proximal to middle segment and then cutting out the tubal segment between the ligatures. The end result is similar to the Pomeroy method of tubal ligation. Two healthy tubal segments remain that can be rejoined by tubal Two-thirds of women with a Parkland tubal ligation become pregnant following tubal reversal surgery.
Placing two ligatures around the fallopian tube in its proximal to midsegment and removing the tubal segment between the two ligatures. Then, the tied end of the segment of fallopian tube attached to the uterus is sutured into the back side of the uterus, and the other tied end is buried in the connective tissue underlying the fallopian tube. As with other ligation/resection methods, the Irving technique leaves behind two healthy tubal segments that can be put back together with tubal reversal microsurgery. The pregnancy rate after reversal of an Irving tubal ligation is 60-70%
A saline-epinephrine solution is injected into the subserosal area of the tube, causing the muscular tube to separate from the serosa. The ballooned serosa is incised, and the muscular tube is withdrawn. A 5-cm section of the tube is then excised and the proximal end ligated. A purse-string suture is applied. The procedure may be extended so as to include fimbriectomy and removal of the isthmus and ampulla with another suture placed around the mesosalpinx.
A. A loop of the ampullary portion of the tube is elevated and then both segments are crushed with a hemostat. B. A strand of nonabsorbable suture material is used to ligate the tube over the crushed area. No tissue is excised. The devascularized loop of tube undergoes aseptic necrosis
Top. A suture is anchored in the mesosalpinx and placed around the tube in the distal ampulla. A second suture may be placed adjacent to the first, and the infundibulum of the tube is excised. Bottom. The tube as it appears following excision of the distal segment.
Top. By blunt dissection, a pocket is developed within the substance of the broad ligament. Traction sutures are placed within the muscular layer of the distal tube and are used to draw the infundibulum into the peritoneal pocket. Bottom. Several sutures of nonabsorbable suture material are then used to anchor the infundibulum of the tube into the new anatomic subperitoneal location. Care must be taken to ensure that the entire fimbriated portion of the tube is firmly held beneath the peritoneum.
REVERSAL OF STERILIZATION
It is restoration of the anatomical & functional continuity of occluded ducts
Re-anastomsis pf f. tubes; reconstruction of abd. ostia; or implantation of healthy segments into the uterus Males – re-anastomsis of vas deferens
Before surgery – considerations:
Validity of reason for reversal Total fertility picture of couple Medical & social circumstances at time of request is made (favorable or not) Duration of the sterilized state 75
REVERSAL OF STERILIZATION
Success of reversal is based on anatomical & functional & proven by –
Female – tubal insufflation, hysterosalpingography or endoscopy; comfirmed when there is intra-uterine pregnancy Male – anatomical success, proven by mere finding of sperm in the ejaculate
Pregnancy rate ff. tubal anastomosis depends on
Method of sterilization Site of anastomosis Length of resected tube Technic employed
A vasectomy is a surgery to render a man unable to have children, or sterile. It is one of the most commonly performed surgeries in America, while surgery to sterilize women is more popular, the vasectomy surgery is far less invasive and offers a much quicker recovery. The vasectomy surgery works by preventing sperm from exiting the body. This is done by severing or blocking the vas deferens, the duct through which sperm travels from the testes and out of the body. Sperm is produced, but it cannot travel outside the body when a man ejaculates. While the surgery is effective at preventing pregnancy, it does not alter the ability to have/maintain an erection. There is no change in the quality or quantity of semen, nor is there a change in the ability to ejaculate.
Vasectomy considered one of most effective, safe & simple methods Why not popular among males –
Interested in proving their virility than assuming responsibility Afraid that it will affect their sex lives Increasing availability of other methods Female sterilization – safer & simpler Lack of interest among family planners Publicity of long-term side effects among monkeys but not proven in man 78
Reasons for decline –
NORMAL MALE ANATOMY
Vasectomy – small incision in the scrotum, the lumen of vas deferens is disrupted to block passage of sperm from testes Female sterilization compared to male has:
20 x increased complication rates 10 – 37 x failure rate 3 x higher cost Complete expulsion of stored sperm n the tract – takes about 3 mos or 20 ejaculations Semen check – 2 consecutive (-) count Take another form of contraceptive 82
Disadvantage – sterility in not immediate
Precautions in vasectomy – It does not cause instant sterility Have to wait 15 – 20 ejaculations before tract becomes devoid of sperm Vas deferens cut – permanganate solution is injected into proximal cut end, so it will flow to seminal vesicle; violet color in urine – most sperms are rendered inactive Very effective – similar to pregnancy rate as those female sterilization
Usually done in the surgeon's office using local anesthesia; scrotum is shaved and cleaned, & anesthesia is given into this area to numb it. Small incision in the upper part of the scrotum, and tie off and cut apart the vas deferens. The "tubes" are cut and sealed by tying, stitching, cauterization or otherwise clamped to prevent sperm from entering the seminal stream. Then use stitches or a skin glue to close your incision.
Types of vasectomy –
without an incision. This is called a no-scalpel vasectomy (NSV). The surgeon will find the vas deferens by feeling the scrotum and then give you a shot of the anesthesia into this area to numb it. Regular - a tiny hole in the skin of the scrotum and seal off the vas deferens. Done by either by pulling the vas deferens through the tiny hole or insert a clip into the hole to seal it; no need to stitches.
New method of vasectomy – no-scalpel technic pioneered in China A special designed fixing clamp encircles & holds the vas w/o penetrating the skin Scrotum & vas sheath – punctured w/ sharp ended hemostat & spread open Vas lifted out of scrotum & cut; then sealed by ligation or coagulation Vas is then put back inside the sheath & scrotum
Compare to failure rate in tubal ligation – 10 – 20 x more likely to fail than vasectomy Restoration after successful vasectomy does not always succeed
Odds for success is about 50% Risk of regret is due to immaturity at time of sterilization Possibility that immune response might cause harmful systemic changes No differences in occurrence of MI or stroke No convincing evidence of increase in testicular CA
A desire to not father a child Pregnancy contraindicated Bacterial skin infection in the groin/scrotum Coagulation disorders or treatment with anticoagulant or antiplatelet therapy Inability to palpate and elevate both vasa Hypersensitivity to palpation, precluding mobilization of the vas Lack of adequate informed consent Depression, psychosexual impairment, or impaired decision making Relative Contraindications Impending infertility, such as menopause or hysterectomy in wife Unresolved conflict or stress 88 Inappropriate expectations of vasectomy
1. Incisions 2. Spermatic Cord
The procedure starts with the administration of local anesthesia, to numb the genitals. Once the solution dries, the surgery begins with 1 or 2 half-inch long incisions on the underside of the scrotum. The vas deferens, the cord that carries sperm, is then located and either cut and tied off or cut and cauterized. Research shows that the use of cautery is the most effective, as it prevents the vas deferens from healing back together. The incision is then closed with sutures, which can be removed at the surgeon’s office in a week to ten days.
In a vasectomy, an incision is made in the man's scrotum. The spermatic cord is pulled out (B) and incised to expose the vas deferens, which is then severed (C). The ends may be cauterized or tied off (D). After the procedure is repeated on the opposite cord, the scrotal incision is closed (E). The patient is not sterile immediately after the procedure is finished. Use other methods of contraception until two consecutive semen analyses confirm that there are no sperm present in the ejaculate. It takes about four to six weeks or 15–20 ejaculations to clear all of the sperm from the tubes. 93
Existing technique vs. no needle approach
Minor Complications – Minor complications occur in 5% to 10% of vasectomy patients. Congestive epididymitis Sperm granuloma Bleeding from the skin incision Extensive ecchymosis Superficial wound infection Suture or clip rejection Skin reaction to the surgical antiseptic solution Neuroma Post-vasectomy pain syndrome 95
VARIATIONS OF VASECTOMY
The No-Scalpel method (coined Key-Hole), in which a sharp hemostat, rather than a scalpel, is used to puncture the scrotum may reduce healing times as well as lowering the chance of infection (incision). An "open-ended" vasectomy obstructs only one end of the vas deferens, which allows continued streaming of sperm (by virtue of the un-sealed vas-deferens) into the scrotum. This method may avoid build-up of pressure in the epididymis. Testicular pain (from "backup pressure") may also be reduced using this method. 96
Major Complications –occur in less than 3% of patients.
Hematoma Scrotal infection Post-vasectomy pain -may last for a lifetime, is estimated to appear in between 5% and 35 The "Vas-Clip" method does not require cutting the Vas Deferens, but rather uses a clip to squeeze shut the flow of sperm. This method may facilitate a better chance/outlook for reversal, as well as reduced pain (post-procedure). Link to dimentia - small number of men with primary progressive aphasia, a rare speech disorder Psychological reactions - depression or anger
Bleeding: A small amount of bleeding should be expected, but serious
The Risks of Vasectomy
bleeding should be reported Hematoma: A collection of blood similar to a bruise but more severe, a hematoma after a vasectomy typically results from blood pooling under the skin at the surgical site. Epidydimitis:A chronic ache or pain in the testicles, best known by the slang term “blue balls," this condition can be resolved with warm compresses in many cases. In severe cases, surgery may be necessary to remove the epydidimis. Sexual Problems:While there is no physical reason for sexual problems, a small minority of men report problems with their ability to function sexually after surgery. This is typically related to feelings about the surgery rather than the surgery itself. Spermatic Granuloma: An abscess that forms at the site of a vasectomy, caused by sperm leaking from the vas deferens after surgery.
Reasons for failures – failure rate is 1% but dependent on:
Unprotected coitus before tract is empty Spontaneous recanalization of vas deferens Division & occlusion of wrong structures Rare undiagnosed congenital duplication of vas Vas can be approach either thru single midline scrotal incision or bilateral scrotal incision Vas is exposed, after cutting its sheath, clamp, cut & ligated - Ligation of cut ends vary – some fold back the proximal end onto itself than tied; some overlap the tied ends while others close the sheath of vas over cut ends Skin is closed w/ one stitch or none at all 99
Technic of vasectomy –local anesthesia
Restoration does not always succeed & factors in restoring fertility Application of meticulous micro-surgical technic for anastomosis Length of time after vasectomy Presence of sperm granulomas No increase in MI or stroke nor cancer Vasectomy – the safest of all VSC procedures; does not affect hormonal balance; does not lessen sexual desire & 100 enjoyment; & male virility is preserved
Reversal procedure to reverse vasectomies using vasovasostomy (a form of microsurgery) Vasovasostomy is effective at achieving pregnancy in only 50%-70% of cases. The rate of pregnancy depends on factors such as: method use & length of time elapsed The body often produces antibodies against sperm, sperm counts are rarely at pre-vasectomy levels. There is evidence that men who have had a vasectomy may produce more abnormal sperm, which would explain why even a mechanically successful reversal does not always restore fertility. higher rates of aneuploidy and diploidy
Vasectomy does not affect a man's ability to have an erection or orgasm, or ejaculate semen. Sperm count gradually decreases after a vasectomy. After about 3 months, sperm are no longer present in the semen. Most men are satisfied with vasectomy. Most couples enjoy not having to use birth control. Alternative Names - Sterilization surgery – male; No-scalpel vasectomy (NSV)
Six to eight weeks after the procedure, a semen sample will be tested for sperm. This is done to make sure the procedure was effective and that no sperm is present. In some cases, it may take longer than 8 weeks for the semen to have no sperm in it, but by 3 months, the semen should be completely free of sperm. When collecting a semen sample, it is important that the semen not come in contact with spermacide, a type of birth control that kills sperm. It is often present in condoms and other types of contraceptives. Three months after the surgery, the semen should have no sperm in it. If there is any sperm in the sample, the man remains fertile and can father children. 103
Semen Sample/Sperm Count After a Vasectomy
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