Voluntary Surgical Contraception

for Women

Tubal Occlusion

1
 Tubal Occlusion: Most Popular
Contraceptive Method Globally

Female: 170 million

Source: Church and Geller 1990.

2
 Types of Tubal Occlusion

! Postpartum
$ Minilaparotomy (Infraumbilical)

! Interval
$ Minilaparotomy
$ Laparoscopy

3
4
 Tubal Occlusion: Client Issues

! The client should make the decision for sterilization

voluntarily.
! The client has the right to change her mind anytime
prior to the procedure.
! The client should understand that voluntary
sterilization (VS) is a permanent (not easily reversible)
method.
! No incentives should be given to clients to accept VS.
! A standard consent form must be signed by the client
before the VS procedure.
! Spousal consent is not required.
5
 Tubal Occlusion: Mechanism of Action

By blocking the
fallopian tubes (tying
and cutting, rings, clips
or electrocautery),
sperm are prevented
from reaching ova and
causing fertilization.

6
 Tubal Occlusion: Contraceptive Benefits

! Highly effective (0.51 pregnancies per 100 women

during first year of use)
! Effective immediately
! Permanent
! Does not interfere with intercourse
! Good for client if pregnancy would pose a serious
health risk
! Simple surgery, usually done under local anesthesia
! No long-term side effects
! No change in sexual function (no effect on hormone
production by ovaries)
1 Trussell et al 1998. 7
 Tubal Occlusion:
Noncontraceptive Benefits

! Does not interfere with breastfeeding

! Decreased risk of ovarian cancer

8
 Tubal Occlusion: Decreased
Risk of Ovarian Cancer

! 39% decrease in risk compared to clients

without tubal occlusion
! Decrease in risk does not depend upon
method of sterilization
! Risk remains low 25 years after surgery

Source: Green et al 1997. 9

 Tubal Occlusion: Limitations

! Must be considered permanent (success of reversal

cannot be guaranteed)
! Client may regret later (age < 35)
! Small risk of complications
! Short-term discomfort and pain following procedure
! Requires trained physician (gynecologist or surgeon for
laparoscopy)
! Slightly decreased long-term effectiveness
! Increased risk of ectopic pregnancy
! Does not protect against STDs (e.g., HBV, HIV/AIDS)
10
 Tubal Occlusion: Long-Term
Effectiveness by Age Group

Age Group Cumulative Failure Rate1

18–33 2.6
> 34 0.7
All ages 1.8

1Pregnancies per 100 women over 10 years

Source: CREST Study 1996. 11
 Tubal Occlusion: Long-Term
Effectiveness by Method

Failure Rate1
Method 1 Year 10 Years
Unipolar coagulation 0.02 0.81
Postpartum partial 0.01 0.75
salpingectomy
Silicone band application 0.62 1.72
Interval partial 0.75 2.01
salpingectomy
Bipolar coagulation 0.35 2.48
Spring clip application 1.82 3.65
1Pregnancies per 100 procedures
Source: CREST Study 1996. 12
 How Effective Is Tubal Occlusion?

Method Pregnancies per 100

Women-Years
Laparoscopy
Ring 0.0–0.6 (N=15 studies)
Coagulation 0.1–1.3 (N=14 studies)
Clip 0.0–0.7 (N=4 studies)
Minilaparotomy
Pomeroy 0.2–0.8 (N=4 studies)

Source: Church and Geller 1990.

13
 CREST Study: Summary of Results1

Risk of pregnancy:
$ higher than previously found in year 1
$ less than 2% over 10 years of use
(18.5/1000 procedures)
$ highest in women under 30
$ lowest for postpartum partial
salpingectomy (8 per 100 procedures)
$ highest for spring clip (37 per 100
procedures)
1CREST 1996.
14
 CREST Study: Summary of Results1
continued

Ectopic pregnancy:
$ 1 in 3 pregnancies following VS is
ectopic
$ 10 year cumulative risk = 7.3/1000
procedures
$ Risk in women under 30 is twice as high
$ Rate of ectopic pregnancy in years 4–10
is three times as high as in years 1–3

1CREST 1996.
15
 Who Can Use Tubal Occlusion
Women:
! Who are age > 22 and < 45
! Who want highly effective, permanent protection
against pregnancy
! For whom pregnancy would pose a serious health risk
! Who are postpartum
! Who are postabortion
! Who are breastfeeding (within 48 hours or after 6
weeks)
! Who are certain they have achieved their desired family
size
! Who understand and voluntarily consent to procedure
16
 Tubal Occlusion: Who May Require
Additional Counseling

Women:
! Who cannot withstand surgery
! Who are uncertain of their desire for future
fertility
! Who do not give voluntary, informed consent

17
 Tubal Occlusion: Conditions
Requiring Precautions (WHO Class 3)
! Unexplained vaginal bleeding (until evaluated)
! Acute pelvic infection
! Acute systemic infection (e.g., cold, flu,
gastroenteritis, viral hepatitis)
! Anemia (Hb < 7 g/dl)
! Abdominal skin infection
! Cancer of the genital tract
! Deep venous thrombosis

Appropriate precautions include delay of procedure until condition

improves or resolves.
Source: WHO 1996.
18
 Tubal Occlusion: Conditions Requiring
an Experienced Clinician with Full
Backup
! Diabetes
! Symptomatic heart disease
! High blood pressure (> 160/100 or with vascular
disease)
! Coagulation (clotting) disorders
! Overweight (> 80 kg/176 lb if H/W ratio not normal)
! Abdominal or umbilical hernia
! Multiple lower abdominal incisions/scars

19
 Complications of
Laparoscopic Sterilization

Short-term
! Occur in less than 1% of all procedures
! Directly related to surgical expertise
Long-term
! Decreased long-term effectiveness

20
 Tubal Occlusion: Intra-operative
Complications
Minilaparotomy and Laparoscopy:
$ Uterine perforation
$ Bleeding from mesoslpinx
$ Convulsion and toxic reactions to local anesthesia
$ Injury to urinary bladder
$ Respiratory depression or arrest
$ Injury to intra-abdominal viscera
Laparoscopy (primarily):
$ Gas or air embolism
$ Vasovagal attack
21
 Tubal Occlusion: Immediate
Postoperative Complications

! Pain at infection site

! Superficial bleeding (skin edges or
subcutaneously)
! Postoperative fever
! Wound infection
! Gas embolism with laparoscopy (very rare)
! Hematoma (subcutaneous)

22
 When to Perform
Tubal Occlusion Procedure

! Anytime during the menstrual cycle you can be reasonably

sure the client is not pregnant
! Days 6–13 of menstrual cycle (proliferative phase
preferred)
! Postpartum: Within 2 days or after 6 weeks
If delivered at home and immunized (tetanus toxoid), can
be performed under antibiotic cover (if no sepsis).
! Postabortion: immediately or within 7 days, provided no
evidence of pelvic infection

23
 Tubal Occlusion: Anesthesia

! Local anesthesia of choice

! General–only in select cases
$ obese
$ associated (documented) pelvic pathology
$ allergy to local anesthesia
$ medical problems

24
 Tubal Occlusion: Client Instructions

! Keep operative site dry for 2 days. Resume

normal activities gradually.
! Avoid sexual intercourse for 1 week or until
comfortable.
! Avoid heavy lifting and hard work for 1 week.
! For pain take 1 or 2 analgesic tablets every 4 to 6
hours.
! Schedule a routine followup visit between 7–14
days.
! Return after 1 week if nonabsorbable stitches
used.
25
 Tubal Occlusion: General Information

! Shoulder pain during 12–24 hours after

laparoscopy is common due to gas (CO2 or air)
under diaphragm.
! Tubal occlusion is effective from time operation is
complete.
! Menstrual periods will resume as usual.
! Use a condom if at risk for STDs (e.g., HBV,
HIV/AIDS).

26
 Warning Signs for
Tubal Occlusion Clients

Return to clinic if following problems occur :

! Fever (greater than 38°C or 100.4°F)
! Dizziness with fainting
! Persistent or increased abdominal pain
! Bleeding or fluid coming from the incision
! Signs or symptoms of pregnancy

27
 Tubal Occlusion:
Mobile Programs (Camps)

! Counseling and followup should be the same as at

fixed sites.
! All recommended infection prevention practices
should be followed.
! Followup for short-term and long-term
complications must be available.

28
 Tubal Occlusion:
Common Medical Barriers

! Age restrictions (young and old)

! Provider bias
! Who can provide:
$ Specialists only
$ Physicians only

29
30
Voluntary Surgical Contraception for Men

Vasectomy

31
 Vasectomy: Global Use

Male: 43 million

Source: Church and Geller 1990.

32
 Vasectomy in the US

! Third most popular contraceptive method

! Used by 13% of married couples of reproductive
age
! Use growing three times faster than oral
contraceptive pill use

Source: Liskin, Benoit and Blackburn 1992.

33
34
 Types of Vasectomy

! No-scalpel technique (preferred)

! Incisional

35
 Incisional Vasectomy

! 1 or 2 incisions in the scrotum

! 99% of operations occur under local
anesthesia
! Different methods of occlusion can be used
– Ligation
– Cautery
– Combination

36
 No-Scalpel Vasectomy

! Developed in China, introduced in US in 1988

! Improved anesthesia
! Clinician holds tubes in place under skin
! One puncture
! No stitches needed

37
 Incisional Vasectomy: Complications
After Procedure in US

Complication Rate1
Hematoma 1.95
Infection 3.48

1Per 100 vasectomies; 65,155 cases

Source: Kendrick et al 1987.
38
 No-Scalpel Vasectomy
Failure rate:
$ 0.2B0.4%
Complications
$ Hematoma
$ Infection
$ Epididymitis
Overall < 2%
Mortality < 0.001%
Source: Carignan 1995.
39
 No-Scalpel Vasectomy: Complications
After Procedure in China

Complication Rate1
Hematoma 0.09
Infection 0.91

1Per 100 vasectomies; 179,741 cases

Source: Li et al 1991.
40
 Comparison of No-Scalpel Vasectomy
and Incisional Approach
Thailand

Complications
Method Cases Number Rate1
No- 680 32 0.4
scalpel
Incisional 523 163 3.1

1 Per 100 vasectomies

2 2 hematoma (surgical drainage not required); 1 infection
3 9 hematoma (2 required surgical drainage); 7 infection

Source: Nirapathpongporn et al 1990.

41
 Advantages of NSV over Incisional
Vasectomy

Advantages of NSV
Entry technique Reduces risk of bleeding and hematoma.
Anesthetic method Does not cause swelling at the injection
and puncture site. Provides regional block
of vasal nerves, which reduces discomfort.
Instruments Vas is secured externally.
Skin closure Not needed.
Damage to tissue Less damage.
Complications Fewer complications.
Time for procedure Requires less time.

Source: AVSC International 1997.

42
 Vasectomy: Client Issues
! The client should make the decision for sterilization
voluntarily.
! The client has the right to change his mind anytime
prior to the procedure.
! The client should understand that voluntary
sterilization (VS) is a permanent (not easily
reversible) method.
! No incentives should be given to clients to accept VS.
! A standard consent form must be signed by the client
before the procedure.
! Spousal consent is not required.

43
 Vasectomy: Mechanism of Action

By blocking the vas deferens (ejaculatory

duct), sperm are not present in the
ejaculate.

44
 Vasectomy: Contraceptive Benefits
! Highly effective (0.1B0.15 pregnancies per 100
women during the first year of use)
! Permanent
! Does not interfere with intercourse
! Good for couples if pregnancy or tubal occlusion
would pose a serious health risk to the woman
! Simple surgery done under local anesthesia
! No long-term side effects
! No change in sexual function (no effect on hormone
production by testes)
45
Vasectomy: Noncontraceptive Benefits

! Does not interfere with woman breastfeeding

46
 Vasectomy: Limitations

! Must be considered permanent (not reversible)

! Client may regret later
! Delayed effectiveness (requires up to 3 months or
20 ejaculations)
! Risks and side effects of minor surgery, especially
if general anesthesia is used
! Short-term discomfort/pain following procedure
! Requires trained physician
! Does not protect against STDs (e.g., HBV,
HIV/AIDS)

47
 Vasectomy: Long-Term Reproductive
Health Effects

! Prostate cancer: slight increased risk reported, but

newer studies fail to support this information
! Testicular cancer: no association based on several
studies
! Cardiovascular disease: no association based on
studies
! HIV transmission: no data to support decreased rate
of transmission

Source: Pollack 1993.

48
 Who Can Use Vasectomy

Men:
! Of any reproductive age (usually #50)
! Who want a highly effective, permanent contraceptive
method
! Whose wives have age, parity or health problems that
might pose a serious health risk if they become
pregnant
! Who understand and voluntarily consent to the
procedure
! Who are certain they have achieved their desired
family size 49
 Vasectomy: Who May Require
Additional Counseling

Men:
$ Who are uncertain of their desire for future
fertility
$ Who do not give voluntary, informed consent

50
 Vasectomy: Condition Requiring
Precautions (WHO Class 3)

! Local skin or scrotal infection

! Acute genital tract infection
! Acute systemic infection (e.g., cold, flu,
gastroenteritis, viral hepatitis)
! Symptomatic heart disease or clotting disorders,
diabetes1

Appropriate precautions include delay of procedure until condition

improves or resolves.

1Procedure may need to be done in a high-level facility.

Source: WHO 1996. 51
 Vasectomy: Conditions Requiring an
Experienced Clinician and Full Backup

! Large varicocele ! Intrascrotal mass (until

cause determined)
! Inguinal hernia
! Undescended testes
! Filariasis
and proven fertility
! Scar tissue
! Cryptorchdism (if
! Previous scrotal bilateral and proven
surgery fertility)
! AIDS-related disease

52
 Vasectomy: US Demographic Data

Site:
$ 75% performed in physician's examining
room
$ 21% in clinics
$ 3% in ambulatory surgical centers
Provider:
$ 72% performed by urologists
$ 28% by general practitioners

53
 Vasectomy: Postoperative Problems

! Wound infection
! Hematoma
! Granuloma
! Excessive swelling
! Pain at incision site

54
 Vasectomy: Client Instructions

! Keep bandage on for 3 days.

! Do not pull or scratch wound while healing.
! You may bathe after 24 hours but do not let the
wound get wet. After 3 days you may wash the
wound with soap and water.
! Wear a scrotal support, keep the operative site dry
and rest for 2 days.

55
 Vasectomy: Client Instructions continued

! For pain take 1 or 2 analgesic tablets every 4 to 6 hours

and apply ice packs.
! Avoid heavy lifting and hard work for 3 days.
! Avoid sexual intercourse for 2 or 3 days or until
comfortable.
$ Use condoms or another family planning method for 3
months or 20 ejaculations.
! Return after 1 week if nonabsorbable stitches used.
! Return for a semen test 3 months after the operation.

56
 Vasectomy: General Information

! Vasectomy does not provide protection from

pregnancy until after 3 months, 20 ejaculations or
when no sperm are seen in a microscopically
examined semen specimen.
! Vasectomy will not affect sexual performance
because the testes still function normally.
! Vasectomy does not provide protection against
STDs, including AIDS. If either partner is at risk, the
couple should use condoms even after vasectomy.

57
 Warning Signs for Vasectomy Clients

Return to clinical if following problems occur:

! Fever (greater than 38BC or 100.4BF)
! Bleeding or fluid coming from the incision
! A very painful or swollen scrotum

58
 Vasectomy: Program Requirements

! Adequate training in counseling and client

assessment (history and physical exam)
! Competent providers trained to operate on awake or
lightly sedated clients
! Steady supply of sterile or high-level disinfected
instruments, gloves and equipment
! Use of internationally recommended infection
prevention practices
! Availability of emergency equipment/drugs
! Referral centers for major problems
59
Vasectomy: Common Medical Barriers

! Age restrictions (young and old)

! Parity restrictions (less than two living children, no
male child)
! Marital status/spousal consent requirements
! Provider bias
! Process hurdles
! Who can provide:
$ Specialists only
$ Physicians only
60