Voluntary Surgical Contraception for Women Tubal Occlusion

dr. Duddy S. Nataprawira, SpOG (K)

Tubal Occlusion: Most Popular Contraceptive Method Globally

Female: 170 million

Source: Church and Geller 1990.

Types of Tubal Occlusion

! Postpartum
$ Minilaparotomy (Infraumbilical)

! Interval
$ Minilaparotomy $ Laparoscopy

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.

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.

Tubal Occlusion: Noncontraceptive Benefits

! Does not interfere with breastfeeding ! Decreased risk of ovarian cancer

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.

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 1833 > 34 All ages

Cumulative Failure Rate1 2.6 0.7 1.8

Pregnancies per 100 women over 10 years Source: CREST Study 1996.

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Tubal Occlusion: Long-Term Effectiveness by Method

Method Unipolar coagulation Postpartum partial salpingectomy Silicone band application Interval partial salpingectomy Bipolar coagulation Spring clip application
1

Failure Rate1 1 Year 10 Years 0.02 0.81 0.01 0.75 0.62 0.75 0.35 1.82 1.72 2.01 2.48 3.65
12

Pregnancies per 100 procedures Source: CREST Study 1996.

How Effective Is Tubal Occlusion?

Method Laparoscopy Ring Coagulation Clip Minilaparotomy Pomeroy Pregnancies per 100 Women-Years 0.00.6 (N=15 studies) 0.11.3 (N=14 studies) 0.00.7 (N=4 studies) 0.20.8 (N=4 studies)

Source: Church and Geller 1990.

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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.

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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 410 is three times as high as in years 13
1CREST

1996.

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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
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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

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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)
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When to Perform Tubal Occlusion Procedure

!
! !

Anytime during the menstrual cycle you can be reasonably sure the client is not pregnant
Days 613 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

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Tubal Occlusion: Anesthesia

! Local anesthesia of choice
! Generalonly 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 714 days. ! Return after 1 week if nonabsorbable stitches used.
25

Tubal Occlusion: General Information

! Shoulder pain during 1224 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).
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Warning Signs for Tubal Occlusion Clients

Return to clinic if following problems occur :
! Fever (greater than 38C or 100.4F) ! Dizziness with fainting ! Persistent or increased abdominal pain ! Bleeding or fluid coming from the incision

! Signs or symptoms of pregnancy

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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

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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.

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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

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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

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Incisional Vasectomy: Complications After Procedure in US

Complication Hematoma Infection

Rate1 1.95 3.48

Per 100 vasectomies; 65,155 cases Source: Kendrick et al 1987.

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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

Rate1 0.09 0.91

Complication Hematoma Infection

Per 100 vasectomies; 179,741 cases Source: Li et al 1991.

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Comparison of No-Scalpel Vasectomy and Incisional Approach

Thailand

Complications Method Noscalpel Incisional Cases 680 523 Number 32 163 Rate1 0.4 3.1

1 2

Per 100 vasectomies 2 hematoma (surgical drainage not required); 1 infection 3 9 hematoma (2 required surgical drainage); 7 infection Source: Nirapathpongporn et al 1990.

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Advantages of NSV over Incisional Vasectomy

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

Instruments Skin closure Damage to tissue Complications Time for procedure

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)
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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)
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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.

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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

! !

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Vasectomy: Who May Require Additional Counseling

Men: $ Who are uncertain of their desire for future fertility

$ Who do not give voluntary, informed consent

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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.

Procedure may need to be done in a high-level facility. Source: WHO 1996.

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Vasectomy: Conditions Requiring an Experienced Clinician and Full Backup

!
! !

Large varicocele
Inguinal hernia Filariasis

!
! !

Intrascrotal mass (until cause determined)

Undescended testes and proven fertility Cryptorchdism (if bilateral and proven fertility)

!
!

Scar tissue
Previous scrotal surgery

AIDS-related disease

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Vasectomy: US Demographic Data

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

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Vasectomy: Postoperative Problems

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

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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.

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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.
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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.
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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
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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
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