Transcript Voluntary Surgical Contraception for Women

Voluntary Surgical Contraception for
Women
Tubal Occlusion
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Tubal Occlusion: Most Popular
Contraceptive Method Globally
Female: 170 million
Source: Church and Geller 1990.
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Types of Tubal Occlusion
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Postpartum
$ Minilaparotomy (Infraumbilical)
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Interval
$ Minilaparotomy
$ Laparoscopy
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Tubal Occlusion: Client Issues
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The client should make the decision for sterilization voluntarily.
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The client has the right to change her mind anytime prior to the
procedure.
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The client should understand that voluntary sterilization (VS) is a
permanent (not easily reversible) method.
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No incentives should be given to clients to accept VS.
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A standard consent form must be signed by the client before the
VS procedure.
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Spousal consent is not required.
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Tubal Occlusion: Most Popular
Contraceptive Method Globally
Female: 170 million
Source: Church and Geller 1990.
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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.
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Tubal Occlusion: Contraceptive Benefits
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Highly effective (0.51 pregnancies per 100 women during first
year of use)
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Effective immediately
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Permanent
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Does not interfere with intercourse
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Good for client if pregnancy would pose a serious health risk
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Simple surgery, usually done under local anesthesia
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No long-term side effects
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No change in sexual function (no effect on hormone
production by ovaries)
Trussell et al 1998.
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Tubal Occlusion:
Noncontraceptive
Benefits
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Does not interfere with breastfeeding
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Decreased risk of ovarian cancer
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Tubal Occlusion: Decreased
Risk of Ovarian Cancer
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39% decrease in risk compared to clients without tubal
occlusion
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Decrease in risk does not depend upon method of sterilization
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Risk remains low 25 years after surgery
Source: Green et al 1997.
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Tubal Occlusion: Limitations
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Must be considered permanent (success of reversal cannot be
guaranteed)
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Client may regret later (age < 35)
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Small risk of complications
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Short-term discomfort and pain following procedure
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Requires trained physician (gynecologist or surgeon for
laparoscopy)
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Slightly decreased long-term effectiveness
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Increased risk of ectopic pregnancy
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Does not protect against STDs (e.g., HBV, HIV/AIDS)
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Tubal Occlusion: Long-Term
Effectiveness by Age Group
Age Group
Cumulative Failure Rate1
18–33
2.6
> 34
0.7
All ages
1.8
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Pregnancies per 100 women over 10 years
Source: CREST Study 1996.
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Tubal Occlusion: Long-Term
Effectiveness by Method
Failure Rate1
Method
Unipolar coagulation
1 Year
0.02
10 Years
0.81
Postpartum partial salpingectomy
0.01
0.75
Silicone band application
0.62
1.72
Interval partial salpingectomy
0.75
2.01
Bipolar coagulation
0.35
2.48
Spring clip application
1.82
3.65
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Pregnancies per 100 procedures
Source: CREST Study 1996.
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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
Source: Church and Geller 1990.
0.2–0.8 (N=4 studies)
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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 4–10 is three times as
high as in years 1–3
1CREST
1996.
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Who Can Use Tubal Occlusion
Women:
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Who are age > 22 and < 45
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Who want highly effective, permanent protection against
pregnancy
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For whom pregnancy would pose a serious health risk
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Who are postpartum
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Who are postabortion
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Who are breastfeeding (within 48 hours or after 6 weeks)
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Who are certain they have achieved their desired family size
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Who understand and voluntarily consent to procedure
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Tubal Occlusion: Who May Require
Additional Counseling
Women:
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Who cannot withstand surgery
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Who are uncertain of their desire for future fertility
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Who do not give voluntary, informed consent
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Tubal Occlusion: Conditions
Requiring Precautions (WHO Class 3)
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Unexplained vaginal bleeding (until evaluated)
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Acute pelvic infection
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Acute systemic infection (e.g., cold, flu, gastroenteritis, viral
hepatitis)
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Anemia (Hb < 7 g/dl)
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Abdominal skin infection
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Cancer of the genital tract
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Deep venous thrombosis
Appropriate precautions include delay of procedure until condition
improves or resolves.
Source: WHO 1996.
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Tubal Occlusion: Conditions Requiring
an Experienced Clinician with Full
Backup
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Diabetes
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Symptomatic heart disease
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High blood pressure (> 160/100 or with vascular disease)
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Coagulation (clotting) disorders
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Overweight (> 80 kg/176 lb if H/W ratio not normal)
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Abdominal or umbilical hernia
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Multiple lower abdominal incisions/scars
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Complications of
Laparoscopic Sterilization
Short-term
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Occur in less than 1% of all procedures
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Directly related to surgical expertise
Long-term
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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
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Tubal Occlusion: Immediate
Postoperative Complications
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Pain at infection site
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Superficial bleeding (skin edges or subcutaneously)
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Postoperative fever
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Wound infection
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Gas embolism with laparoscopy (very rare)
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Hematoma (subcutaneous)
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When to Perform
Tubal Occlusion Procedure
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Anytime during the menstrual cycle you can be reasonably
sure the client is not pregnant
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Days 6–13 of menstrual cycle (proliferative phase preferred)
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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).
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Postabortion: immediately or within 7 days, provided no
evidence of pelvic infection
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Tubal Occlusion: Anesthesia
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Local anesthesia of choice
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General–only in select cases
$ obese
$ associated (documented) pelvic pathology
$ allergy to local anesthesia
$ medical problems
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Tubal Occlusion: Client Instructions
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Keep operative site dry for 2 days. Resume normal activities
gradually.
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Avoid sexual intercourse for 1 week or until comfortable.
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Avoid heavy lifting and hard work for 1 week.
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For pain take 1 or 2 analgesic tablets every 4 to 6 hours.
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Schedule a routine followup visit between 7–14 days.
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Return after 1 week if nonabsorbable stitches used.
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Tubal Occlusion: General Information
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Shoulder pain during 12–24 hours after laparoscopy is
common due to gas (CO2 or air) under diaphragm.
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Tubal occlusion is effective from time operation is complete.
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Menstrual periods will resume as usual.
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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:
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Fever (greater than 38°C or 100.4°F)
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Dizziness with fainting
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Persistent or increased abdominal pain
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Bleeding or fluid coming from the incision
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Signs or symptoms of pregnancy
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Tubal Occlusion:
Mobile Programs (Camps)
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Counseling and followup should be the same as at fixed sites.
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All recommended infection prevention practices should be
followed.
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Followup for short-term and long-term complications must be
available.
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Tubal Occlusion:
Common Medical Barriers
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Age restrictions (young and old)
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Provider bias
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Who can provide:
$ Specialists only
$ Physicians only
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