Voluntary Surgical Contraception for Women Tubal Occlusion

1. Voluntary Surgical Contraception for WomenTubal Occlusion

2. Tubal Occlusion: Most Popular Contraceptive Method Globally Female: 170 million Source: Church and Geller 1990.

3. Types of Tubal Occlusion • Postpartum • Minilaparotomy (Infraumbilical) • Interval • Minilaparotomy • Laparoscopy

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: Most Popular Contraceptive Method Globally Female: 170 million Source: Church and Geller 1990.

6. 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.

7. 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.

8. Tubal Occlusion: Noncontraceptive Benefits • Does not interfere with breastfeeding • Decreased risk of ovarian cancer

9. 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.

10. 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)

11. Tubal Occlusion: Long-Term Effectiveness by Age Group 1Pregnancies per 100 women over 10 years Source: CREST Study 1996.

12. Tubal Occlusion: Long-Term Effectiveness by Method 1 Pregnancies per 100 procedures Source: CREST Study 1996.

13. How Effective Is Tubal Occlusion? Source: Church and Geller 1990.

14. 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.

15. 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.

16. 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

17. 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

18. 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.

19. 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

20. 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

21. 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

22. 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)

23. 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

24. Tubal Occlusion: Anesthesia • Local anesthesia of choice • General–only in select cases • obese • associated (documented) pelvic pathology • allergy to local anesthesia • medical problems

25. 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.

26. 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).

27. 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

28. 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.

29. Tubal Occlusion:Common Medical Barriers • Age restrictions (young and old) • Provider bias • Who can provide: • Specialists only • Physicians only