1 Voluntary Surgical Contraception for Women Tubal 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 (0.5 1 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 1 Pregnancies 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 Results 1 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) 1 CREST 1996.

15 CREST Study: Summary of Results 1 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 1 CREST 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 (CO 2 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