1. Vasectomy (Male Sterilization) Session III: Who Can Have a Vasectomy?
This session covers the following topics:
Who can have vasectomy
The WHO’s medical eligibility criteria
Vasectomy for men with HIV and AIDS
Client assessment/evaluation

2. Session III Objectives
By the end of the session, the participant will be able to:
State who can have a vasectomy
Define the medical eligibility criteria (MEC)
List the MEC classification used for permanent methods such as vasectomy
Demonstrate an ability to screen a client for eligibility for vasectomy
Explain: The objectives of this session are as follows:
By the end of this session participants should be able to:
State who can have vasectomy
Define the medical eligibility criteria (MEC)
List the MEC classification used for permanent methods such as vasectomy
Demonstrate an ability to screen a client for eligibility for vasectomy

3. Who Can Have Vasectomy? Most men can have a vasectomy.
But they may need to wait if:
They have problems with their genitals, such as infections, swellings or lumps, or injuries in the penis or scrotum.
They have other serious health conditions or infections (e.g., diarrhea).
Vasectomy is a safe procedure; with proper counseling and informed consent, any man can have a vasectomy safely.
This includes men who have no children or few children, those who are not married, young men, men who do not have permission from their wife or spousal consent, those at risk of STIs, or those who are infected with HIV, regardless of whether they are receiving antiretroviral drugs.
No medical condition would be an absolute contraindication for vasectomy.
In some situations, men opting to have a vasectomy may need to wait if they have problems in the genital area—for example, ulcers in the genital region, infections, injuries, or swellings or lumps in the penis or scrotum. Men with other systemic health conditions, such as diarrhea, may also need to wait until the condition has resolved following treatment.
In all instances, careful counseling is important to ensure that the man will not regret his decision to have the vasectomy

4. Medical Eligibility Criteria
What are the MEC?
State the categories used for permanent methods of contraception.
Display Slide
Ask
What is Medical Eligibility Criteria?
Allow some responses from participants
Explain
The MEC are one of the WHO evidence-based guidelines on contraceptive use. The MEC inform the FP provider if a client with a certain medical or physical condition can use a contraceptive method effectively and safely. The 5th edition of the WHO Medical Eligibility Criteria was recently launched for use.
At the national level, FP programs develop national guidelines on contraceptive use for service providers. This national guidelines development process is informed by evidence-based publications and resources, such as the latest version of the WHO MEC for contraceptive use.
Ask the participants to: state the MEC categories used for permanent methods of contraception.
Allow some responses then
Explain:
According to the WHO medical eligibility criteria, male and female sterilization are categorized into four distinct categories:
A = Accept
C = Caution
D = Delay
S = Special

5. MEC Categories for Male Sterilization (Vasectomy)
Category
Description
When Clinical Judgement is Available
A=Accept
There is no medical reason to deny the client a vasectomy.
Use the method.
C=Caution
The procedure can normally be conducted in routine settings, but with extra preparations and precautions.
May have some risks, but advantages outweigh any risks.
D=Delay
Delay the procedure until the condition is evaluated or corrected.
The theoretical or proven risks may outweigh benefits of the procedure if the condition is not corrected.
S=Special
The procedure should be undertaken in settings with an experienced surgeon, staff, and equipment for anesthesia and other back-up support.
Theoretical or proven risks may outweigh the benefits of the procedure if it is not performed in settings that have the capacity to manage complicated cases.
Display Slide
Explain:
There is really no absolute contraindication for vasectomy. There are however some conditions or circumstances when certain precautions need to be addressed or when the provider needs to delay a procedure to allow time for further evaluation of the condition or treatment of the client.
In a few instances, the client’s health condition may necessitate that the procedure be performed by a highly skilled surgeon and in other clinical settings with additional equipment and supplies (to support provision of general anesthesia or other kinds of support that the client may need because of his condition).
The four categories listed earlier are meant to assist the provider in determining when and where the client can have the vasectomy procedure performed safely, depending on the outcomes of an evaluation of his health condition.
The rationale for assigning different conditions to specific categories is based on evidence where theoretical and proven risks are compared to advantages and benefits to the client if sterilization is performed as the contraceptive method of choice. The procedure should, however, be performed in the right setting, to ensure infection prevention and the availability of all necessary equipment and supplies, as recommended by national and institutional service provision guidelines.
For Category A (Accept), the advantages and benefits of vasectomy outweigh the theoretical and proven risks associated with the vasectomy procedure on the client with the particular condition. There is therefore no reason to restrict the client’s eligibility for vasectomy. The method can thus be provided to all clients who have been counseled and who have opted for vasectomy.
In Category C (Caution), the conditions classified here have elevated theoretical or proven risks although the advantages and benefits of the vasectomy still outweigh such risks. Certain precautionary measures or extra preparations and precautions are recommended to minimize any such risk. Client with such conditions can have the procedure performed in routine settings, but with extra precautions and preparations.
In Category D (Delay), the conditions may elevate theoretical or proven risks to the client if the vasectomy procedure is performed. It is therefore recommended that the procedure be delayed to allow for time for the condition to be further evaluated and corrected. At this point, the client can then have the procedure since the advantages and benefits of vasectomy far outweigh the risks after the condition is resolved.
As for Category S (Special), the few conditions that fall in this category pose an increased theoretical or proven risk if the vasectomy procedure is performed in routine settings. The risks of complications are minimized if the procedure is performed by an experienced surgeon and staff in clinical settings with the required equipment for anesthesia and other back-up support.
It is important to note that under most circumstances, the female sterilization procedure carries higher risks than vasectomy, which is a simpler procedure.

6. Eligibility Criteria for Vasectomy
WHO Category
Conditions (Selected Examples)
A=Accept
Sickle cell disease, mild hypertension, clients at risk of HIV or STIs
C=Caution
Young men, varicocele, hydrocele, previous surgery, depressive mental disorders, diabetes
D=Delay
Systemic infections such as diarrhea, local infection of the penis or scrotum (balanitis), scrotal skin infection or ulcers, STIs, elephantiasis, intrascrotal mass
S=Special
Undescended testis or cryptorchidism, inguinal hernia, coagulation disorders
Display slide
Explain:
Category A includes conditions such as sickle cell disease, other chronic ailments (such as mild hypertension), and clients at risk of HIV or other STIs.
Category C includes young men who are unmarried or who have no or few living children, clients with mental disorders (including those with depressive disorders); all of these clients require careful counseling so they understand the permanence of vasectomy. Other conditions in this category include clients with a varicocele or hydrocele (unilateral or bilateral) and clients with diabetes.
Ask if all participants understand what a varicocele or a hydrocele is
Allow a few responses from participants
Possible responses are:
A varicocele is an abnormal engorgement of the veins/ blood vessels from the spermatic cord and structures within the scrotum.
A hydrocele is an abnormal accumulation of fluid in a sac within the scrotum.
Category D conditions include any systemic infections, including diarrhea, local infections of the penis and scrotum such as balanitis (an inflammation commonly caused by infections of parts of the penis), scrotal skin infections or ulcers, and STIs, all of which are likely to increase the risks of wound infection and therefore compromise postoperative recovery. Other conditions or chronic infections that may need delays include elephantiasis and intra scrotal mass(es) that may require further evaluation.
Category S includes conditions such as coagulation disorders, which may necessitate special preparation of the client before surgery to ensure that the procedure does not put him at risk. Inguinal hernia is another condition that may also be managed by skilled surgeons when they perform a vasectomy, since the vas is also accessible through the inguinal incision. However, unless the hernia is bilateral, the other vas will still need to be accessed and ligated. In cryptorchidism or undescended testis, again the skills of an experienced surgeon may be required to access the vas and where appropriate manage the undescended testis.
Source: WHO MEC 5th Edition

7. Understanding the MEC Checklist for Vasectomy
How to determine a client’s eligibility for vasectomy
Inquiring about medical condition
MEC checklist for vasectomy
Display slide
Explain:
The WHO MEC for vasectomy checklist is a simple and easy-to-apply tool that was developed by WHO to aid the provider in determining a client’s eligibility for vasectomy. This is done by asking the client if he has any of the conditions listed in the MEC. The two-page tool contains a set of questions relating to different medical conditions that are relevant to the procedure. As a health care provider, one should use the aid to ask each client these questions. If the answer to all questions is “no,” then the client can be classified as Category A, and he can have the procedure at any time in routine settings.
The first part of the tool is the introductory section, with instructions on how to use the tool and an explanation of the all of the MEC categories for male sterilization. The second part of the tool contains the actual questions.
If a client responds “yes” to any of the questions, follow the instructions on the tool. These recommend caution, delay, or special arrangements and possible action(s). Elaborate this by giving examples using the tools.
Remind the participants that the client evaluation, which includes a physical examination, is an important complement to the use of the checklist.
Source WHO Family Planning: A Global Handbook for providers 2011

8. Vasectomy Use by Men with HIV
Men with asymptomatic or mild HIV clinical disease or severe, advanced HIV disease on antiretroviral drugs can SAFELY have vasectomy. (Special arrangements are needed for advanced clinical disease.)
Patients need to be aware that vasectomy does not protect against HIV infections or STIs.
Promote consistent condom use to prevent transmission of infections.
No one should be coerced or pressured to accept vasectomy, whether or not they are seropositive.
Display slide
Explain:
According the WHO’s Medical Eligibility Criteria for Contraceptive Use, clients who are asymptomatic or who have a mild form of HIV clinical disease, according to WHO’s classification of HIV/AIDS disease (whether they are receiving antiretroviral drugs or not) can have the vasectomy procedure in routine settings. WHO’s classification of mild forms of AIDS (also known as clinical stage 2) includes patients confirmed with HIV infection who have symptoms such as weight loss of more than 10%, recurrent infections of the respiratory system, recurrent oral lesions, fungal infections of the nails, herpes zoster infections, and skin lesions. Patients should however be counseled that vasectomy does not protect them against HIV or other STIs and that they should continue consistent use of the male or female condom to prevent infections.
Patients with advanced or severe forms of HIV clinical disease who are receiving antiretroviral drugs can also safely have a vasectomy, but special arrangements should be in place for this category of clients.
It should be emphasized that clients with HIV clinical disease, as with all other seronegative male clients, should not be coerced or pressured to accept vasectomy.

9. Client Assessment/Evaluation
Client history
Family and reproductive history
Past medical history (previous surgeries, existing medical conditions, etc.)
History of allergies
History of Injuries to genitalia
Physical examination
General examination
Abdominal examination
Examination of the genitalia (penis and scrotum)
Routine laboratory investigations not necessary unless for evaluation of coexisting condition(s)
Display slide
Explain:
A client opting for vasectomy should be further assessed for any health condition to determine his clinical eligibility for the procedure; the outcomes of the assessment also helps the provider to determine and discuss with the client when and where the vasectomy will be performed and the type of provider to do so.
This assessment is conducted through a client-provider interaction in which the health care provider takes a medical history and a family and reproductive history and asks about past medical conditions (including surgery, particularly to the genitalia, for any condition). Other relevant information gathered in this assessment includes current ailments or acute conditions, such as any systemic infections (e.g., diarrhea), chronic conditions such as diabetes, hypertension, allergies to specific types of medication, coagulation disorders, current or past treatment for mental or depressive illness, and any other conditions.
The provider should also inquire about the client’s family history, including his marital status, number of children, future fertility intentions, relations with his spouse, and sexual history, including experience of symptoms indicative of STIs. Extremely anxious clients may need additional preparations for vasectomy. Those who are young and have no living children may require careful counselling to ensure that they understand that vasectomy is permanent, thus avoiding subsequent dissatisfaction and regret.
A physical examination also forms part of the client assessment or evaluation. It should be guided by the outcomes of the medical history; however, at minimum, it should include a quick general examination of the client, followed by a mandatory examination of the lower abdomen and the genitalia. The provider should assess the penis and scrotum to determine the ease of palpation of the vas and other structures, such as the testis in the two sides of the scrotal sac; the provider should also inspect for evidence of previous scrotal surgery, injuries to the genitalia, presence of ulcerative conditions or tumor growths, balanitis, scrotal swelling or tumors, presence of varicocele or hydrocele. Signs suggestive of an inguinal hernia and undescended testis should also be looked for.
Any evidence of active infections, such as diarrhea, balanitis, urethritis, and scrotal skin infections, will require the surgery to be delayed, to avoid wound sepsis and related complications. Difficulties in palpating the vas may necessitate extra preparations for adequate anesthesia and the services of a skilled surgeon; similarly, clients with inguinal hernia and cryptorchidism or undescended testis may require special attentions.
Routine laboratory examination prior to the procedure is not necessary unless the client has a medical condition that requires investigation, such as diabetes, liver or renal disease, or a coagulation disorder.
It is also not necessary to request the client to have a semen analysis prior to surgery. Vasectomy can also be done even if there is no provision for postprocedure semen analysis (e.g. during outreach, etc.).
The provider-client interaction should also include a discussion of the findings from the assessment and their implications on how to proceed with the selected contraceptive option.

10. Case Studies
Inform
Inform the participants that they will now spend some time discussing case studies in groups. Quickly divide them into groups of two or three participants per group and pass out Handout #5 with instructions on the group exercise.