1. Vasectomy (Male Sterilization) Session IV: Providing Vasectomy
This set of slides covers the following topics:
Timings of vasectomy procedure
Key counseling topics for vasectomy
Correcting rumors and misunderstandings
Points of informed consent
Verifying informed decision making before surgery
Counseling about possible side effects and complications
Explaining the vasectomy procedure
Supporting the vasectomy user
Postoperative care
Medical reasons to return to the clinic after vasectomy
Managing side effects and complications

2. Session IV Objectives
By the end of this session, participants will be able to:
State when the client can have the vasectomy procedure
Counsel a client for the vasectomy procedure
Effectively counter or correct misunderstandings or misconceptions and rumors about vasectomy in the local settings
List the side effects and the intraoperative, immediate postoperative, and long-term complications associated with vasectomy
Counsel the client about side effects of vasectomy
Describe management of complications and side effects
Display slide
Explain:
The overall purpose of this session is to demonstrate how to provide vasectomy.
The objectives of this session are:
By the end of this session, participants will be able to:
State when the client can have the vasectomy procedure
Counsel a client for vasectomy procedure
Effectively counter or correct misunderstandings or misconceptions and rumors about vasectomy in the local settings
List the side effects and the intraoperative, immediate postoperative, and long-term complications associated with vasectomy
Counsel the client about side effects of vasectomy
Describe the management of complications and side effects

3. Timing of the Vasectomy Procedure
When can a client have a vasectomy?
The procedure can be performed at any time if:
The client has made the request and is prepared.
No medical conditions warrant delay of the vasectomy.
The client has made an informed and voluntary decision (provided written informed consent).
The provider is prepared and ready, with the right equipment and supplies to perform the procedure.
If any of the above conditions are not met, there can be a delay.
The client may need to be referred if he has a condition that needs special attention.
Display Slide
Ask:
When can the client have vasectomy?
<Allow a few responses then advance the slide presentation to reveal the answers>.
Explain
The vasectomy procedure can be performed at any time if :
The client has made the request and is prepared for the procedure
There is no medical condition(s) that would require referral, delay or special precautions,
There is evidence that the client has made an informed and voluntary decision including a written informed consent
The skilled provider is ready to provide quality vasectomy services.
Clients may need to wait if:
They have problems with the genitals such as infections, swellings, injuries, lumps or ulcers in the penis or scrotum.
The have systemic infections such as diarrhea
Clients with serious conditions such as coagulative disorders, inguinal hernia, unilateral undescended testis, large varicocele or hydrocele, should be referred for further evaluation and management by experienced surgeons in facilities with equipment and supplies for general anesthesia and other support

4. Key Counseling Topics for Vasectomy (1)
What the client knows about vasectomy
What vasectomy is and how it works
Permanence—the decision should be carefully considered
Safety and efficacy
Benefits
Information about other available methods
Display Slide
Ask:
What are counseling topics that a provider should discuss with a potential vasectomy user?
<Have your co-trainer to list them on the flipchart as they are mentioned by participants>
<Allow adequate time for listing of topics>
When there are no more responses from participants, Inform them that you will now display what you have prepared.
<Advance the slide to reveal the answers – note that additional responses are on slide 5>
Explain
The following are some of the key counseling topics that the provider needs to cover during a counselling session.
What the client already knows about this method. This information will assist the provider to tailor the discussions appropriately and, where needed, provide correct and complete information about vasectomy, if the client’s knowledge is incomplete and/or incorrect.
What vasectomy is and how it works. The provider needs to inform the client what vasectomy is (i.e., that it is a permanent method of contraception for men. Vasectomy is a safe, simple, and short surgical procedure that involves cutting and blocking the tubes that carry the sperm to the penis.)
The permanence of the method. The client needs to fully understand the implications of having a vasectomy for his ability to father children in the future. The decision to have a vasectomy should therefore be made after careful consideration.
Safety and efficacy of the method. The provider should also explain to the client that the procedure is safe and simple and that the client remains awake during the procedure. The method is also one of the most effective methods of contraception; however, the client must understand that the contraceptive action only takes effect after a period of about three months. The client must therefore use other temporary methods, such as condoms, to avoid making his spouse pregnant.
Health and other benefits. The provider should also explain to the client the health and nonhealth benefits of vasectomy.
Availability of other FP methods. The provider must explain that the facility offers a full range of contraceptive methods and should describe all of the different methods that are available for the client and his spouse.
Ask if there are any questions or comments and respond as needed.

5. Key Counseling Topics for Vasectomy (2)
The vasectomy procedure
Possible side effects and complications
No protection against STIs and HIV
Pre-procedure and post-procedure instructions
Giving informed consent for the procedure
Display slide
Explain:
The key counseling topics on vasectomy are
Vasectomy procedure: The provider should discuss the vasectomy procedure with any client who is interested in this method. The discussion should include what the procedure entails, the pain management regimen that will be used, where, how, and by whom the procedure will be performed, what attire the provider and the client will be instructed to wear prior to the procedure, who else may be in the procedure area/room and their roles, what the client may feel during the entire procedure and how he should respond to any pain or discomfort, the time it will take for the provider to complete the procedure, what the client will feel after the procedure, and what will happen in the immediate postoperative period before he is discharged.
Side effects and complications: The provider should also discuss the possible side effects and complications. The client should be informed that while vasectomy has no side effects and that complications are uncommon-to-rare when the procedure is performed by a skilled provider, in a few instances some complications may occur. Such complications or problems include bleeding during surgery or immediately after the procedure, formation of a hematoma, and pain. Other complications include infections, formation of granulomas, and, in rare instances, failure of the procedure. If the client makes a hasty decision, the client may later regret the vasectomy. 
Protection against STI and HIV: The provider should be sure to confirm the client’s understanding that the vasectomy procedure does not protect him from any STIs, including HIV, and that for protection, he will need to use a barrier method such as the male or female condom. The provider will need to help the client assess his risk of contracting any of these infections and advise him accordingly.
Pre- and postprocedure instructions: The provider should discuss with the client when and where he will have the procedure, as well as what he needs to do on the day before and on the day of the procedure. Additionally, the provider should discuss with the client when he should expect to be discharged after the procedure and should give instructions on what the client should do during the immediate postoperative period.
Informed consent As a surgical procedure, vasectomy can only be performed if the client voluntarily provides written informed consent for the procedure. The informed consent is provided by the client during counseling. The provider should ensure that all of the client’s concerns and questions about vasectomy have been fully addressed and that the client is satisfied with the information about the method of his choice before he gives written informed consent.
Ask if there are any questions or comments and respond as needed.

6. Correcting Rumors and Misunderstandings about Vasectomy (1)
What are rumors and misunderstandings or misconceptions?
Exercise
In rare instances, vasectomy may cause testicular cancer. (True/False)
The volume of ejaculate from vasectomized men is always significantly lower than that of non-vasectomized men. (True/False)
Vasectomy causes vascular problems for men, especially those who have chronic hypertension. (True/False)
Vasectomy is not castration. (True/False)
Vasectomy does not interfere with manhood or sexuality in any way. (True/False)
It is easier to perform female sterilization on a female client than to perform a vasectomy on a man. (True/False)
Vasectomy makes men obese and weak. (True/False)
Display slide
Ask:
What are rumors and misconceptions or misunderstandings?
Allow a few responses from the participants.
Explain:
Rumors are unconfirmed stories that are normally transferred from one person to another by word of mouth or any other means of communication, such as by mobile phone or in some instances through social media.
Exercise
Inform the participants that they will now do an exercise by working individually to answer a few questions on rumors. Instruct them to remove a sheet of paper from their notebooks on which to record their responses; at the end of the exercise, they will hand the sheet to their immediate neighbor to be scored. The questions will actually be statements, and it will be up to the participants to decide whether the statement is true or not. The responses should be true/false. Inform the participants that the person who answers all questions correctly will receive a small gift as recognition of their performance.
Make sure that all of the participants are ready before you advance the slide to display the questions.
Reveal the questions one by one and give the participants three minutes to respond.
The statements are:
In rare instances, vasectomy may cause testicular cancer.
The volume of ejaculate from vasectomized men is always significantly lower than that of nonvasectomized men.
Vasectomy causes vascular problems for men, especially those who have chronic hypertension.
Vasectomy is not castration.
Vasectomy does not interfere with manhood or sexuality in any way.
It is easier to perform female sterilization on a female client than to perform a vasectomy on a man.
Vasectomy makes men obese and weak.
At the end of three minutes, ask the participants to share their sheets of paper with a neighbor to be scored. Advance to Slide 7 to reveal the correct responses.

7. Correcting Rumors and Misunderstandings about Vasectomy (2)
Answer Key
In rare instances, vasectomy may cause testicular cancer. (False)
The volume of ejaculate from vasectomized men is always significantly lower than that of nonvasectomized men. (False)
Vasectomy causes vascular problems for men, especially those who have chronic hypertension. (False)
Vasectomy is not castration. (True)
Vasectomy does not interfere with manhood or sexuality in any way. (True)
It is easier to perform female sterilization on a female client than to perform a vasectomy on a man. (False)
Vasectomy makes men obese and weak. (False)
Allow time for scoring then ask which participant(s) answered all questions correctly and give the prize(s) to the winners.
Advance the slides

8. Correcting Rumors and Misunderstandings about Vasectomy (3)
What are some rumors and misunderstandings about vasectomy?
It is castration.
It makes the man weak.
It makes the man obese.
The man cannot ejaculate during intercourse.
It interferes with manhood and sexuality.
It may cause testicular cancer.
Take steps to correct rumors and misunderstandings about vasectomy.
Display slide
Explain
In general, rumors arise when:
An issue or information is of importance to people, but it has not been clearly explained.
There is nobody available who can clarify or correct the incorrect information by providing facts.
The original source of the rumors is perceived to be credible.
Clients have not been given enough information about contraceptive options.
People are motivated to spread them for political reasons.
A misconception or misunderstanding is a mistaken interpretation of ideas or information. If a misconception is imbued with elaborate details and becomes a fanciful story, then it acquires the characteristics of a rumor.
<Allow some time for questions or comments, and respond to these as appropriate.>
State that some misconceptions and rumors include the following:
Vasectomy
Is castration.
Makes the man weak.
Makes the man obese.
Prevents the man from ejaculating during intercourse.
Interferes with manhood and sexuality.
May cause testicular cancer
Ask:
How would you as a provider respond to rumors or misunderstandings during a counseling session?
<Allow a few responses, and if they mention all of the steps in the correct order, reinforce by quickly reviewing them again.>
Explain:
These are the recommended steps for dealing with rumors and misunderstandings: 
Listen carefully and politely. Do not laugh or interrupt the client to give the correct information.
Define to the client what a rumor or misunderstanding is.
Find out where the rumor came from, and talk to the people who started it or repeated it. Check whether there is some basis for the rumor.
Explain the facts.
Use strong scientific facts about FP methods to counter misinformation.
Always tell the truth. Never try to hide information about side effects or problems that might occur with various methods.
Clarify information with the use of demonstrations and visual aids.
Give examples of people who are satisfied users of vasectomy (only if they are willing to have their names used). This kind of personal testimony is most convincing.
Reassure the client by examining him and inform him about his current physical condition .
Counsel the client about all FP methods.
Ask the participants if they have any questions or comments, and respond to these as needed.

9. Role Play on Correcting Rumors and Misconceptions
Instructions
Each group discusses the script provided and agrees on who will be the client and who will play the role of the provider.
Quickly practice the role play.
Present the role play in plenary.
Advance the slide
Explain
Participants will now do a role play on correcting misconceptions and rumors and misconceptions.
Divide the participants into three groups and give each group a script for the providers and the clients.
Ask them to decide in their groups who will play the roles of a client and a provider. They should then read through the scripts and practice the role play session so that they are ready to perform it in plenary. (Handout #6)
Allow five minutes for the discussions and the practice in groups.
Call all participants back together and ask each group to perform the role play. Allow time for a feedback session after each role play.
Ask if there are any questions, and respond to these as needed.

10. Points of Informed Consent
What is informed consent?
Points of informed consent
Temporary methods are available.
Vasectomy is a surgical procedure.
The procedure has risks and benefits.
It prevents the client from having any more children.
It is permanent; it cannot be reversed.
You can decide against the procedure at any time before surgery.
The method does not protect against HIV and STIs.
<Display slide and advance >
Ask
What is informed consent?
<Allow a few responses>
Explain
Informed consent is “a medical, legal, and rights-based construct whereby a client agrees to receive medical treatment, such as surgery for a permanent method of contraception, or to take part in a study, based on knowledge of all appropriate and available options, information about these options, and an understanding of the relevant medical facts and potential risks associated with the methods/treatment options”
The provider should ensure that the client makes a voluntary decision and is not rushed or coerced into giving the written consent.
An informed consent form should be used to secure the signature. It is only the man who can give written informed consent; spousal consent is not mandatory.
Clients who cannot read or write must initial the informed consent forms after the contents have been explained to them and all of their concerns and questions addressed. In such instances, a witness may also be required to append their signature on the form. The provider who has obtained written informed consent is also expected to sign the form.
Advance the slide and explain that:
The information that a client should know about vasectomy before giving informed consent includes the following:
Temporary, reversible methods of contraception that they as a couple can use are available.
Vasectomy is a surgical procedure.
Vasectomy is a permanent method of contraception and therefore irreversible.
If the procedure is performed and is successful, the client will not be able to have any more children.
Though simple and safe and having some benefits, the procedure carries some risks associated with the anesthesia and surgery.
The client is free to change his mind about having the procedure done at any time before the surgery.
The procedure will not protect him from STIs, including HIV infection.
Distribute copies of Handout #7 and review the content. Allow time for questions and comments, and respond to these as needed.
Inform the participants that they will have a chance to practice using the form during the practical sessions.

11. Verifying Informed and Voluntary Decision Making Just before Surgery
Ask the
client these
questions:
STOP
CAUTION GO
Should not have
surgery now
Needs more
counseling
Signs of a
sound decision
WHO made the decision for sterilization?
Someone else
Client decided (but partner objects)
Client and partner (or client, if single)
WHEN did the client decide not to have more children?
Now
Recently
Some time ago
WHY did the client choose permanent contraception?
Pressure from
someone else
Belief that permanent method can be reversed
Desire for no more children
HOW did the client decide?
While upset or
under stress
Without enough consideration or information
After consideration and full information
WHAT does the client know about vasectomy?
Does not know that it:
• Is permanent
• Is a surgical method
• Means he cannot have more children
Has some misunderstandings about contraceptive methods
Understands that it:
WHAT does the client know about other contraceptive methods?
Would prefer another
method if available
Has little knowledge of other methods or their availability
Knows of other methods, but prefers permanent contraception
<Display Slide>
Explain:
In many settings, counseling of the client may take place several days or weeks before the date of the actual procedure; moreover, the client may be counseled by a different provider who may be stationed at the community level or at a static facility away from where the actual procedure is to be performed. It is therefore the responsibility of the surgeon to verify that the client made an informed and voluntary decision, irrespective of whether he signed the written consent form. This is to ensure that the client did not sign the form under any duress or any form of coercion.
The verification is ideally done by the surgeon just before surgery.
This slide shows a simple job aid that can be used by the surgeon to check the client’s readiness for the vasectomy. It should be used just before starting any part of the surgery.
This tool has a series of questions that the surgeon asks the client; from his responses, the surgeon can decide whether to proceed with the surgery or not. It is also recommended that the surgeon carefully observe the client’s behavior during this interaction—for example, an extremely nervous client who seems to be interested in the possibilities of reversal of the procedure in the future may not be the right candidate for the procedure.
Distribute copies of Handout #8 and review it, explaining how it should be used.
Inform participants they will have a chance to practice using the tool during model and clinical practice sessions.
Ask if there are any questions, and respond to these, as needed.
Source: Engenderhealth, 2007

12. Counseling about Possible Side Effects and Intraoperative, Immediate Postoperative, and Long-Term Complications
The client should be informed that vasectomy has very few side effects.
Some of these are transient, such as:
Discomfort, bruising, and slight pain at the operative site; tends to subside with analgesics and rest
Some blood streaks in ejaculate immediately after the procedure
In rare instances, the client may have persistent dull pain for several months after the procedure.
Risks associated with the procedure include the following:
Bleeding and/or accumulation of blood clots
Infection or abscess at the operation site with or without fever, pain
Failure of the method
Display slide
Explain
During counseling, prior to giving informed consent, the client should fully understand the side effects and possible complications of vasectomy.
The provider should therefore explain to the client that vasectomy has very few side effects, if any, and that most of these are transient and subside after a short period of time.
Some of these side effects include discomfort, bruising, and slight pain over the wound, which normally subsides with analgesics and bed rest.
The client may also notice a few streaks of blood in his ejaculate immediately after the procedure.
In rare instances, the client may experience persistent dull pain in the scrotal area for several months after the procedure.
Clients should also be informed that the procedure carries some risks that are associated with the drugs used for pain management and the surgical procedure and complications that may arise, although these are rare. These risks include the following:
Bleeding may increase during and after the procedure, and blood clots may accumulate.
The wound may become infected, which can lead to formation of an abscess. Such an infection may manifest itself as a painful swelling, oozing of fluid or pus from the wound, or general malaise, with or without fever.
Lastly, in very rare instances, the method may fail. In some cases, this may result in pregnancy in the man’s spouse. In other instances, where semen analysis is routinely performed, there will be evidence of high numbers of sperm and high sperm motility several months or years after the procedure.
After the procedure, clients should be counseled as they receive the postoperative instructions about side effects or any complication that may arise and how to prevent these.
Allow time for comments and questions, and respond to these as needed.>

13. Explaining the Vasectomy Procedure
You will remain awake throughout the procedure.
You will receive a pain-relieving medication.
A small opening will be made in the scrotum.
The vas (i.e., the tubes that carry sperm) will be identified, cut, and tied.
The opening will then be closed.
You will be expected to rest for at least half an hour.
If all is well after 30 minutes, you will be discharged.
Display slide
Explain
A client who selects vasectomy as his method of choice needs to know what will happen during the NSV procedure. The provider should explain the procedure at a level of detail that will enable the client to understand what to expect. The provider should use simple language and avoid medical jargon.
Clients should know the following:
The provider will assist in positioning the client on the procedure table, before exposing the operation site.
The provider will use proper infection prevention procedures at all times. (This includes cleansing the operation site with antiseptics, covering the operation site, and wearing gloves, gowns, etc.) He will receive instructions from the provider on what to do during the procedure.
The client will receive an injection of local anesthetic in the scrotal area to prevent pain. He stays awake throughout the procedure.
The provider feels the skin of the scrotum to find the vas deferens—the two tubes in the scrotum that carry the sperm.
Using a specially designed instrument, the provider grasps one of the tubes and makes a puncture in the skin over the tube.
The first tube is then lifted through the puncture site, cut, and tied. In some instances, the cut tubes are closed with heat or electricity. The other tube is also secured and tied through the same puncture site.
The puncture site is then covered with an adhesive bandage.
After the procedure, the client will be expected to rest for at least half an hour.
If all is well, he will receive instructions at discharge.
In most instances, this explanation about the procedure should be adequate; however, the provider should allow the client to seek clarification about the procedure and provide additional information as needed.
<Allow time for comments and questions from the participants, and answer these, as appropriate.>

14. Supporting the Vasectomy User (1)
How can a provider support a vasectomy user?
The period for supporting a vasectomy user includes any time before, during, and after the procedure.
It involves self care:
What to do before the procedure (instructions)
What the client should do during the vasectomy procedure
What to do immediately after the procedure
Follow-up visits (scheduled or planned and unscheduled visits)
What to do about most common problems
Display slide
Ask:
How can a provider support the client who opts to use vasectomy?
Allow a few responses and have a co-trainer list them on the flip chart.
<Advance the slide and explain:>
Supporting the vasectomy user includes explaining self-care for vasectomy before coming for the procedure and after the procedure.
How to prepare himself for the procedure
What he should do after the procedure
When to return to the clinic/facility
To support the user, the provider should discuss the instructions verbally and give the client written or pictorial instructions. Alternatively, if the client has come with his spouse or with a caretaker, the provider should also explain the instructions to the spouse or caretaker, if the client consents.

15. Supporting the Vasectomy User (2)
Preoperative instructions
Wear clean, loose-fitting clothing.
Have a bath and ensure that the external genitalia are cleaned well.
Do not shave the operation area.
Postoperative instructions
Rest for 2 days.
Put cold compresses on the scrotum for the first 4 hours.
Wear snug underwear or pants.
Keep the puncture site clean and dry for 2–3 days.
Do not have sex for at least 2–3 days.
Use condoms or any other effective contraceptive for 3 months.
Use medicine provided for pain.
Return to the facility on the specified date.
Display slide
Explain:
These are the preprocedure and post-procedure instructions.
Before the procedure, the client should have a bath and ensure that he cleans his external genitalia before coming to the facility.
The client should wear clean, loose-fitting clothing to the health facility.
He does not need to shave the operation area.
After the procedure, the client should do the following:
Rest for two days.
If possible, put cold compresses on the scrotum for four hours, to decrease pain and bleeding.
Wear snug underwear or pants for 2–3 days to help support the scrotum (point out image on slide). This will lessen swelling, bleeding, and pain.
Keep the puncture site clean and dry for 2–3 days. The client can use a towel to wipe his body clean, but he should not soak in water.
Avoid having sex for 2–3 days.
For three months after the procedure, use condoms or another effective FP method.
Take the pain-relieving medicine provided when he is in pain.
Return to the facility on the specified date. (In settings where semen analysis is routinely performed, the client should be advised when to come for semen analysis to verify if the vasectomy was successful and if there is a need for repeat visits. In limited-resource settings, routine semen analysis to confirm the success of vasectomy is not mandatory. A nonmotile sperm count of less than100,000/ml is a confirmation that the vasectomy was successful.
Share a sample of written and pictorial preprocedure and postprocedure instructions, and review them.
Ask if there are any questions, and respond to these as needed.
Loose-fitting pants
Snug pants

16. Postoperative Care NSV is a simple procedure.
It requires short rest period for observation before discharge.
Discharge the client if he is stable and the wound is not bleeding.
Give analgesics for pain.
Give postoperative instructions.
Encourage follow-up visits—scheduled or unscheduled.
Conduct semen analysis.
Display slide
Explain:
NSV is a short, simple, and safe procedure. The postoperative period is not normally eventful.
The client should be observed for at least 30 minutes after the procedure before discharge.
Before discharge, the provider should ensure that the client has no complaint, is in stable condition, and is experiencing no bleeding from the operation site.
For pain management, the client should be given analgesics for the first few days.
The client should also receive postoperative instructions.
Ask:
What are some useful postoperative instructions?
Have one of the co-trainers prepare to list the responses on a sheet of flipchart paper. Allow some time for questions, until it is evident that no new points will be coming from the participants.
The responses should include
Care for the wound
Bed rest
When to resume light, normal duties,
When to resume sex
How to use the pain-relieving drugs
How to protect against pregnancy in the first three months after vasectomy
The follow-up schedule
What to do if:
He experiences any problems or complications or has any questions.
They suspect that the spouse has conceived.
When to come for semen analysis.
Review the list of responses and discuss each response, as needed.
Ask if there are any questions or comments, and respond to these, as needed.

17. Medical Reasons to Return to the Clinic after Vasectomy
All clients are welcome at any time after vasectomy if:
They have problems or questions.
They experience swelling in the first few hours after surgery.
They have a fever in the first 3 days.
There is pus or bleeding from the wound.
There is worsening pain, heat, and redness of the wound.
The spouse/partner has conceived.
Display slide
Explain
All client should understand that they are welcome to visit the clinic at any time after the procedure, particularly when they have:
Problems or questions/concerns about the procedure
Swelling at the operation site that seems to be getting worse
Fever
Pus, serous fluid, or bleeding from the operation site
Worsening pain, heat, and redness of the wound
Contraceptive failure.
Inform the participants that you will discuss what to do when the client presents with such complaints in detail later in the session.
Inform participants that you will be discussing what to do when the client presents with such complaints in detail later in the session.

18. Helping the Vasectomy User
Helping vasectomy users entails managing any problems or addressing any concerns after the procedure.
Complications reported include:
Bleeding or blood clots after the procedure
Wound infection
Abscess formation
Persistent pain lasting for months after the procedure
Emergence of a new medical condition
Display slide
Explain:
Vasectomy users who come to the facility or call in for assistance in the immediate postoperative period, or several months or years later, need prompt assistance from the provider.
The provider should welcome the client and take time to explore the nature of his concerns or problems.
This process may involve taking a history and examining the client to make a definitive diagnosis of the problem before deciding on the appropriate treatment.
Problems or complications and side effects that may affect the man’s satisfaction with vasectomy include:-
Bleeding or accumulation of blood clots after the procedure
Wound infection
Abscess formation
Persistent pain lasting for months after the procedure,
Method failure
Other illnesses or medical conditions that may not be related to vasectomy
In instances where the provider can confirm after history and examination of the operation site that the condition or illness is unrelated to the procedure, the client needs reassurance that he is recovering well from the procedure and that the condition or problem he is experiencing does not result from the procedure. The provider should also explain to the client what condition he thinks the client has and what form of assistance or treatment is required, including what can be done at that facility and whether he needs more specialized care, which may only be available at different facility. If needed, the client should be referred to the appropriate section within the same facility or to a different facility.

19. Intraoperative, Immediate Postoperative, and Long-Term Complications of Vasectomy (1)
Side effects
What is the most important thing that you can do for a man who complains of problems that you think are transient side effects associated with the vasectomy procedure?
Side effects
Management or actions to be taken
Discomfort, pain, and swelling after the procedure
Reassurance, wear snug pants or underwear, use cold compresses, analgesics, rest
First ejaculate after procedure may have some blood stains
Reassurance
Display slide
State that you will now discuss how to manage the problems (which includes side effects and complications) that may affect clients who have had a vasectomy
<Advance the slide and state that you will begin by looking at the side effects>
Ask:
What is the most important thing that you can do for a man who complains of problems that in your judgement are transient side effects associated with the vasectomy procedure?
Accept responses from participants, then inform them that you will now compare their responses with answers you have prepared on the slide.
<Advance the slide to reveal the table summarizing management or actions needed to address side effects and complications>.
Explain:
A client who complains of discomfort, pain, or swelling needs follow-up counseling and reassurance. The provider should provide detailed information about the side effects and also provide analgesics for symptomatic relief of pain. Clients should also be advised on the importance of rest and, where applicable, use of scrotal support. If possible, he can apply cold compresses for the first  four hours after the procedure, which may decrease pain and bleeding. Good counseling and explanation of possible side effects before the client has the vasectomy are important in reducing anxiety and enabling the client to tolerate the method’s transient side effects. It is also an important factor influencing client satisfaction.
If the client’s complaint is about the appearance of streaks of blood in his first ejaculate, he needs to be reassured that this is temporary and should subside with subsequent ejaculations.
Once again, the provider should revisit the postoperative instructions with the client, as appropriate.
Remind the client that he is welcome to call in or visit if he has any concerns or if he experiences problems.
 The first four hours after what? The procedure?

20. Intraoperative, Immediate Postoperative, and Long-Term Complications of Vasectomy (2)
Management/actions needed
During the vasectomy procedure
Bleeding
Intraoperative—use gentle surgical technique, avoid vessels on sheath of vas, inspect surgical site, to identify and ligate/cauterize bleeders. Ensure that there is no bleeding before closing wound.
Injury to other structures of the spermatic cord
Be careful when conducting procedure.
Immediately after the NSV procedure
Bleeding and blood clots formation
Reassurance that minor bleeding or small uninfected clots usually go away without treatment. Large blood clots need surgical drainage; prevention during surgery is key. Infected blood clots require hospitalization and antibiotics
Infection at operation site
Counsel, and clean the infected area, Give antibiotics, continue to follow up until infection has resolved.
Abscess formation
Counsel. Arrange to drain the abscess, clean the area with antiseptic, drain the abscess, Dress wound as appropriate. Give oral antibiotics and analgesics as needed. Return after treatment or there is pain, reddening, heat, or drainage of wound.
Display slide
Explain:
Hemorrhage
Hemorrhage is a complication that may occur either during the procedure or after it. The provider can prevent hemorrhage during the procedure by ensuring that he/she is gentle and avoids severing small vessels around the vas when striping the sheath and inspecting the wound to identify and ligate or cauterize bleeder(s), before dressing the wound.
At the end of the procedure, the provider should verify if there is any evidence of active bleeding. In most instances, the bleeding may be controlled with compression. However, if blood clots accumulate, the provider should prepare the client for evacuation of the clots and arrest of the bleeders. Clients with such problems also need counseling and reassurance.
Injury to other structures of the spermatic cord
Such injuries are very rare, and in most instances the surgeon can avoid them by following the recommended steps and avoiding rushed movements when using dissecting forceps. (Note: In most instances, this will be an injury to the vessels within the cord.)
Infection
If a client reports back to the facility a few days after the procedure complaining of pain or persistent swelling, redness, and oozing of pus or fluid from the operation site, it is highly likely that the wound is infected. In some instances, these symptoms may also be associated with fever and general malaise. The provider should explain to the client the nature of the problem and institute treatment. Such treatment includes cleaning the infected operation site and applying a dressing. The client should also receive a full course of antibiotics. A follow-up visit may be required if the infection does not resolve after the course of antibiotics. The provider can prevent postoperative sepsis by ensuring that there is no break in aseptic practice during the procedure, detecting symptoms such as fever and pain at an early stage, and managing them with antibiotics, as needed. Additionally, the provider should ensure that the client understands the postprocedure instructions related to wound care.
In very rare instances, when there is evidence of abscess formation, the client should be counseled and advised on the recommended management of the condition. Treatment of an abscess requires drainage. If this is possible at the facility, arrangements should be made for the abscess to be drained; otherwise, the client may need to be referred to facilities where this can be done and the client can be discharged on a full course of antibiotics. A follow-up visit will be required to assess progress.

21. Intraoperative, Immediate Postoperative, and Long-Term Complications of Vasectomy (3)
Management/actions needed
Long after the NSV procedure
Sperm granuloma formation
Refer for specialized care.
Chronic testicular pain or pain lasting for months
Counseling, elevation of the scrotum, soaking in warm water, analgesics; provide antibiotics if infection is suspected. If pain persists, refer for more specialized surgical intervention or for further management.
Pregnancy
Counsel, and discuss options available to manage complication. Prevention: Ensure identification and occlusion of vas is done as recommended. Consider repeat vasectomy or other alternative contraceptive methods, etc.
Refer spouse to antenatal clinic.
Regret and dissatisfaction
Counsel client—good counseling is key to prevention of regret. May need to discuss other viable options (e.g., adoption, assisted reproduction, etc.)
Display slide
Explain:
Sperm granuloma formation
Clients may present with persistent relatively painless swelling or “nodules” in the scrotum several months after vasectomy. If granuloma formation is suspected, the client should be counseled and referred to a specialist for care.
Chronic testicular pain or pain lasting for manths
Clients presenting with persistent pain after the procedure should be counseled and advised to use scrotal support to see if this provides lasting relief, and/or to soak in warm water. Analgesics should also be provided. Providers should also offer antibiotics if infection is suspected. If pain persists for several months and the client cannot tolerate it any further or seems depressed, he should be referred for further care.
Pregnancy
Pregnancy of the spouse following a vasectomy procedure may be an indication of method failure—if the vas recanalized, or if the surgeon did not ligate and excise both vas, or in extremely rare instances if there is an an aberrant vas. Additionally, if the client does not follow instructions and has unprotected sex with his spouse in the first three months postprocedure, the spouse is likely to conceive. To prevent method failure, the provider should follow the recommended steps for identifying, isolating, and occluding the vas. Techniques such as fascial interposition, in addition to thermal or electrical cauterization, have been reported to have persistently lower failure rates. Postprocedure semen analysis to confirm successful occlusion of the vas may be helpful to some extent.
All clients opting for vasectomy must be informed of the very small risk of failure before undergoing the vasectomy.
The client and the spouse should receive counseling and be told of the options for managing the problem. The spouse should be referred for antenatal care. A repeat vasectomy may also be arranged for the client. The couple may also consider other contraceptive options soon after the current pregnancy.
Regret and dissatisfaction with the method
Clients who made a hasty decision to have a vasectomy or who were not adequately counseled may experience regret several years after the procedure. Good counseling and screening of clients for eligibility may avoid such regret. Vasectomy should be considered permanent. Clients presenting with regret should be counseled and told about the options at their disposal, such as assisted reproduction, adoption, and in some instances reversal. Clients should however be informed that vasectomy reversal is expensive and not always successful.
NOTE:
Explain that other complications and side effects, though rare, may be associated with the pain medication used during the procedure. These include allergies and related drug reactions that may be associated with lidocaine and any analgesic or sedatives used. Such conditions should be managed symptomatically. Drug allergies can be avoided if the provider takes good history from clients who have experienced similar incidents in the past.

22. Role Plays and Case Studies
<Follow the step-by-step instructions in the Facilitator’s Guide section on facilitating role plays, to prepare for and conduct this activity
Discuss the learning objectives of the role-play activity.
Review the instructions for the client, the provider, and the observer roles and the other learning resources developed for the activity.
View a demonstration role play and clarify any questions.
Conduct role plays in small groups, based on the scenarios provided, and discuss the reactions.
Discuss the activity in a large group (plenary) session.
Review Handouts # 9, 10, and 11 with the participants. The content of these handouts includes:
Five different role-play scenarios, each with the client information sheet and observer information sheet (Handout # 9)
The instructions sheet, which describes the roles of the provider, observer, and client (Handout # 10).
The role play observation checklist (Handout # 11)
Role-play scenario/information sheets for clients and observers for role plays that you have selected or adapted.
Use the following questions to help the small groups structure the feedback that they will provide to each other after each role play. (Prepare a flipchart to display these discussion questions where they can be easily seen by all small-group participants.)
What was going on between the provider and the client?
What did the provider do that was effective in this situation?
What might the provider consider doing differently if this situation were to happen again?
How did the provider attend to the items on the counseling observation checklist and the case-specific observation included in the role play description?
After the small groups conduct each role play, encourage the groups to talk about what happened during the role play from the perspective of the provider (self assessment), the client (personal satisfaction with the interraction), and the observer (objective assessment using the role-play observation checklist, including case-specific observations that are included in the role-play description).
For the Case Studies
Divide the participants into 2–4 groups.
Distribute Handout # 12, and assign each group a different case study. Ask the group to review the case studies and answer questions to present their answers to the rest of the group,
Allow 15 minutes for discussion of the cases and for the groups prepare their answers, and then use five minutes to present their answers to the rest of the group.