Vasectomy is surgical sterilization for men, a contraceptive method that is considered
permanent. It is very safe, has few side effects, and has reported annual pregnancy rates
of less than 1 percent.
Despite its many advantages, vasectomy is widely used in only a few countries,
including China, India, Thailand, Korea, the United Kingdom, Canada and the United States.
About 45 million couples worldwide rely on vasectomy for contraception, compared with
about 150 million female sterilization users,1 even though
male sterilization is safer and easier to perform.
In many developing countries, the procedure is not widely available. Even if it is
available and men have heard of it, many believe incorrectly that the procedure affects a
man's sexual functioning and weakens his strength. Campaigns to improve access to
vasectomy highlight important lessons: that enough providers need to be trained so that
services are readily available; that sustained promotional campaigns encourage use; and
that male clinics or other features that make men feel comfortable help promote its use.
Competent counseling is also essential to success.
"With a lot of effort providing all of these elements, we have seen slow but
encouraging progress," explains Evelyn Landry of AVSC International (AVSC) in New
York, which has worked to expand vasectomy services in developing countries for more than
20 years. Nevertheless, even in Brazil, Colombia, Kenya and Mexico where model programs
have been conducted, the proportion of married couples of reproductive age using
vasectomy, while increasing, is still 1 percent or lower.
Although vasectomy is considered one of the most effective contraceptive methods
available, there have been no long-term effectiveness studies, similar to research
available on female sterilization. Couples who rely on vasectomy must use another method
for many weeks after the procedure, until sperm are no longer present in the man's
ejaculate. A semen sample after vasectomy can help determine when this occurs.
Recent small studies raise questions about how long it takes after a vasectomy for a
man to achieve azoospermia (absence of living sperm in a man's semen) and indicate that
there is a wide variability in time to azoospermia. Providers
should advise clients that vasectomy, like other contraceptive methods, is not perfect and
that failures can occur.
Myths and facts
Men are often reluctant to consider vasectomy because of inaccurate information and
myths. A study in Colombia found that both men and women still believe, incorrectly, that
vasectomy affects a man's sexual performance.2 Vasectomy does
not affect production of male hormones that control the sex drive, erection, or masculine
features, such as facial hair or muscle tone. The method simply prevents sperm from being
in the ejaculate. In the procedure, the provider cuts the vasa deferentia, through which
sperm travel from the testicles to the urethra during ejaculation. After vasectomy, the
testicles continue to produce sperm that eventually degenerate and are excreted, like
other body cells.
Until recent years, many men in developing countries had not heard of the procedure. In
1988, for example, only 35 percent of men and 20 percent of women in Kenya knew about it,
according to Demographic and Health Survey, a U.S.-based program that assists developing
countries in conducting surveys on fertility, family planning, and maternal and child
heath. Five years later, after promotional campaigns and provider training by AVSC and
others, 56 percent of men and 41 percent of women knew about vasectomy, and most knew
where services could be obtained.3 "Men were more
interested in learning about family planning, including vasectomy, than we thought they
would be," says Joseph Dwyer, director of AVSC's eastern and southern African
programs. "Men have eagerly attended educational sessions and snapped up the
pamphlets."
After learning about the method, men need services that are sensitive to their needs.
While clinics are making progress in serving men, it takes time to adjust to male clients.
A recent study in Kenya found that when men sought information about having a vasectomy,
about half of the clinics visited were not adequately prepared for male clients.
"Provider discomfort about vasectomy itself was quite apparent," the study
reported, and the clients felt "as if they had invaded women's space." The
counselors who were rated poor or fair in attitude were all women. "This comes from a
lack of experience with vasectomy as a family planning method, limited experience in
counseling men, and little chance to talk openly about such issues with any man," the
report concluded.4 In the study, done in conjunction with
several family planning agencies, four men trained in good counseling techniques and
vasectomy made a total of 14 visits to seven different clinics. The clinics did not know
that the men were pretending to be clients as part of a study.
In deciding to have a vasectomy, couples need information about the important role
vasectomy plays within a range of family planning options. Interviews with 218 couples in
six countries found that "both men and women cited concern for the woman's health as
a principal reason" for having a vasectomy. The report thus concluded that
"encouraging men to have vasectomy for their partner's sake and stressing that it is
a man's 'turn' to take responsibility for family planning may be effective promotional
strategies."5 The study was done by AVSC in Bangladesh,
Kenya, Mexico, Rwanda, Sri Lanka and the United States.
Another theme throughout the study was the value of friends helping to inform couples.
Word of mouth from satisfied clients and formal advertising and promotion are the factors
most important for expanded use in Sri Lanka, says Dr. Sriani Basnayake, medical director
of the Sri Lanka Family Planning Association.
No-scalpel approach
The "no-scalpel" approach to vasectomy (NSV), first developed in China during
the 1970s, has rapidly expanded throughout the world. Using a forceps-like instrument to
puncture the scrotum instead of making an incision with a scalpel, NSV helps to reduce
fears and makes the operation quicker, easier, safer and less painful than the traditional
incision approach. In a traditional vasectomy, a provider makes one or two incisions, each
1 cm to 2 cm long, in order to reach the two vasa. With NSV, a clamp holds the vasa in
place just under the skin, so that the forceps can puncture the skin, grasp a vas and pull
it out to be cut and occluded. Both approaches into the scrotum require local anesthesia
with a needle, but NSV needs only one needle insertion instead of two or more with the
standard incision.
NSV is less painful and causes fewer bleeding problems. In an FHI-sponsored
multi-country randomized trial among 1,428 men (705 having NSV and 723 with the standard
incision), the NSV group had only 10 men with hemotomas (blood clots) compared with 67 in
the standard group, and just one with infection at the entry site compared to eight who
had incisions. The NSV group also reported significantly less pain.6
The study found other benefits. The NSV men resumed intercourse sooner than did the
other group. Also, the operating time for the majority of NSV men was six minutes or less,
compared with seven minutes or more for the standard incision group. FHI conducted the
study in Brazil, Guatemala, Indonesia, Sri Lanka and Thailand. The men were asked to
return twice to discuss complications or complaints, between three and 15 days
postvasectomy and at 10 weeks, when a semen sample was tested. In Thailand, a limited
study of about 1,200 men served by the Population and Community Development Association at
the 1987 King's Birthday Vasectomy Festival found far fewer complications among the NSV
group.7
"Now we know that with the no-scalpel approach, men recover faster, hurt less and
have less chance of bruising and infection," says Susan McMullen of FHI's clinical
trials division. "Plus, it is just as effective and men do not have to worry about an
incision."
Other than fear and temporary discomforts, health concerns are relatively rare. While
questions remain about whether vasectomy may increase the risk of prostate or testicular
cancer, recent research findings indicate that there is no link between cancer and
vasectomy.8 When concerns were first raised, a panel of
experts appointed by the U.S. National Institutes of Health concluded that providers
should continue to offer vasectomy, that reversal should not be attempted to prevent
prostate cancer, and that screening for prostate cancer should not be any different for
men who have had a vasectomy.9
Promotional campaigns
Recent campaigns have sought to expand and improve vasectomy services, especially in
Latin American countries. An analysis of six vasectomy expansion projects in Brazil,
Colombia and Mexico concluded that vasectomy promotion is more successful if it involves
wives. "For example, vasectomy might be presented to women as an alternative to
female sterilization -- especially when they would be most receptive to such information,
such as in the postpartum period," concluded Ricardo Vernon of the Population
Council. Involving men who have had a vasectomy to encourage use among other men helps to
develop an interest in the procedure, and having a staff well-trained in identifying and
counseling potential clients for referrals is important, the study found.10
The study also found mass media promotion to be useful, especially in cities where
access to the method is better. The Asociación Probienestar de la Familia Colombiana
(Profamilia), the largest family planning provider in Colombia, conducted a five-month
radio and newspaper campaign to promote men's services, including vasectomy, as an
experiment for four clinics in four mid-sized cities. Each clinic also hired a promoter to
give talks in the clinics and in the communities. Two Profamilia clinics used for
comparison in the study did not use media promotion. In the clinics using promotion, the
number of vasectomies more than doubled in one year (from an average of 57 to 125 per
clinic), compared with a significantly smaller increase in the two control clinics (40 to
63 per clinic).
Mass media campaigns are expensive to sustain, however. The Profamilia study and a
similar one conducted by the Brazilian agency, Promocăo de Paternidade Presponsavel
(PROPATER), found that the social and demographic characteristics of the men who learned
about vasectomy through the media campaigns were similar to those who learned about it
through other sources, such as word of mouth. "Mass media that reach the largest
number of potential acceptors should be emphasized," reports Vernon.
The PROPATER project estimated that the cost of each additional vasectomy acceptor
recruited by a magazine advertising campaign to be U.S. $39, or $3.12 per couple-year of
protection, assuming an average of 12.5 couple-years of protection for a vasectomy.
Profamilia, using similar assumptions and methodology, estimated that each additional
couple-year of protection cost U.S. $7.50. A thorough cost analysis would need to account
for longer time periods and other factors, such as the cumulative effects of referrals
made by satisfied vasectomy acceptors and the cost of additional staff training.
"AVSC's experience in Kenya suggests that mass media should ideally be sustained
longer than a year," says Mary Nell Wegner, director of AVSC's Men as Partners
program. In a focus group of eight Kenyan men who had chosen vasectomy, "they
mentioned that short-term mass media campaigns can be detrimental because those who are
skeptical about the procedure or fear that it is some sort of a conspiracy feel vindicated
when the campaign suddenly stops."
The use of male clinics or separate waiting rooms for men may encourage use.
"Profamilia made large gains in promoting vasectomy when it started two male clinics
in Bogotá and Medellín in 1985," report Vernon and his colleagues in an analysis of
four clinics designed to serve men. "Using the completely segregated approach of
these clinics might be successful in conservative cultures where vasectomy remains an
unknown and little requested method."11
During the past decade, Instituto Mexicano del Seguro Social (IMSS), Mexico's largest
provider of family planning services, has focused on improving access to vasectomies. The
number more than tripled in six years, from 6,100 in 1988 to 20,000 in 1994 and continues
to grow. IMSS followed a four-part strategy. It adopted NSV as the program's standard and
trained doctors in NSV, which triggered a new interest in vasectomy among doctors. Second,
it used a comprehensive approach in training all personnel involved in providing
vasectomy, encouraging them to work together as a team. Third, IMSS is making vasectomy
available at the primary-care level, with plans to provide vasectomies at 260 of its 1,500
clinics. Finally, it is providing ongoing supervision and technical support to the service
delivery sites, including assistance with mass media and interpersonal promotion efforts.12
-- William R. Finger
References
- United Nations. Department of Economic and Social
Resources. World Contraceptive Use, 1994, poster. New York: United Nations, 1995.
- Escobar MC. An Exploratory Study on Service
Providers' Attitudes towards Vasectomy: Profamilia Clinics, Colombia. Bogotá: AVSC
International, 1996.
- Kenya National Council for Population and Development,
Kenya Central Bureau of Statistics, and Macro International. Kenya Demographic and
Health Survey 1993. Calverton, MD: Kenya National Council for Population and
Development, Kenya Central Bureau of Statistics, and Macro International, 1994.
- Wilkinson D, Wegner MN, Mwangi N, et al. Improving
vasectomy services in Kenya: lessons from a mystery client survey. Reprod Health
Matters 1996;7:115-21.
- Landry E, Ward V. Perspectives from couples on the
vasectomy decision: a six-country study. Reprod Health Matters 1997;special
issue:58-67.
- Family Health International. Final Report: A
Comparative Study of the No Scalpel and the Standard Incision Method of Vasectomy in Five
Countries. Research Triangle Park, NC: Family Health International, 1996.
- Nirapathpongpron A, Huber DH, Krieger JN. No-scalpel
vasectomy at the King's Birthday Vasectomy Festival. Lancet 1990;335(8694):894-95.
- Schwingl PJ, Guess HA. Vasectomy and cancer: an update. Gynaecology
Forum 1996;1(1):24-28.
- Healy B. Does vasectomy cause prostate cancer? JAMA
1993;269(20):2620.
- Vernon R. Operations research on promoting vasectomy in
three Latin American countries. Int Fam Plann Perspect 1996;22(1):26-31.
- Vernon R, Ojeda G and Vega A. Making vasectomy services
more acceptable to men. Int Fam Plann Perspect 1991;17(2):55-60.
- Jezowski TW, Alarcon F, Juárez C. A Successful
National Program for Expanding Vasectomy Services: The Experience of the Instituto
Mexicano del Seguro Social. AVSC Working Paper No. 8. New York: AVSC International,
1995.
For more information, visit Family Health International's Website at www.fhi.org
Go to FHI's Network |
Copyright