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IPPF MEDICAL BULLETIN. 1993 Jun; 27(3):1-2.Sterilization consists of occlusion of the vas deferentia or the Fallopian tubes to prevent the sperm and ovum from joining. Counseling is important since voluntary surgical and contraception is a permanent contraceptive method. Trained counselors should know about and discuss other contraceptive methods, the types of anesthesia available, and the different sterilization procedures and stress the permanent nature of sterilization and the minimal risk of failure. Counseling must maintain voluntary, informed consent and not coerce anyone to undergo sterilization. It is best to counsel both partners. Vasectomy should be encouraged because it is simpler and safer than female sterilization. Most sterilization techniques are simple and safe, allowing physicians to conduct them on an outpatient basis. Local anesthesia and light sedation are the preferable means to reduce pain and anxiety. In cases where general anesthesia is required, the patient should fast for at least 6 hours beforehand and the health facility must have emergency resuscitation equipment and people trained in its use available. Aseptic conditions should b maintained at all times. Vasectomy is not effective until azoospermia has been achieved, usually after at least 15 ejaculations. The no-scalpel technique causes less surgical trauma, which should increase the acceptability of vasectomy. Vasectomy complications may be hematoma, local infection, orchitis, spermatic granuloma, and antisperm antibodies. Spontaneous recanalization of the vasa is extremely rare. Postpartum sterilization is simpler and more cost-effective than interval sterilization. Procedures through which physicians occlude the Fallopian tubes include minilaparotomy, laparoscopy, and vaginal sterilization via colpotomy or culdoscopy. They either ligate the Fallopian tubes or apply silastic rings or clip to them. Vaginal sterilization is the riskiest procedure. Reversal is more likely with clips. So complications from female sterilization are anesthetic accidents, wound infection, pelvic infection, and intraperitoneal hemorrhage. About 1% of all sterilization clients request reversal. Pregnancy rates are low with reversal.
OUTLOOK. 1990 Jun; 8(2):7-9.This article summarizes the most recent data on WHO's multicenter clinical trial test of the low dose progestin-releasing vaginal ring as an effective contraceptive for women. The study involved 1005 women aged 19-34 and was carried out from 1980-86 at 19 centers in 13 countries, including 9 developing countries. The overall findings on vaginal ring use included: the ring's effectiveness was comparable to oral contraceptive (OC) effectiveness, pregnancy rates increased with increasing body weight, about 1/2 of the users had discontinued the ring by 1 year, the ring disrupted menstrual bleeding patterns in about 1/2 of all users, and about 1/4 of all users expelled the ring at least once but most continued to use it. The irregular bleeding pattern was the main reason for discontinuation. Part of the reason for having different ring contraceptive effectiveness in different countries could be due to differing average weights of the women. Increasing risk of expulsion was directly related to increasing age by approximately 3% with each year of age. For effective use of 90-day low-dose levonorgestrel-releasing vaginal ring, appropriate clients should have the following: a dislike for inserting and removing vaginal devices, low weight, counselling on potentially irregular bleeding, and counseling on how to deal with an expulsion. (author's modified)
In: Intrauterine contraception: advances and future prospects, edited by Gerald I. Zatuchni, Alfredo Goldsmith, and John J. Sciarra. Philadelphia, Pennsylvania, Harper and Row, 1985. 354-64. (PARFR Series on Fertility Regulation)Little data is available from developing countries on the incidence of ectopic pregnancy and the associated risk factors: pelvic inflammatory disease (PID), sexually transmitted diseases (STDs), intrauterine devices (IUDs), and abortion. To address this problem, the World Health Organization conducted a multinational case-control study between 1978 and 1980 of factors associated with ectopic pregnancy in 12 centers, 8 in developing countries and 4 in developed countries. Results suggest that risk factors are similar in women from developing and developed countries. The only exceptions were increased risks of ectopic pregnancy associated with spontaneous abortion or smoking in developing but not developed country centers. This may reflect misreporting of illegal induced abortion or postabortion complications, and behavioral differences between smoking and nonsmoking women in developing countries. All methods of contraception prevent pregnancy and so provide protection against ectopic pregnancy. This protective effect is least with the IUD, however, and accidental conceptions during IUD use or after sterilization carry an increased risk of ectopic pregnancy. With the IUD, this probably reflects both differential protection against intrauterine and extrauterine pregnancy and an increased risk of IUD-related PID resulting in tubal damage. The risk of ectopic pregnancy is also increased in women with a previous history of PID or a prior pregnancy. However, cesarean section was found to reduce the risk of ectopic gestations in all comparison groups.
Studies in Family Planning. 1984 Nov-Dec; 15(6/1):253-66.This paper critically analyzes claims for the effectiveness of the Billings method of natural family planning and raises questions about the wisdom of actively promoting this method. The Billings method, developed in Australia, is based on client interpretation of changing patterns of cervical mucus secretion. Evaluation of the method's use-effectiveness has been hindered by its supporters' insistence on distinguishing between method and user failures and by the unreliability of data on sexual activities. However, the findings in 5 large studies aimed at investigating the biological basis of the Billings method provide little support for the claims that most fertile women always experience mucus symptoms, that these symptoms precede ovulation by at least 5 days, and that a peak symptom coincides with the day of ovulation. Although many women do experience a changing pattern of mucus symptoms, these changes do not mark the fertile period with sufficient reliability to form the basis for a fully effective method of fertility control. In addition, the results of 5 major field trials indicate that the Billings method has a biological failure rate even higher than the symptothermal method. Pearl pregnancy rates ranged from 22.2-37.2/100 woman-years, and high discontinuation rates in both developed and developing countries were found. Demand for the method was low even in developing countries where calendar rhythm and withdrawal are relatively popular methods of fertility control, suggesting that women of low socioeconomic status may prefer a method that does not require demanding interaction with service providers and acknowledgment of sexual activity. The Billings method is labor-intensive, requiring repeated client contact over an extended time period and high administrative costs, even when teachers are volunteers. It is concluded that although natural family planning methods may make a useful contribution where more effective methods are unavailable or unacceptable, many of the claims made for the Billings method are unsubstantiated by scientific evidence.
Temas de Poblacion. 1981 May; 7(12):14.The World Health Organization (WHO) has financed a study of the Billings method of family planning in 3 developing and 2 developed countries to obtain objective data on the effectiveness of the method. Although 40% of the 870 couples had previously used another abstinence method and all were highly motivated to use the technique, the life-table pregnancy rate for the year following training in the method reached 20%. 11 studies of the cervical mucus method have been carried out in India, Tonga, Colombia, and Chile and in the US and Australia, often in new programs which did not employ uniform teaching methods. 2 Indian studies showed pregnancy rates of under 6/100 woman years, while 2 studies in developed countries showed rates under 15 and 2 showed rates over 30/100 woman years. Most of the studies have attributed the high pregnancy rates to the failure of couples to observe abstinence. Pregnancy occurred in the 5 countries partcipating in the WHO studies primarily as a result of the failure of couples to abstain from sexual relations during periods identified as fertile, despite active promotion of natural family planning and assistance from instructors at monthly intervals. Other reasons for the high failure rate were late occurrance of mucus flow relative to the time of ovulation, overly early appearance of mucus, and failure to observe or to interpret correctly the mucus symptom. Mucus patterns and facility of interpretation can be affected by various physiological or psychological factors, such as vaginal or cervical infection, vaginal secretion due to sexual stimulation, medicines, tension, and illness. The common observation of higher pregnancy rates among couples who wish to postpone rather than prevent a birth appears to be particularly important in the case of abstinence methods.