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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.
New York, New York, AVSC, 1991. 28 p.The annual report for 1990-1991 of the Association for Voluntary Surgical Contraception (AVSC) enumerates changes that came about in 1990, accomplishments of the last decade, and then summarizes activities by region with a brief feature on 1 country in each. Some of the developments in 1990 included introduction of Norplant, a training workshop in Georgia for physicians from newly independent CIS states, and the Male Involvement Initiative. The Gulf War delayed major activities requiring travel. Overall, in 1990 the AVSC provided 133,328 sterilizations, 72% female and 28% male in 50 countries, trained 325 doctors, led 58 courses in counseling and voluntarism training 568 counselors, and published or collaborated on numerous professional articles and teaching materials. In-country work emphasized no-scalpel vasectomy and minilaparatomy female sterilization under local anesthesia. As an example of country projects in 20 African nations, a client-oriented, provider-efficient system for improving clinic management and quality of care called COPE, was the focus in Kenya. Male responsibility was an emphasis in Latin America. In India, where sterilization is the most popular contraceptive method, training centers were upgraded in 12 states. In the US, AVSC conducted training sessions for physicians in laparoscopy under local anesthesia.
CEYLON MEDICAL JOURNAL. 1990 Dec; 35(4):136-42.The story of the Sri Lankan Family Planning movement is told from its inception in 1953, prompted by a visit by Margaret Sanger 1952. The Family Planning Association of Sri Lanka was founded with the health of women and children, and both contraception and infertility treatment as its policies. The first clinic, called the "Mothers Welfare Clinic," treated women for complications of multiparity: one woman was para 26 and had not menstruated in 33 years. The clinic distributed vaginal barriers, spermicides and condoms, but the initial continuation rate was <5% year. Sri Lanka joined the IPPF in 1954. In 1959, after training at the Worcester Foundation, and a personal visit by Pincus, the writer supervised distribution of oral contraceptives in a pilot project with 118 women for 2 years. Each pill user was seen by a physician, house surgeon, midwife, nurse and social worker. In 1958 Sweden funded family planning projects in a village and an estate that reduced the birth rate 10% in 2 years. The Sri Lankan government officially adopted a family planning policy in 1965, and renewed the bilateral agreement with Sweden for 3 years. In 1968 the government instituted an integrated family planning and maternal and child health program under its Maternal and Child Health Bureau. This was expanded in 1971 to form the Family Health Bureau, instrumental in lowering the maternal death rate from 2.4/1000 in 1965 to 0.4 in 1984. During this period IUDs, Depo Provera, Norplant, and both vasectomy and interval female sterilizations, both with 1 small incision under local anesthesia, and by laparoscopic sterilization were adopted. Remarkable results were being achieved in treating infertile copies, even from the beginning, often by merely counseling people on the proper timing of intercourse in the cycle, or offering artificial insemination of the husband's semen. Factors contributing to the success of the Sri Lankan planned parenthood program included 85% female literacy, training of health and NGO leaders, government participation, approval of religious leaders, rising age of marriage to 24 years currently, and access of all modern methods.
JOURNAL OF THE TENNESSEE MEDICAL ASSOCIATION. 1986 Feb; 79(2):75-6.275 laparoscopic tubal ligations were done safely and economically at the Planned Parenthood of Memphis outpatient clinic from May 1983 to June 1985. Patients were carefully selected and counselled, eliminating those with previous abdominal surgery, excluding cesarean section, and those with ongoing pregnancy or serious gynecological or medical problems. The trained staff of experienced laparoscopic surgeons and certified registered nurse anesthetists practiced emergency procedures before surgery. Anesthesia was a minimal amount of nalbuphine (Nubain) 20 to 40 mg and droperidol (Inapsine) 1.25 to 2.5 mg; or fentanyl 0.1 to 0.25 mg and droperidol 1.25 to 2.5 mg; occasionally nitrous oxide inhalation. Some women received droperidol 1.25 to 2.5 mg or diazepam 2.5 to 5 mg beforehand. The laporoscopic procedure, performed through a small intraumbilical incision, employed the fallop ring. The incision was closed with 000 Dexon subcuticular sutures. There were minor side effects in 23: nausea in 20, vomiting in 2 and wound infection in 1. Two pregnancies occurred: 1 was not detected in the preliminary pregnancy test and the other was a procedure failure. The sterilization program is considered safe and resonably priced, $450 compared to $1150 to 1469 in area hospitals outpatient clinics.
[Voluntary sterilization in France and in the world] La sterilisation volontaire en France et dans le monde.
Paris, Masson, 1981. 277 p.This monograph, directed not only to medical and paramedical personnel but to sterilization seekers as well, touches upon all aspects of voluntary sexual sterilization. The history of sterilization is follwed by a review of female and male anatomy and physiology, and of present available and reversible methods of contraception. All surgical, laparoscopic, tubal, electrocoagulation, culdoscopic, or hysteroscopic methods of female sterilization are described, and results, including morbidity and mortality, complication rates, side effects, and failure rates are presented. This part of the monograph is illustrated with clear and schematic drawings. Problems related to demand for reversal of sterilization are discussed. The same is done for male sterilization, its techniques and complications. The monograph discusses the ever increasing demographic problem in the world , and the role and the extent of voluntary sexual sterilization in industrialized countries and in third world countries, stressing the efforts of those international agencies, such as WHO, IPPF, the Population Council, the European Council, UNFPA, and the World Federation of Associations for Voluntary Sterilization, which promote sterilization around the world, and offer sterilization services. The authors then investigate the role of the physician in the decision to recur to sterilization as a permanent contraceptive method, and in deciding the proper surgical technique. A special chapter discusses the psychological conflicts related to sterilization, especially those which arise before the intervention, and which may very well represent the strongest contraindication to sterilization. A final chapter is devoted to France and to the sociocultural aspects which make sterilization more or less acceptable, the existing legislation, and the professional problems linked to sterilization interventions.
In: Phillips JM, ed. Endoscopy in gynecology: the proceedings of the Third International Congress on Gynecologic Endoscopy, San Francisco. Downey, California, American Association of Gynecologic Laparoscopists, 1978. 213-25.The Office of Population of the U.S. AID (Agency for International Development) has given priority to the development of new and improved means of fertility control and to their rapid dissemination and utilization throughout the developing world. Dr. Clifford Wheeless of Johns Hopkins developed a laparoscopic technique of sterilization by electrocoagulation which he publicized in 1967. USAID established a center at Johns Hopkins for the training of developing country physicians in this technque for laparoscopic sterilization under local anesthesia. USAID has provided funds for the establishment of other training centers in female sterilization, development of an improved laparoscope package, and provision of laparoscopic equipment to developing countries. Tables present the dollar value of support for various AID-funded, population-related activities since 1967. So far, 1228 physicians from 68 countries have received AID-sponsored laparoscopic training. More than 800 AID-purchased laparoscopes have been distributed to training gynecologists in 62 countries during the period 1972-77. Other sterilizing techniques and equipment which will accomplish the purpose more easily and safely are under investigation. The effect of the program has been to accelerate the use of female sterilization.
Geneva, Switzerland, WHO, 1980. 47 p. (WHO Offset Publication No. 26)This report outlines the World Health Organization's guidelines for female sterilization techniques. The following conclusions and recommendations concerning individual techniques are discussed: 1) laparotomy, particularly immediately postpartum, is the basic sterilization technique since it can be made available in any surgically equipped facility without extra requirements. 2) minilaparotomy is more demanding in skills and training requirements. However, it is a simple procedure on outpatient basis which makes it suitable for large-scale programs. 3) Colpotomy requires specialized training in obstetrics and gynecology. It has the same advantages as minilaparotomy, but it cannot be used postpartum. 4) Laparoscopy is the most complex sterilization form, and the most expensive. It can be used for sterilization, but its primary role is in diagnosis. 5) Culdoscopy costs slightly less than laparoscopy but has all of the same limitations as laparsocopic method (i.e., expensive, sophisticated university of facilities and training. 6) Hysterectomy is not recommended for sterilization. The need for adequate counseling services in addition to technical expertise is underlined.
UNICEF-meeting to determine and coordinate medical/technical aspects of family planning supplies-April 29, 1974. [Memorandum]
Washington, D.C., U.S. Government, 1974 May 1. 5 p.A meeting was held among personnel from UNICEF, WHO, IPPF (International Planned Parenthood Federation), and UNFPA (United Nations Fund for Population Activities. The meeting was held to determine and coordinate funding aspects of family planning supply programs. UNFPA agreed to fund OCs (oral contraceptives), condoms, Depo-Provera, spermicides, IUDs, and abortion equipment for UNICEF programs. It was mentioned that AID (the U.S. Agency for International Development) supplies most of the contraceptives needed for IPPF activities. WHO sets standards and prepares lists of acceptable contraceptive supplies. The UNFPA funding called for $2 million for OCs, $1 million for condoms, and much lesser amounts for the other types of contraceptives.
International Family Planning Perspectives. 1979 Sep; 5(3):127-9.The International Fertility Research Program (IFRP) is sponsoring research in 30 developing countries and 13 developed nations in an effort to develop more effective contraceptive methods. Particular emphasis is being placed on developing contraceptives for women in developing countries where nutritional, health, and sanitation conditions make current methods either difficult or less effective to use. Trials of a pill regimen including vitamin supplementation are underway in Sri Lanka, and a progestogen-only pill for use by lactating women is being tested in Egypt and India. Progestogens apparently do not modify the content of maternal milk. Another study involves the testing of a Lippes loop which releases Trasylol, a bleeding suppressant, in an effort to overcome bleeding problems associated with IUD use. The IFRP has developed and is testing biodegradable appendages which can be attached to IUDs to help retain the device in postpartum women during the period when the uterus is enlarged. Other efforts are being directed toward improving and simplifying sterilization procedures. In Chile, pellets of quinacrine have been inserted into the upper area of the uterus. As the pellets dissolve the quinacrine enters the tubes and produces scar tissue which eventually closes the tube. This research may pave the way toward the development of a non-surgical sterilization method. Animal studies of a reversible sterilization procedure in which a condom-like device is fitted over the ends of the tubes are in progress. In another project a modified laparoscope, called the Laprocator, is being evaluated. The device does not use electricity and is particularly suitable for use in areas in which electricity is lacking or the source is unstable. The device is used in a procedure called suprapubic endoscopy in which only a small incision is needed. Insufflation of the abdomen is unnecessary, and elastic rings are used to close the tubes. IFRP will undertake an innovative motivational project in the Middle East during the coming religious holidays.
In: Diczfalusy, E., ed. Regulation of human fertility. (Proceedings of the WHO Symposium on Advances in Fertility Regulation, Moscow, USSR, November 16-19, 1976) Copenhagan, Denmark, Scriptor, 1977. p. 111-134A 6-month regimen for managing infertile men and/or women ideally forms 4 stages: 1) history and examination of the couple; 2) confirmation of ovulation, compatibility of sperm and mucus, and seminology; 3) tests for tubal patency; and 4) detailed endocrine tests for abnormalities found in Stages 1-3. Medical history should include emotional stress and work pressures, if any. Ovulation confirmation requires 2 tests combined from these 4: 1) basal body temperature; 2) endometrial biopsy; 3) blood progesterone levels; and 4) urinary pregnanediol. These procedures are outlined in detail, and figures chart body temperature variations and expected progesterone and pregnanediol levels. Assessment of cervical mucus and measurement of sperm penetration combine in vitro and in vivo tests. The Sims-Huhner test (postcoital test), though not standardized, is used to analyze sperm-mucus interaction by quantitative scoring of sperm count and motility. Other in vitro tests are the sperm-mucus match test and the fractional postcoital test (both described). Tubal patency is investigated by tubal insufflation with CO2, hysterosalpingography, endoscopy, and laparoscopy. Additional Stage 4 tests include vaginal cytology and assessment of estrogen and progesterone effects.
Guide to equipment selection for M/F sterilization procedures. Guide du materiel utilise pour les procedures de sterilisation des hommes et des femmes.
Population Reports. Series M: Special Topics. 1977 Sep; (1): p.This is a guide to aid in selecting and maintaining the proper equipment used in the following sterilization procedures: 1) minilaparotomy, 2) laparoscopy, 3) conventional laparotomy, 4) colpotomy, 5) culdoscopy, and 6) vasectomy. Prototype, experimental, or infrequently used instruments are not discussed. Colpotomy, minilaparotomy, and conventional vasectomy are low-technology procedures requiring relatively simple, locally produced instruments, e.g., retractors, forceps, and scalpels. High-technology equipment consists of specialized items, e.g., laparoscopes and culdoscopes. These are produced in a limited number of technically advanced countries. Equipment donor agencies are discussed. The following factors must be considered in selecting equipment: 1) suitability for the intended procedures, 2) quality of the instrument, 3) ease of repair, and 4) initial cost. Each type of equipment is pictured, diagrammed, described, and charted against others of its kind. Maintenance and repair guidelines are provided.
[Unpublished] 1975. 21 p.Depo-Provera has not been used on a widespread basis in the Philippines because the Federal Drug Administration has not approved it, and a large share of their family planning budget is funded by USAID. Although Governor Luiz made Depo-Provera available to 800 acceptors; it was too expensive to compete with free contraceptives. On a trip to Thailand Governor Luiz witnessed the long-term effects of a Depo-Provera program begun in 1965: fewer children and better living conditions. Laparoscopy is too expensive an operation in training and instruments required to be used in the Philippines. Mini-lap is effective and inexpensive. A Thai doctor taught a Philippine doctor the procedure in only 2 operations. The Philippine doctor can train many others quickly, and equipment can be manufactured locally.
Conclusions and recommendations of the IPPF Central Medical Committee (CMC) and its panel of experts on sterilization.
In: Kleinman, R.L., ed. Male and female sterilization. A report of the meeting of the IPPF Panel of Experts on Sterilization, Bombay, January 11-14, 1973. London, International Planned Parenthood Federation, 1973. p. 8-12The conclusions and recommendations fall into 3 categories, i.e., policy, administrative and technical. Important points in the 1st category include; that sterilization be available and avilable on request, that it be voluntary, and that facilities for reversal procedures be free and avilable. Administrave recommendations include; that no arbitrary hospital stay be assinged to vasectomy patients, that no arbitrary selection criteria concerning previous training or surgical skill be used in accepting personnel for vasectomy patients, that no arbitrary selection criteria concerning previous training or surgical skill be used in accepting personnel for vasectomy training, and that endoscopic techniques should not be done without an anesthetist. Among the technical recommendations were: that postpartum sterilization under local anesthesia by laparotomy be encouraged, as that is the simplest of all female procedures; taht vaginal procedures should only be done with proper operative and anathestic facilities; that division of the uteirne tubes by the Pomeroy technique using 0 chromic catgut should be employed in mass programs of female sterilization; the removal of part of the uterine tube for biopsy and histological examination as a check on the success of the operation should not be done; general anesthesia should never be used for a simple vasectomy unless there are complications; and that tetanus toxoid should not be given to avoid infection.
In: World Health Organization (WHO). World Health Organization expanded programme of research, development, and research training in human reproduction: fourth annual report. Geneva, Switzerland, WHO, November 1975. 33-36. (HRP/75.3)Methods of tubal occlusion being studied for use in developing countries are summarized. A comparative clinic trial will be undertaken in the CCCR network to assess safety of tubal occlusion by surgery when performed postpartum through a vertical miniincision and when performed as an interval procedure by minilaparotomy, laparoscopy, colpotomy, or culdoscopy. 8 chemical tubal occluding agents are being studied at the Central Drug Research Institute in India. Postcoital birth control methods are being investigated including: methods to alter the rate of ovum transport, methods of changihg oviduct motility (including the effect of steroids, catecholamine stimulating and blocking agents, prostaglandins, ergot derivatives, and oxytocics), and methods affecting ovum survival. A WHO Symposium on "Ovum Transport and Fertility Regulation" was held in June 1975 in San Antonio, Texas, to present the work of these various scientists.
[Unpublished] . 12 p.In 1972 the US Agency for International Development (USAID) began to provide funds to Johns Hopkins and other universities to train developing country personnel in laparoscopic sterilization technique. The demand for this training and AID's perceived need for a mechanism to provide developing country doctors with current training in family planning and other aspects of reproductive health led, in 1974, to the creation of the Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO). One of its purposes was to provide short-term training in laparoscopy for overseas physicians and to arrange for distribution and maintenance of laparoscopic equipment. JHPIEGO was also conceived of as a broad based program for training in reproductive health emphasizing the important role that family planning plays in reproductive health. Most of this USAID supported training now takes place in medical centers in the developing countries. The training usually consists of 2-4 weeks of didactic and clinical work in many aspects of reproductive health of which training in laparoscopy is often an important part. After the laparoscopic training, each qualifying trainee is visited at his/her own hospital by a consultant who helps set up the laparoscopic equipment for use. A significant number of supervised laparoscopic procedures are then performed by the trainee over a period of several days. When the consultant trainer is satisfied with the skill of the particular trainee, a laparoscopic unit is given to the trainee's institution. By September 1983, 2500 physicians from approximately 100 countries had received this type of JHPIEGO training, and more than 1600 of them have since been provided with laparoscopies at their home institutions. USAID funded laparoscopic training and equipment and other types of training and equipment also have been provided to the developing countries by the Association for Voluntary Sterilization (AVS). These 2 groups have now cumulatively provided laparoscopic training for at least 3800 physicians from developing countries. The Falope Ring applicator is now in use throughout the world, and JHPIEGO and AVS have converted their overseas laparoscopes to include this capability and for the past 5 years all laparoscopes supplied by USAID have had this Falope Ring capability. The laprocator, a simplified laparoscope which is designed for use of the Falope Ring, was developed in response to USAID's interest in lowering costs and maintenance requirements. USAID has provided over 1000 of these simplified systems to more than 75 developing countries. The use of laparoscopy in the voluntary sterilization programs of the Philippines, in India, and in Africa are reviewed. Voluntary sterilization has grown each year in popularity and is now the method of birth control in most widespread use around the world.