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[Unpublished] 1993. , 23,  p.In 1993 in Tanzania, the Association for Voluntary Surgical Contraception (AVSC) helped the Tanzania organization UMATI and the Ministry of Health (MOH) evaluate the 5-year Permanent and Long-Term (P<) Contraception Program. The program planned to use the findings to develop action workplans to address the issues and to expand services. The assessment team visited sits in Dar es Salaam, Iringa and Mbeya, and Arusha and Moshi. In 4 years, the program had expanded from 2 sites to 35 sites nationwide. It trained 250 family planning providers in tubal ligation. P< providers performed more than 9000 tubal ligations (90,000 couple years of protection). The program has surpassed all its service objectives, which contributed to a lack of resources. It established a national network of interested health providers and administrators. Demand for services outpaces the supply countrywide. Since clients and providers have accepted tubal ligation, the government has incorporated sexual sterilization into its national family planning program. It is now preparing to introduce the contraceptive implant Norplant. USAID/AVSC and UMATI/IPPF, (International Planned Parenthood Federation) support 3 full-time staff positions and plan on adding staff in area offices. Other than the 3 AVSC-funded positions in UMATI, UMATI, and MOH have provided all staff time. Other donors to the P< Contraception Program include the development agencies of the UK and Germany and perhaps the World Bank. The MOH has requested future goods from UNFPA for the Interim Norplant Expansion Program. The 2 major outcomes of the assessment were realization of the need to support full-time physician-nurse teams in each UMATI area office and MOH agreement to integrate training for P< methods into the national training strategy. UMATI and USAID planned to add 2 more area offices. Service obstacles were insufficient trained staff, expendable supplies, and equipment to expand to the 35 sites (25 were planned). The key management problem was failure to completely integrate the P< program into the UMATI mainstream.
Contraception. 1973 Jul; 8(1):67-73.The World Health Organization (WHO) Program of Research in Human Reproduction that began in 1972 deals with the development of a variety of safe, acceptable, and effective methods for the regulation of human fertility. Research has concentrated on areas where international collaboration would be most likely to accelerate the development of new methods. The program is clinically oriented and emphasizes meeting the objectives in the shortest possible time. Collaborative task force research was started in the following fields: 1) methods to interfere with the transport and/or survival of the ovum; 2) methods to prevent the implantation of the fertilized ovum in the uterus; 3) contraceptive methods for men that affect the fertilizing capacity of sperm by interfering with their maturation and survival without affecting sexual competence; and 4) methods to regulate sperm migration and survival in the human female.
New York, New York, AVSC, 1993 Sep. 8 p.Neither the US Food and Drug Administration nor WHO have yet endorsed intrauterine insertion of quinacrine for tubal occlusion in women. Quinacrine is very inexpensive and easy to produce and insert, which make it open to abuse. Free and informed choice and safety must be upheld as well as quality of care in family planning services. The few studies of quinacrine use for nonsurgical sterilization have small sample sizes and very short-term follow-up. They have largely occurred in Chile, Egypt, and Indonesia. One study suggests that quinacrine increases the risk of cancer. Recently a field trial of 31,781 women undergoing nonsurgical sterilization with quinacrine pellets was conducted in Viet Nam. The pregnancy rate at 1 year was 2.63. At 2 years it was 4.31 for cases with 2 insertions. At 5 years, for women with just 1 insertion, it was 5.15. There were 19 ectopic pregnancies. Major complications included 2 cases of severe bleeding, 2 hysterectomies (severe pain and amenorrhea, adhesions in the cervical canal), 1 case of premenstrual pain and dysmenorrhea, 1 case of pelvic inflammatory disease, and 1 allergic reaction. Only minor side effects occurred. The study methodology was flawed, however. For example, the researchers did not bide by the inclusion criteria they claim to have used. They also extrapolated failure rates and side effects based on subsets to the whole group. Thus, this study cannot be used to conclude that quinacrine pellets are safe and effective. Further, well-designed studies addressing short and long-term safety are warranted. If studies find quinacrine pellets to be safe and effective, their low cost and ease of insertion make it a promising method in areas of high maternal mortality, with low access and availability of family planning services, and great unmet need for permanent methods.
FAMILY PLANNING WORLD. 1992 Jan-Feb; 2(1):7, 21.Even though Brazil's BEMFAM program stopped providing sterilization services over a year ago, many sources hostile to BEMFAM in the Brazilian government are still accusing it of misconduct. BEMFAM is sponsored by the International Federation of PLANNED Parenthood and was investigated and cleared of any wrong doing by the Brazilian government. In Brazil it is against the law to perform sterilization for the purposes of birth control, yet it is estimated that there are between 6-20 million such operations each year. Over 65% of the births in Brazil are by Caesarian section and it is common for women to ask their doctors to perform a tubal ligation at the same time. Abortion is illegal in Brazil, but there are an estimated 1.4-2.4 million abortions each year. 56% of Brazilian women use contraceptives, with 90% using either the pill or illegal sterilization. 90% of those who use the pill obtain it over the counter at pharmacies with inadequate knowledge on how to use it. 80% of the people receive their health care from the Brazilian government.
Association for Voluntary Sterilization - Consultant Team. Trip report: the People's Republic of China, Beijing, Chongqing, Wuhan, Guangzhou, June 19-30, 1985.
[Unpublished] 1985. 41,  p.The Association for Voluntary Sterilization consultant team visited Beijing, Chongqing, Wuhan and Guangzhou, China in June 1985, to review innovative nonsurgical methods of male and female sterilization. There are 2 variations on vasectomy, performed with special clamps that obviate a surgical incision. The 1st is a circular clamp for grasping the vas through the skin, and the 2nd is a small, curved, sharp hemostat for puncturing the skin and the vas sheath, used for ligation. Vas occlusion with 0.02 ml of a solution of phenol and cyanoacrylate has been performed on 500,000 men since 1972. The procedure is done under local anesthesia, and is controlled by injecting red and blue dye on contralateral sides. If urine is not brown, vasectomy by ligature is performed. The wound is closed with gauze only. Semen analysis is not done, but patients are advised to use contraception for the 1st 10 ejaculations. Pregnancy rates after vasectomy by percutaneous injection were reported as 0 in 5 groups of several hundred men each, 11.4% in 1 group and 2.4% in another group. The total complication rate after vasectomy by clamping was 1.8% in 121,000 men. 422 medical school graduates with surgical training have been certified in this vasectomy method. Chinese men are pleased with this method because it avoids surgery by knife, and asepsis, anesthesia and counseling are excellent. Female sterilization by blind transcervical delivery of a phenol-quinacrine mixture has been done on 200,000 women since 1970 by research teams in Guangzhou and Shanghai. A metal cannula is inserted into the tubal opening, tested for position by an injection of saline, and 0.1-0.12 ml of sclerosing solution is instilled. Correct placement is verified by x-ray, an IUD is inserted, and after 3 months a repeat hysteroscopy is done to test uterine pressure. Pregnancy rates have been 1-2.5%, generally in the 1st 2 years. Although this technique is tedious, requiring great skill and patient cooperation, it can be mastered by paramedicals. The WHO is assisting the Chinese on setting up large studies on safety and effectiveness, as well as toxicology studies needed, to export the methods to other countries.
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.
Advances in Planned Parenthood. 1980; 15(3):77-81.In 1977 the PPAN (Planned Parenthood Association of Nashville) began providing minilaparotomy sterilization services on an outpatient basis. The experience of 218 women who received sterilizations at the clinic between 1977-1979 indicated that it was feasible and safe to provide this service on an outpatient basis. The historical development of the program, the procedures and instruments used to perform the sterilizations, and the sterilization outcomes for the 218 patients were described. Prior to program initiation, the Medical and Executive Directors of PPAN attended a workshop on outpatient female sterilizations conducted by AVS (Association for Voluntary Sterilization) and the Planned Parenthood Federation of America. Subsequently a protocol for minilaparotomy sterilization was submitted to the National Medical Office of the Federation by the PPAN. The protocol was approved and the program was implemented. Based on the success of the 1st 18 months of operation PPAN received a grant from AVS to train personnel from other clinics to provide similar services. During the 1st clinic visit patients are thoroughly counseled and given a pelvic examination. During the 2nd visit the patient is given a complete physical examination and laboratory tests, including a pregnancy test, are performed. During the 3rd visit the patient receives additional counseling and the sterilization is then performed. A modified Pomeroy procedure is performed under local anesthesia. Patients were discharged 2 hours after surgery. 96% of the patients returned for suture removal and 50% returned for a later recommended check-up. A follow-up survey indicated that more than 90% of the patients were satisfied with the service. For 4 of the 218 patients the sterilization was not completed. In 2 cases the round ligament was mistaken for the tube and sterilization was not achieved, in 1 case the patient became upset and the procedure was halted, and in another case adhesions prevented ligation. At the time of the operation it was discovered that 2 patients had luteal phase pregnancies. There were no major immediate complications but there were 1) 2 cases of subcutaneous hematomas; 2) 1 brief episode of postoperative thrombophlebitis, 3) 2 cases of wound abscesses; and 4) 3 cases of mild cystitis and endometritis.
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.
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.
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.
WHO Special Programme of Research, Development and Research Training in Human Reproduction: Programme on Sterilization.
WFAVS Report, No. 1, September 1978. p. 2-3.Research on female sterilization represents one of the priorities of WHO's Special Programme of Research, Development and Research Training in Human Reproduction. The strategy of its Task Force on sterilization concerns safety, simplification, and service delivery. Evaluation of short-term sequelae of tubal occlusion performed postpartum or as an interval measure involved no major clinical problems. Concern over long-term sequelae has led to testing and comparison of 3 operative techniques - laparoscopic tubal cautery, Pomeroy tubal ligation, and laparoscopic clip application - in order to determine the extent of subsequent menorrhagia. A future study will be concerned with psychological sequelae, comparing women requesting sterilization for birth control; preoperative and postoperative general complaints of a presumed psychological origin, and patterns of menstruation and sexual activity will be recorded. New methods being developed include a technique that would safely and simply occlude the tubes by the transcervical blind delivery of a chemical agent. The most successful approach to date has been the use of methylcyanacrylate delivery through the tubes by a device designed for the purpose. A study is being planned for use of the technique with volunteer hysterectomy patients.
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.