Vasectomy: Safe, Convenient,
Effective-and Underutilized

Method-Specific Characteristics and Considerations

Effectiveness: Vasectomy is highly effective, comparable to female sterilization and to long-term, reversible female methods such as implants and IUDs. Vasectomy is not effective immediately, however, and WHO recommends that the couple use alternative contraception for 3 months after the procedure. Risk of failure (pregnancy) is commonly quoted as from 0.2% to 0.4%, but failures rates as high as 3-5% have been reported. Failure may be due to client behavior (when alternative contraception is not used after the procedure) or may be due to technical failure from the procedure.

Safety: Vasectomy is very safe, with few medical restrictions. Major morbidity and mortality is rare and adverse long-term effects have not been found. Minor complications such as post-operative infection, bleeding/hematoma formation, and short or longer-term pain occur at reported rates of 5-10%. The no-scalpel technique has a much lower incidence of post-operative complications than by incision.

HIV/AIDS: Vasectomy does not protect against HIV infection. Being HIV-positive is not a reason to be denied vasectomy. A man with AIDS who is clinically stable may also receive vasectomy.

Regret: Most men who choose vasectomy do not regret their decision. There are clear correlates of subsequent regret, however: young age, marital instability, and decisions made under financial or other pressure. Thus careful and complete pre-vasectomy counseling is critical.

Counseling: Counseling should be "two-way." It should address fears (e.g., about post-procedure sexual functioning or pain) and correct myths (e.g., "vasectomy equals castration," or "it makes you weak"). It should emphasize that vasectomy: is intended to be permanent; is difficult to reverse; can fail; does not protect against STIs including HIV; and does not take effect immediately after the procedure, hence alternative contraception must be used. Screening for risk indicators for regret should also be done, and the informed consent (authorization) process should be completed.

Programmatic Considerations

No-scalpel vasectomy (NSV) is the preferable vasectomy technique. It should be provided by well-trained and motivated providers in properly equipped health facilities where attention is given to good surgical technique, infection prevention, and counseling.² When performed by a trained operator, vasectomy takes 15 minutes or less.

Lessons learned: Service access and quality can be increased by: being attentive to the needs of men and to the needs of vasectomy providers; taking a holistic approach (i.e., addressing both "demand" and "supply" factors); and focusing on the fundamentals of service delivery.

Successful NSV programs generally include the following ingredients:

• Effective promotion, providing accurate information via multiple means, including mass media (billboards, newspaper/magazine ads, radio/TV spots, telephone hotlines), community channels, and interpersonal communication, using satisfied vasectomy clients where feasible.³
• Attention paid to the needs of men, providing: thorough, sensitive counseling; privacy and confidentiality; and an array of convenient and affordable services.⁴
• Skilled individual providers and teams, who are well-trained, well-equipped, and who are actively providing quality NSV information and services.⁵
• Strong leadership by "champions," influential and committed providers or institutions who are particularly active in providing quality NSV services, and are willing to "replicate themselves."
• Collection and use of data for program design, to identify champions, and to focus activities.
• Tailoring the program to the local context; e.g., by developing private sector and/or mobile outreach services, and by using appropriate approaches, technologies, and methodologies.

¹Vasectomy is safer than female sterilization since it is less invasive and almost always performed under local anesthesia.
²Many studies using mystery clients have shown that very often vasectomy is not even mentioned when family planning is being discussed with clients, even with those who indicate that they want to limit future births.
³Multiple communication channels can create a synergistic effect, and should be targeted to women as well as men. This is important because "Vasectomy is as much an IEC operation as a surgical operation." Brazil, Colombia and Guatemala were able to double their vasectomy caseload through multimedia campaigns. Telephone hotlines increased caseloads in Kenya and the U.S.
⁴For example, be open on evenings or weekends; maintain male-only clinics, if feasible, or at least separate waiting areas; use male providers; offer general male health care and reproductive care for sexual dysfunction, STIs, infertility, etc., in addition to NSV.
⁵A systematic analytic approach, e.g., Performance Improvement, is useful to identify gaps in providers' knowledge, communication or surgical skills, and other program needs. If training is the indicated intervention, on-the-job and whole-site training are proven effective approaches.

Where to get more information: www.maqweb.org

References
Contraceptive Sterilization: Global Issues and Trends. EngenderHealth, New York, NY, 2002.
No-Scalpel Vasectomy: An Illustrated Guide for Surgeons. EngenderHealth, New York, NY, 2003.

Last Revised: 10/29/04
Produced in association with The Maximizing Access and Quality Initiative

Designed and produced by: The INFO Project at the Johns Hopkins Bloomberg
School of Public Health/Center for Communication Programs