Expand male contraceptive services by offering no-scalpel vasectomies
No incision, no stitches, faster procedure, and faster patient recovery
How can your family planning clinic reach out to men in your community? Consider offering no-scalpel vasectomy services. Although vasectomy traditionally has been used by white middle- to upper-class men, low-income and minority men also will choose the sterilization method when adequate providers and funding assistance are made available, and the service is marketed to them.
This finding was borne out by a recent study of a two-year national program sponsored by AVSC International, a nonprofit reproductive health care advocacy organization based in New York City.1 With funding from the David and Lucile Packard Foundation in Los Altos, CA, and the Huber Foundation in Rumson, NJ, AVSC provided on-site, hands-on training for physicians working in 43 publicly funded health centers in 17 states. Sites were provided with surgical instruments, training materials, and a media kit. Providers were contacted the year following their training to track the use of the method.
The training program increased the number of clinics providing vasectomies by 39% and expanded the number of men obtaining them by 18%. Ten clinics that had not provided vasectomies before the program now perform a total of more than 350 per year, the study found.
The push to broaden no-scalpel vasectomies in the public sector continues, says Jeanne Haws, MPA, director of U.S. programs for AVSC. Public health providers in Florida will take part in a training session in Orlando in April led by Heidar Heshmati, MD, MPH, PhD, director of the Brevard County Health Department in Merritt Island. This training session, a partnership with the state of Florida and AVSC, will include 50 physicians and nurse teams, who Heshmati and others hope will initiate no-scalpel vasectomy services in their clinics.
It is time for no-scalpel vasectomy to be offered to a broader population, says Joel Feigin, MD, associate professor of family medicine at Robert Wood Johnson Medical School in New Bruns-wick, NJ, and director of the Coventry No-Scalpel Vasectomy Center in Phillipsburg, NJ.
"It’s up to us to make sure this excellent service is also available and promoted in the public sector," says Feigin, who serves as a trainer for AVSC. "People think of vasectomy in a private setting because these are people who have the insurance and can afford it. Services are more available in the private sector. I think that’s in part because of the demand."
Look at the method
The no-scalpel vasectomy was developed in China by surgeon Shunqiang Li of the Chongqing Family Planning Scientific Research Institute and has been used in that country since 1974. The technique was introduced in the United States in 1988 and constitutes about one-third of the half-million procedures performed each year in this country.2
No-scalpel vasectomy differs from conventional vasectomy in that it eliminates the need for an incision in the scrotum to reach the vas deferens, the tubes that carry sperm from the testes to the ejaculatory duct and then into the urethra. In a conventional vasectomy, once the scrotum has been numbed with a local anesthetic, the provider makes one or two cuts in the skin, lifts the tubes to cut and block them, then closes the incision with suture. In no-scalpel vasectomy, the provider feels for the tubes under the skin, injects anesthetic, then holds them in place with a specially designed ring forceps. These forceps, which do not penetrate the skin, hold the vas deferens in place as a sharp-tipped dissecting forceps punctures and stretches a small opening in the skin and the vas sheath. The vas then is lifted out and occluded as in conventional vasectomy methods.3 There is very little bleeding with the no-scalpel technique, and no stitches are needed to close the tiny opening, which heals quickly with no scar.
No-scalpel vasectomies are better accepted by patients, says Thomas R. (Randy) Pritchett, MD, a urologist on the clinical faculty of the University of Washington and the urology department at Virginia Mason Medical Center in Seattle. Discomfort during and after the procedure is reduced, the risk of getting a complication in the early postoperative period is decreased, and recovery is quicker so patients can return earlier to the work force, explains Pritchett, also an AVSC trainer.
The procedure takes 15 to 20 minutes in Heshmati’s office, and the patient feels no pain, he says. He talks to his patients as he performs the vasectomy, and many cannot believe it when he tells them the procedure is complete. When Heshmati informs patients there has been no cut and asks them to see if they can locate the tiny puncture, the men are extremely pleased.
While the no-scalpel technique offers a more elegant approach to conventional vasectomy, Feigin believes its biggest strength lies in the fact that it eliminates the use of a scalpel in a sensitive area. "Just the name no-scalpel vasectomy’ sounds good to men because they are always pretty afraid of having a knife down there."
Pritchett agrees with that observation. "The name itself is helpful, but it’s the procedure which really is an improvement."
As with conventional vasectomy, no-scalpel vasectomy must be considered a permanent form of contraception, even though improved microsurgical techniques mean better chances of restoring fertility. Counseling protocols for obtaining informed consent must be in place before the provision of any such sterilization procedure.
Providers can offer no-scalpel vasectomies with limited resources, Feigin says. The method does not require much equipment, space, or time. Effective counseling may be performed in a 20-minute session. After informed consent is obtained and a waiting period has been met, the surgical procedure is quickly performed, with brief follow-up care scheduled and a semen testing protocol in place to ensure sterilization is complete.
Provider success with the technique rests with hands-on learning of the method as originally developed by Li, says Feigin, explaining that providers may work with a partner or another provider who is proficient in the technique to gain mastery of the method.
Pritchett says: "I tell family planners that they should work with one of their partners who also does vasectomy or with an associate who can help them until they get comfortable with the technique, or they’re not going to like it, and they’re going to quit doing it."
If a clinic is interested in developing vasectomy services, it must approach the service from a comprehensive standpoint, Feigin notes. "You have to develop a very strong counseling component to the program. You have to commit to providing the highest level of surgical expertise, build in strong follow-up care in terms of the actual surgical patients, and also in terms of ensuring that sterility has been achieved through appropriate semen testing."
Plan an active marketing campaign to draw men into your facility, Feigin suggests. Market-ing strategies do not have to be expensive, say authors of the AVSC vasectomy project study. Get out the word through your established patients by placing signs and handouts in the waiting areas and exam rooms, and include fliers in your billing statements. (AVSC is developing a poster on no-scalpel vasectomy. See the resource listing below for contact information.) Also, seek free publicity through press releases to local newspapers and radio and television stations.
Once your staff are committed to the service and the word is out, be prepared for patients at your door, Heshmati says. Even though his clinic does not advertise, it maintains a waiting list, due to patient word of mouth about the success of the method, he says.
"It is very well accepted by the nursing staff, and the patients are happy," he notes. "Complica-tions are low, and the pain is less. It is a great technique, I think."
(Editor’s note: A blue-ribbon panel concluded in 1993 after reviewing research on prostate cancer and vasectomy that there was insufficient basis for recommending against the contraceptive method. Patients, however, continue to ask questions about such risks. Feigin and Pritchett offer their counseling approaches to these questions on p. 31.)
References
1. Haws JM, McKenzie M, Mehta M, et al. Increasing the availability of vasectomy in public-sector clinics. Fam Plann Perspect 1997; 29:185-186, 190.
2. Marquette CM, Koonin LM, Antarsh L, et al. Vasectomy in the United States, 1991. Am J Pub Health 1995; 85:644-649.
3. Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology. 16th edition. New York City: Irvington Publish-ers; 1994, p. 397.
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