A two year experience with vasectomy in the Philippines

Media

Part of The Journal of the Philippine Medical Association

Title: A two year experience with vasectomy in the Philippines
Creator: Reyes, Pedro M., Jr.
Language: English
Source: Volume 52 (Issue Nos. 3-4) March-April 1976
Year: 1976
Subject: Vasectomy – Philippines; Male contraception; Training of medical residents
Rights
Fulltext: A Two Year Experience with Vasectomy in the Philippines * *A Program Supported by Pathfinder Fund, Inc., Boston, Massachusetts. PEDRO M. REYES, JR., M.D., F.A.C. S., F.A.A.P. INTRODUCTION VASECTOMY is of maximum usefulness in the male whose desired family size has been attained and whose marital partner is still young and unwilling to undergo the inconveniences and uncer tainties of conventional contraceptive practices. The sterilization counterpart in the female, no matter what technic is used, involves entry into the peritoneal cavity and therefore carries a potential ly serious risk. Vasectomy, as has been developed in this program, is a short, painless, low cost, procedure with a high success rate (100% of all patients returning for semen examination), low complication rate, and virtually without side effects. There have been a total of 690 acceptors during the last 2 years of the program and a review of our ex periences wiU serve to crystallize some thoughts on how the program can be rendered more effective, particularly in relation to the overall program of the government towards population growth rate control. Inertia of the Initial Acceptance of Vasectomy. Educational, cultural, and religious factors have, in the past, limited the ac ceptance of vasectomy in the Philippines as a family planning technic. The pro gram was intended to gain entry into a heretofore poorly tapped source of fer tility control — the male half of the marriage partnership — representing 50% of all actively reproductive individ uals. Although the program had been planned months before, Its operation started only on November 1, 1973. The venue of the vasectomy program was a suite on the third floor of the Institute of Maternal and Child Health Building of the Children’s Medical Center at 11 Banawe, Quezon City. Partitioning of the alloted space created a waiting room — reception room, an office for inter viewing prospective acceptors, and an operating room complete with an ope rating table and overhead operating lamp. Actually, the Vasectomy Clinic Was part of an Advanced Family Plan ning Technology Clinic (an euphemistric name for Voluntary Sterilization Clinic) in which the female counterpart was as signed to Dr. Restituto Buenviaje, who did the female sterilization by transva57 58 Reyes, Jr. March-April, 1976 J. P. M. A. ginal tubal resection. The office staff of the whole clinic consisted, initially of only one nurse, later re-enforced by the addition of a licensed midwife. The Project Director of the Program initial ly at its most difficult first year was Dr. Fe del Mundo. The vasectomy program was given a quota of 200 acceptors for the first year. Optimism rode high at the start of the program, since the Institute of Maternal and Child Health had over 390 Family Planning Clinics all over the Philippines with 144 of these in the Greater Manila Area and surrounding provinces, all of which were potentially large sources of acceptors. Disappointingly, only 2 pa tients came for vasectomy during the first 4 months of operation of the clinic? Realizing that acceptors were not forth coming from the Family Planning Clinicsj the clinic staff and some concerned staff members of the I.M.C.H. began their own motivational campaign. Sor ties were made into different quarters for informational seminars. The first targets were the municipal councils of the suburban towns of San Juan, Ri zal; Quezon City; Pasay City; Caloocan City; and Mandaluyong, Rizal. Abrupt ly, in March, 1974, 6 acceptors came. Each month since then, the number of ac ceptors increased progressively (See Chart), so that by the end of the pro ject year on October 30, 1974, there were 37 acceptors more than the quota of 200 The Importance of a Continuous Motivational Campaign. The second year of operation of the Vasectomy Clinic was allo ted 450 ac ceptors. During tho first month (No vember, 1974) 59 acceptors came. Sub sequent months showed regular fluctua tions in the number of acceptors. Each month showing a decline in acceptors was followed by a motivational cam paign, causing an increase in the subse quent months. During the latter half of the 2nd year of operation, a precipitous drop in the number of acceptors had to be countered with informational semi nars conducted by Mrs. Alice Area, the Clinic Nurse, mostly in industrial firms with a high male population. This ex perience during the second year con vinced us that a continuing motivational canlpaign is necessary for a steady stream of acceptors. Spreading the Popularity of Vasectomy During the first year of operation of the Vasectomy Clinic, a visit was made to Gasan, Marinduque, on the invitation of the town mayor and his wife, so that interest in vasectomy may be awakened in the area. During this visit, which was on the last week-end of August, 1974, 13 acceptors submitted for vasectomy, and a local health officer was trained in the technic so that continuity of the pro gram in the area would not be disrupted. This pattern of itinerant surgery and concomittant training of a physician in the area has been repeated more often during the second year of operation, when visits were carried out in the following allotcd to the vasectomy clinic. places: 1. Bacolod City November 23-24, 1974 — 27 cases 2. Angono, Rizal April 2, 1975 6 cases 3. Angono, Rizal August 4, 1975 9 cases 4. Pasig, Rizal August 9, 1975 11 cases 5. Novaliches, Rizal August 30, 1975 7 cases 6. Angono, Rizal September 24, 1975 1. case Vasectomy 59. VjVjrp * ? . Nor >4 • Fig. 1. Graph shows difficulty of initial operation and need for continuous motivational efforts to insure success of the program. 60 Reyes, Jr. In each of these places one or more trainees were on hand to utilize the pa tients for training. In each place, care was exercised so that the initial experi ence of the community with vasectomy was pleasant. The procedure had to be fully accepted and not discredited by in curring unpleasant complications. The Vasectomy Clinic as Training Center. The Institute of Maternal and Child Health, recognizing the potentialities of vasectomy as an effective fertility con March-April, 1976 J. P. M. A. trol tool, entered into a program of train ing rural physicians to do vasectomy, with the Vasectomy Clinic as its pri mary training center. Groups of 2 or more physicians were sent to the Va sectomy Clinic for practical training in the operation. A minimum of 5 assisted vasectomies and 5 actually performed operations were required of each trainee and at the end of the training schedule, a certificate was awarded. Physicians trained in vasectomy at the Clinic sponsored by the I.M.C.H. are listed below: LIST OF PHYSICIANS TRAINED ON VASECTOMY 1st Quarter: July, Aug. Sept. ’75 F.Y. — 1975-76 July 7-11, 1975 1. Dr. Antonio F. Dioneda (C) Dioneda Family Planning Clinic Balogo, Sorsogon July 14-18, 1975 1. Dr. Sotero A. Escarilla, Jr. Iriga City Puericulture & Family Planning Center, Iriga City 2. Dr. Eduardo C. Enojado Naga City Puericulture & Family Planning Center Naga City July 21-25, 1975 1. Dr. Dominador N. Braganza (C) Guinobatan Puericulture & Family Planning Center Guinobatan, Albay 2. Dr. Vicente E. Borre (C) Virac Puericulture & Family Planning Center Virac, Catanduanes 3. Dr. Ernesto S. Antolin (C) Balanga Puericulture & Family Planning Center Balanga, Bataan August 4-8, 1975 1. Dr. Tadeo D. Cortez (C) Nueva Ecija Doctor’s Hospital & Family Planning Clinic Cabanatuan City 2. Dr. Tiburdo S. Madas (C) Mayor Joaquin Macias Medical/ Surgical & FP Clinic Sindangan, Zamboanga del Norte 3. Dr. Lolita R. Tudayan (C) Training Division Institute of Maternal & Child Health, 11 Banawe, Quezon City August 11-15, 1975 1. Dr. Apollo Q. Duque (C) San Fernando Norte Puericulture & Family Planning Center Cabiao, Nueva Ecija 2. Dr. Roque C. Alba (C) Santiago Puericulture & Family Planning Center Santiago, Isabela August 18-22, 1975 1. Agerico L. Tecson Candaba Puericulture & Family Planning Center Candaba, Pamnanga 2. Dr. Aida M. Gatchalian (C) Bo. Kapitolyo Puericulture & Family Planning Center Pasig, Rizal Volume 5S Nos. 3-4 August 26-30, 1975 t. Dr. Virgilio L. Morales (C) Naguilian Puericulture & Family Planning Center Naguilian, La Union September 2-6, 1975 1. Dr. Estrellita M. Fullantes (C) Juan Sumulong Memorial Puericul ture & Family Planning Center Tanay, Rizal September 9-13, 1975 •1. Dr. Magdalena V. Catalan (C) Family Planning Physician E. Rodriguez Memorial Hospital & Family Planning Clinic Marikina, Rizal •2. Dr. Ma. Eliza Tech Veloso (C) Family Planning Physician Pasig Puericulture & Family Planning Center Pasig, Rizal ♦3. Dr. Rosalinda V. Viado (C) Family Planning Physician Baranca-Ibaba Puericulture & Family Planning Center * Mandaluyong, Rizal September 22-26, 1975 1. Dr. Virgilio M. Orillo (C) Family Planning Physician Bo. Washington Family Planning Clinic Surigao City 2. Dr. Maximo D. Soliman (C) Family Planning Physician Tanza Puericulture & Family c — Certified — Trained in the field by itinerant team Vasectomy 61 Planning Center Tanza, Iloilo City 2nd Quarter: October, November and December 1975 October 6-10, 1975 1. Dr. Samuel J. Babol (C) Babol’s Family Planning Clinic Matalam, North Cotabato 2. Ramon V. Blancia, M.D. (C) Blancia Hospital & Family Planning Clinic Molave, Zamboanga del Sur 3. Dr. Rene S. Sison (C) Sison’s Medical & Family Planning Clinic Valencia, Bukidnon October 6-10, 1975 (continuation! *1. Dr. Diosdado C. Asuncion (C) Municipal Health Officer Zambales (Masinloc) ♦2. Dr. Salvador V. Fune (C) Municipal Health Officer Sta. Cruz, Zambales ♦3. Dr. Lauro B. de Jesus (C) Municipal Health Officer Castillejos, Zambales ♦4. Dr. Bulan F. Roste (C) Municipal Health Officer Cabangan, Zambales October 21-25, 1975 1. Dr. Isabel O. Henares City Health Officer Bacolod City 2. Dr. Pedro S. de Guzman St. Jude’s Hospital Dimasalang, Sampaloc, Manila (Dr. Oscar Estrada & Dr. Lolita Tudayan) The vasectomy clinic has also trained 2 physicians of the I.M.C.H. for iti nerant vasectomy visits to various cities and towns of the Philippines. These phy sicians are Dr. Oscar Estrada and Dr. Lolita Tudayan. Dr. Estrada has since done over 606 vasectomies in over 30 ci ties and towns. Dr * Tudayan was re cruited primarily to train I.M.C.H. Fa mily Planning Clinic Physicians and Mu nicipal health of ficers in the provinces. To date, she has trained 4 municipal health physicians in Zambales province and 3 I.M.C.H. physicians in the Pasig Pueri culture and Family Planning Center in Pasig,1 Rizal. She next expects to go to train 10 physicians in Isabela Province very shortly. 62 Reyes, Jr. An Improved Vasectomy Technic Early in the first year of the Program, a standardized vasectomy technic that would enhance the acceptability of the operation was devised. The technic util ized 2 incisions, was virtually bloodless and painless, and accomplished in 3 to 5 minutes. Standardization of the pro cedure made it possible to train doctors adequately after assisting 5 and actual ly performing 5 vasectomies. This technic of vasectomy was depict ed in photographs, which together with the text of the first year experience with the program, was presented as a scientMje exhibit at the Annual Con vention of the Philippine College of Surgeons, held at the Pines Ho tel in Baguio City in December, 1974 and at the Annual Convention of the Philippine Pediatric Society held at the Hotel Intercontinental in May, 1975. Slides have also been made of the tech nic and these are projected during in formational seminars and lectures of the Clinic Staff. Motivational campaigns are also rendered interesting and convincing by showing these slides. The details of the technic of vasectomy as done in this clinic are as follows • 1. The whole scrotum and penis are rendered aseptic with Povidone Iodine (Betadine Solution). 2. Drapes are placed so that only the scrotum is exposed. 3. The left was deferens is grasped firmly so that the tip of the index fing er is beneath the vas and the thumb over it. 4. Xylocaine 1% solution is injected into the scrotal skin directly over the vas. Infiltration is continued into the tissues around the vas to avoid reflex pain in the abdomen when the vas is ex posed. March-April, 1976 J/P. M. A 5. A piece of gauze is used to press on the skin swollen by the injection un til the vas is easily discerned under the skin. 6. A small 3/4 centimeter transverse incision is made over the skin overlying the vas, making sure that the incision is made at the exact site of the infiltration of anesthesia. 7. A small towel clip with the jaws open just enough to accommodate the vas is used to pick it up and deliver it out of the scrotal skin. 8. The sheath of the vas is then in cised cleanly to expose the vas as a naked tube. 9. The vas is then picked up with the tip of a straight iris scissor. 10. A small straight mosquito clamp is then inserted beneath the vas so that 2 centimeters of it is fully exposed by pushing the clamp beneath the vas al most to the handle. 11. Two mosquito clamps are applied on both extremities of the exposed vas and at least 1 centimeter of vas is ex cised . 12. The cut exposed ends of the vas are ligated with 4-0 silk and the sutures cut short. 13. The vas is then allowed to slip back into the scrotal sac. 14. No sutures are necessary for the skin. Sutures cause pain and abet in fection . 15. The opposite side is similarly treated. 16. Compression on the operated area is applied by the patient’s right hand over a gauze dressing for 2 minutes to establish hemostasis. The simplicity and ease of execution of the operation as devised have result ed in a low morbidity. There were orily Vasectomy 63 VoJunje 52 Nos. 3-j 6 complications out of 69.0 vasectomies done, representing a complication rate of 0.8 of one percent. These complica tions were: 1. Hematoma ..................... 2 2. Swelling (edema) ........ 1 3. Oozing ........................... 1 4. Spermatic cyst ............ 1 5. Decreased libido ............ 1 TOTAL ~6 There were 337 patients out of 690 acceptors who returned for semen exa mination. All these showed no sperms in the semen after 30 ejaculations or 60 days following vasectomy. The success rate of the vasectomy based wholly on 337 patients who returned for semen examination is 100%. ACCEPTOR PROFILE The largest number of acceptors (50%) were in the age group 31-40 years. FIRST YEAR ACCEPTORS November 1, 1973 — October 31, 1974 Age Wife 20 — 25 18 26 — 30 48 31 — 35 64 36 — 40 51 41 — 45 8 46 — 50 1 514- 0 Unknown 47 TOTAL 237 Husband 11 38 71 69 31 13 3 1 237 SECOND YEAR ACCEPTORS November 1,1974 to October 31. 1975 Age Wife Husband 15 — 19 0 0 20 — 24 44 12 25 — 29 108 71 30 — 34 163 123 35 — 39 111 151 40 — 44 20 73 45 — 49 4 14 50 4- 2 9 Unknown 1 0 TOTAL 453 453 March-April, 197* J. P. M. A. 64 Reyes, Jr. The largest group of acceptors had 4-6 children (over 50%). FIRST YEAR ACCEPTORS November 1» 1973 to October 31, 1974 Number of Children: 0 — 1 .................................................................................................. 0 2 — 3 65 4 — 6 142 7 — 9 25 10 4- ...................................................................................................... 5 237 SECOND YEAR ACCEPTORS November 1, 1974 — October 31, 1975 Number of Children: 0 — 1 ................................................................................................. 0 2 — 3 129 4 — 6 ................................................................................................ 265 7 — 9 49 10 4- ................................................................................................... 10 453 The occupation profile of the acceptors FIRST YEAR November 1. 1973 to October 31, 1974 Occupation: Privately employed..................... 90 Laborers ...................................... 42 Drivers ........................................ 33 Gov’t employees ......................... 15. Businessman ............................... 10 Fishermen .................................... 7 Salesmen .................................... 7 Farmers ...................................... 4 Jobless ....................... .................. Vendors ................. . ............... U.S. Navy ............................ Janitors ...................................... Self-employed ............................. Pastors ........................................ Unknown ...................................... Student ........................ 1 < * in in co c m c m Vasectomy 65 Volume 55 Nos. 3-4 SECOND YEAR November 1, 1974 — October 31, 1975 Occupation: Laborers ..................................... 134 Privately employed ................. 91 Drivers ...................................... 68 Gov’t employees ....................... 34 Self-employed .......................... 25 Farmers ..................................... 19 Vendors .................................... 13 Salesmen ................................... 13 Fishermen .................................... 12 Jobless ........................................ 11 Restaurant workers ..................... 9 Unknown ....................................... 6 Security guards ......................... 5 Janitors ....................................... 4 Hospital workers ....................■.. 3 Students ................................ 3 Pastors .................... 3 Almost 2/3 of the patients came from the Greater Manila area and 1/3 came from the surrounding provinces. Some of the latter were done at visits to the provinces. FIRST YEAR November 1, 1973 — October 31, 1974 Patient’s Address: Patients from Manila & Greater Manila area ................. 169 Patients from the provinces ..................................................... 68 SECOND YEAR November 1. 1974 — October 31, 1975 Patient’s Address: Patient’s from Manila & Greater Manila area .................................... 337 Patients from the Province ..................................................................... 116 SUMMARY The vasectomy program of the Child ren’s Medical Center as funded by the Pathfinder Fund Inc. of Boston, Mas sachusetts, has just completed its sec ond year of operation. A total of 690 vasectomies have been accumulated with a success rate of 100% (based on acceptors who returned for semen exa mination) the complication rate is 0.8 of one per cent. The acceptability of the program, which took 5 long months be fore taking off, was to a large extent due to the technic of operation which has made the procedure a short, virtual 66 Reyes, Jr. ly painless bloodless one, with a low complication rate. The clinic has de veloped from one initially geared pure ly for service to one with a training ori entation. Trainees come from rural areas and this augurs well for the adop tion of vasectomy as a practical method of fertility control in the provinces. Vasectomy, however, has not yet reached the stage of acceptability that female sterilization now enjoys, and mo tivational efforts have to be maintained unrelentingly if the movement for vasec tomy is to maintain its momentum. Therefore, a certain amount of the funds for vasectomy programs should go to this particular item. The acceptor profile reveals that the majority of those who submit to the procedure are in the age group 30-40 years. The large majority have over 4 children at the time of sterilization. This trend is still not too favorable for population growth rate control. Motiva tion should therefore be directed towards those with three children or less. The class of present acceptors is on the side of the more educated segment March-April, 1976 J. P. M. A. of the population with a relatively high income level. The informational, edu cational and motivational thrusts of a.iy program for vasectomy must therefore be more vigorously directed at the eco nomically poorer and less educated seg ment of the population who in the long run are the ones who most need vasec tomy for fertility control. The movement to popularize vasecto my as a fertility control measure should emphasize its effectiveness, its low cost, its simplicity of execution with the mi nimum of instruments, and the feasibility of its widespread implementation with out sophisticated training of those who do it in a rural setting. When with drawal of support from foreign fundings deprive the country of what now is abundantly available contraceptive ma terials and devices, we may have to lay more emphasis on vasectomy as a prac tical solution to the problem of fertility control. This program which we are undertaking has given us an insight into the problems of this sterilization move ment in males, but at the same time, it has broken down some of the barriers that had heretofore prevented its ac ceptance .