Describe the terminal methods of contraception and emergency contraception.

Terminal Methods

• Female sterilisation (tubectomy) occludes or divides the fallopian tubes, preventing the sperm and ovum from meeting
• The approaches — minilaparotomy, which may be interval, postpartum (through a small sub-umbilical incision, since the uterus is enlarged) or with caesarean section; and laparoscopic sterilisation, using rings or clips
• Laparoscopy is quicker with a smaller scar and faster recovery, but requires equipment, training and general or regional anaesthesia, whereas minilaparotomy can be done under local anaesthesia in a camp or a PHC
• The techniques — pomeroy (a loop of tube ligated and excised), the commonest; modified Pomeroy; FALOPE rings; and clips
• Male sterilisation (vasectomy) occludes the vas deferens
• NO-scalpel vasectomy (NSV) uses a puncture rather than an incision, and has less bleeding, less pain, fewer infections and faster recovery than the conventional technique
• The comparison between vasectomy and tubectomy is the heart of this topic, and it favours vasectomy on every technical criterion:
• Vasectomy is simpler, performed under local anaesthesia, takes about 10 minutes, is an outpatient procedure, is cheaper, has a lower complication and failure rate, and does not require entering the peritoneal cavity
• Tubectomy requires entering the abdomen, carries the risks of anaesthesia and of visceral injury, and has a longer recovery
• Yet the overwhelming majority of Indian sterilisations are tubectomies, and the reasons are entirely social rather than medical:
• The myth that vasectomy causes loss of strength, masculinity or sexual ability, which is false but deeply held
• The residual fear from the coercive vasectomy campaign of the emergency, which attached lasting stigma to the operation
• The assumption that contraception is a woman’S responsibility
• Loss of wages for a male breadwinner, real or feared
• Programme and provider orientation toward female methods, including the organisation of camps for tubectomy
• The counselling points that address these — vasectomy does not affect erection, ejaculation, the volume of semen, libido or the ability to work, since the sperm form a very small proportion of the ejaculate and testosterone continues to be secreted into the blood
• The critical practical point about vasectomy — it is not effective immediately; another method must be used for about 3 months or 20 ejaculations, until azoospermia is confirmed by semen analysis
• Failure to explain this is a common cause of unintended pregnancy and of litigation
• By contrast tubectomy is effective immediately
• The complications — of vasectomy: haematoma, infection, sperm granuloma, chronic scrotal pain, and rarely spontaneous recanalisation; of tubectomy: anaesthetic complications, bleeding, infection, injury to bowel or bladder, and, if failure occurs, a higher proportion of ectopic pregnancy
• Ethical and legal requirements — fully informed, voluntary, written consent from the person undergoing the procedure, with spousal consent not required; explanation that the method is permanent and that reversal cannot be guaranteed; disclosure of the failure rate; and adherence to the Supreme Court directions on sterilisation camps and compensation

Emergency Contraception and Choosing a Method

• Emergency contraception prevents pregnancy after unprotected intercourse, and its indications are unprotected intercourse, a burst or slipped condom, missed pills, expulsion of an IUCD, failure of withdrawal, and sexual assault
• The methods:
• Levonorgestrel 1.5 mg as a single dose, taken as early as possible and within 72 hours — the standard method in India, available over the counter
• Its efficacy declines with every hour of delay, which is why "as soon as possible" matters more than the 72-hour limit
• Ulipristal acetate, effective up to 120 hours
• The copper IUCD inserted within 5 days, which is the most effective emergency method of all, and has the great advantage of providing ongoing contraception thereafter — a point routinely missed, since a woman needing emergency contraception evidently needs a regular method too
• The YUZPE regimen of combined pills is now largely superseded
• Its mechanism — chiefly delay or inhibition of ovulation
• IT IS not AN abortifacient and does not disrupt an established pregnancy — a point that must be stated clearly, since the confusion between emergency contraception and medical abortion is widespread among both public and providers
• The counselling points — it is for emergency use, not for regular use, being less effective than any regular method and having a higher failure rate with repeated use; it gives NO protection against sexually transmitted infection; menstrual irregularity is common afterwards; and the consultation should be used to start a regular method and to consider STI testing where relevant
• Matching the method to the couple is the practical skill:
• Newly married, no children — condoms, combined oral pills, or centchroman
• Spacing after one child — IUCD, injectable, implant or pills
• Breastfeeding — progestogen-only pill, injectable, IUCD, condom or lactational amenorrhoea; avoid combined pills early
• Family complete — sterilisation, or a long-acting reversible method if there is any doubt
• Woman over 35 who smokes — avoid combined pills; use IUCD, progestogen-only methods or sterilisation
• Risk of sexually transmitted infection — condoms, with dual protection by adding another method
• The concept of unmet need is how a programme should judge itself — the proportion of married women of reproductive age who wish to space or limit births but are not using any contraception
• In India unmet need is concentrated among young women wanting to space, and among the poor, the less educated and certain states
• The reasons for unmet need are worth listing, since they are not chiefly lack of supply — fear of side effects, which is the commonest reason given; opposition from the husband or family; lack of knowledge; poor access or quality of services; and religious or cultural objection
• Since fear of side effects predominates, the remedy is counselling and quality of care rather than more supplies — which is the conclusion the data support and the one programmes most often resist
• Vasectomy is simpler and safer than tubectomy, yet India performs mostly tubectomies for entirely social reasons
• Vasectomy is not effective for about three months, and another method must be used until azoospermia is confirmed
• Tubectomy is effective immediately, unlike vasectomy, which is a distinction with real consequences
• Vasectomy does not affect erection or libido, since sperm are a tiny part of the ejaculate and testosterone still enters the blood
• Emergency contraception is not an abortifacient, and does not disrupt an established pregnancy
• It works chiefly by delaying ovulation, which is why timing relative to the cycle determines its efficacy
• Efficacy falls with every hour of delay, so as soon as possible matters more than the seventy-two hour limit
• The copper IUCD is the most effective emergency method and provides ongoing contraception, which is routinely forgotten
• Spousal consent is not required for sterilisation, though written informed consent from the person certainly is
• No-scalpel vasectomy uses a puncture, with less bleeding, pain and infection than the conventional technique
• Minilaparotomy can be done under local anaesthesia, which is why it suits a camp or PHC setting better than laparoscopy
• Pomeroy is the commonest tubectomy technique, ligating and excising a loop of tube
• Explain that reversal cannot be guaranteed, which is an essential element of consent for any permanent method
• Fear of side effects is the commonest reason for unmet need, ahead of lack of access or supplies
• The remedy for unmet need is counselling and quality of care, not more commodities, which programmes resist
• Unmet need is concentrated among young women wanting to space, and among the poor and less educated
• The Emergency left lasting stigma on vasectomy, which is a political fact with a continuing clinical consequence
• Match the method to the stage of family building, since a newly married couple and a completed family need different things
• Use the emergency consultation to start a regular method, since a woman needing it evidently needs one
• Ulipristal extends the window to five days, which matters where presentation is delayed
• Sterilisation failure gives a higher ectopic proportion, which should be considered in any later abdominal pain
• Follow the Supreme Court directions on camps, which govern standards, consent and compensation after documented failures