Contraception Editorial April 2011

Reversing the United States Sterilization Paradox by Increasing Vasectomy Utilization

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David K. Turok, Grace Shih, Willie J. Parker

When a better contraceptive method is chosen much less often than a lesser comparator, it is the responsibility of family planning researchers and practitioners to investigate why this is the case and improve the situation. As the accompanying review article¹ discusses, vasectomy, when compared to the more costly, less efficacious option of female sterilization, is clearly a superior method for limiting family size. Yet vasectomy is utilized far less frequently than female sterilization, warranting study and resolution of this situation.

As the most common method of contraception used in the United States, sterilization is a crucial contraceptive option. The paradox of sterilization mentioned above where the more costly, less efficacious and more morbid option of female sterilization is more commonly used than vasectomy is even more pronounced in Latino and African American communities.² While there will always be women and couples for whom female sterilization may be the better option (those who desire sterilization and are having a repeat cesarean delivery, those without a current partner and have completed child bearing or women whose partner is not willing to have a vasectomy), from the standpoint of safety, efficacy and societal cost benefit, it would be more sensible if the vast majority of sterilizations performed in this country were vasectomies. Shifting the balance of sterilization utilization to favor vasectomy over female sterilization will require a multifaceted approach. Attention will need to be focused on supply issues (provider willingness and ability to offer the service) and demand issues (increasing men’s awareness, acceptance and selection of the procedure), with progress occurring ideally in both areas simultaneously.

An integral step to increasing vasectomy use is increasing the number of providers trained in the simple, no-scalpel vasectomy (NSV) procedure. This would make the service more readily available and increase the number of enthusiastic supporters of the practice in the community. Members of the family planning community should lead this shift towards vasectomy as the primary sterilization method in this country. These providers often have contact with patients and families during pregnancy, as contraceptive counseling including sterilization, is a routine part of prenatal and postpartum care. This would require that more family planning providers, most of whom are women’s health specialists, learn the simple technique of NSV. With 500,000 vasectomies currently performed per year, in the United States, this ability would represent a considerable opportunity to expand clinical services.³

Vasectomy can be made more appealing to men. While many medical procedures have provider-dependent variation in approach, there are clear advantages to the NSV technique⁴ which support that the incisional approach be abandoned at this time. The no-scalpel technique also appeals to patients as it implies a less invasive procedure. Use of minimally invasive labels may make it easier for men to acknowledge their contraceptive responsibility. There are currently very few contraceptive options for men. Thus, it is extremely important to appeal to men when they have the opportunity to be utilized once their family size is complete. Integrating men into the contraceptive decision is imperative and challenging, as the history of fertility control has always focused on women since it is their health that is directly affected by pregnancy and childbirth. The limited involvement of men in fertility control in the United States is illustrated by the fact that they were only invited to be participants in the National Survey of Family Growth after 2000.⁵ It is time to break this tradition and involve men in contraceptive decision-making.

High quality research will be crucial to guide advances in vasectomy provision and utilization, and this is an area where the family planning community has significant strengths. While the majority of current vasectomy research focuses on technique, the expansion of services will require a diverse approach into the supply and demand side issues addressed above, questions best addressed by the new and growing discipline of health services research. Exploration of the obstacles to vasectomy use, especially in communities of non white ethnicity and the medically underserved is needed. Qualitative techniques and surveys may be advantageous when initiating this line of investigation. Results from these studies can guide the development of interventions designed to increase vasectomy uptake. In addition, investigation into quality of life issues, particularly sexual satisfaction, may provide important information for those considering the procedure. The willingness of family planning providers to learn and offer NSV will also need to be addressed. This will require specific attention to provider attitudes involving provision of services to men, issues of service reimbursement, and the determination of the optimal way to train providers to perform vasectomy.

As we look to expand vasectomy services in the United States, we will do well to model our efforts after the success in increasing intrauterine device use in this country over the last decade. Here, there was an introduction of a new device that offered excellent contraceptive efficacy with minimal risk and a favorable side effect profile. Providers received training while research focused on increasing access and acceptance. This kind of programmatic expansion can also occur with vasectomy where we have an improved approach, NSV, that can be offered to appropriate candidates. One major difference is that this change will not have the advantage of being funded by a large private corporation invested in its success. However, subjecting women to even the small risks of tubal ligation or occlusion when they could be better served by vasectomy is a reproductive justice issue and there is a long history of the United States family planning community pursuing initiatives that are driven by that powerful force. Sustained effort over time has the potential to change this situation. If this effort is targeted toward both the supply and demand side of vasectomy utilization, there is tremendous potential to provide families with optimal choices for sterilization and reverse the paradox that currently exists.

David K. Turok
Department of Obstetrics and Gynecology
University of Utah Health Science Center
Salt Lake City, UT

Grace Shih
University of California, San Francisco
San Francisco, CA

Willie J. Parker
Planned Parenthood Metropolitan Washington
Washington, DC

References

1. Shih G, Turok DK, Parker WJ. Vasectomy: the other (better) form of sterilization. Contraception. 2011;83:310–315. Abstract | Full Text | Full-Text PDF (129 KB)
2. Barone MA, Johnson CH, Luick MA, Teutonico DL, Magnani RJ. Characteristics of men receiving vasectomies in the United States, 1998-1999. Perspect Sex Reprod Health. 2004;36:27–33. MEDLINE
3. Barone MA, Hutchinson PL, Johnson CH, Hsia J, Wheeler J. Vasectomy in the United States, 2002. J Urol. 2006;176:232–236[discussion 6]. Abstract | Full Text | Full-Text PDF (80 KB)
4. Nirapathpongporn A, Huber DH, Krieger JN. No-scalpel vasectomy at the King’s birthday vasectomy festival. Lancet. 1990;335:894–895. Abstract
5. Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth. Vital Health Stat. 2005;23:1–160.