Roadside billboards in the United Kingdom draw attention to the two round handles of a surgical instrument, arranged to suggest a man's testicles. "Handled with care," reads the billboard, "Marie Stopes Vasectomy Clinic, call in confidence." Inquiries about vasectomy increased dramatically after the campaign began last fall.
"Promoting vasectomy is critical," says Julie Douglas of Marie Stopes International (MSI) in London, who coordinated the campaign. "There is a lot less information available about vasectomy, compared to women's methods. Plus, men do not go to the doctor for regular checkups." The United Kingdom is one of the few countries in the world where about the same percentage of men (16 percent) and women (15 percent) use sterilization.
Every year, MSI launches a vasectomy promotion that includes advertising in local newspapers and on billboards at football stadiums. This year's campaign includes an eye-catching poster at subway stations and on buses that shows a man's torso, naked except for a white fig leaf. "Vasectomy? We've got it covered," reads the poster.
"These are light-hearted and bold ideas, with some shock value," says Douglas. "Men are tense and worried about vasectomy. Will it hurt? How will it affect my sex life? Being light-hearted helps open the door." Douglas is quick to point out that such slogans are too suggestive for many developing countries, where MSI has not been as explicit in vasectomy campaigns. Prevailing social norms should guide the content of promotional campaigns, she says.
Promotional campaigns in developing countries have also been successful. In Colombia, vasectomy promotions include a radio campaign. In Jamaica and Uganda, brochures are distributed. Providers in Sri Lanka, Mexico, Kenya and other countries encourage word-of-mouth promotion by satisfied clients.
Campaigns need to be put in the larger context of promoting all contraceptive methods. "The point is not to promote one method over another, but rather to make sure that potential family planning clients know of all of their choices," says Mary Nell Wegner, director of AVSC International's Men as Partners Initiative based in New York. Determining exactly how to promote vasectomy, and how much to promote it, may be keys to expanding this underused method.
Safe, but underused
Correcting misunderstandings about the method and even making men aware of this option can be among the goals of information campaigns. Even where people have heard of vasectomy, many continue to believe incorrectly that it affects a man's sexual performance or impairs his strength. Correct information is crucial in any promotional effort and in personal counseling. Vasectomy does not affect the production of male hormones that control sex drive and such masculine features as facial hair. Vasectomy simply prevents sperm from entering the ejaculate. The provider cuts the vasa deferentia, through which sperm travel from the testicles to combine with semen. After vasectomy, the testicles continue to produce sperm, and the sperm eventually degenerate and are excreted like other body cells.
Vasectomy is effective, safe, quick to perform and has few side effects. The procedure typically takes minutes to complete, requires only local anesthesia, and only a small proportion of men experience short-term blood clotting or infection, considered to be minor problems. Questions remain about whether vasectomy may increase the risk of prostate cancer, but available research is not conclusive. Pregnancy rates are thought to be less than 1 percent, although no long-term effectiveness studies have been conducted similar to research on female sterilization.
The no-scalpel approach emphasizes that no knife is necessary, which comforts some men. Using a puncture instrument to gain access to the vasa, the no-scalpel procedure requires less anesthesia and is just as effective as the incision approach. Also, men recover faster and they experience less pain, bruising and infection compared with men who used the incision method, according to an FHI study.1
Vasectomy is not immediately effective because viable sperm remain for weeks in the urethra above the cut vasa. International guidelines recommend that couples use another method of contraception, such as condoms, for 12 weeks or 20 ejaculations, after which these residual sperm should be gone. However, men should be advised to return if possible for a follow-up semen analysis, to verify that no sperm are present (azoospermia). Without an analysis, couples cannot be certain that azoospermia has been achieved. Like all contraceptive methods, vasectomy is not perfect and failures do occur. The exact time to azoospermia, which means the complete absence of sperm in the ejaculate, is not known. Preliminary data from FHI and AVSC International research indicate a wide variability in the time and number of ejaculations before men reach azoospermia.2
While vasectomy is safe and effective, it is underused. About 45 million couples worldwide rely on vasectomy for contraception, compared with about 150 million for female sterilization. Over the last decade, promotional efforts in Colombia, Kenya, Mexico and other countries have resulted in some increased use, but even there, less than 1 percent of married couples of reproductive age use vasectomy. Only in China, the Republic of Korea and a few developed countries (Australia, Canada, the Netherlands, United Kingdom and United States) do 10 percent or more of couples rely on this method.3
Why men use it
In an MSI questionnaire returned by about 500 men who received a vasectomy in 1997, 27 percent said they chose vasectomy to relieve their partner from using contraception. Another 31 percent said they had completed their family, and vasectomy was the best permanent form of contraception.
In a six-country study involving in-depth interviews with 218 couples, virtually all couples cited economic reasons and a concern for women's health as a motivating factor for not wanting any more children. The results were remarkably similar across the six countries surveyed -- Bangladesh, Kenya, Mexico, Rwanda, Sri Lanka and the United States. In every country, many couples chose vasectomy because it was a safer choice than tubal ligation.4
Research in Brazil, Colombia and Mexico also found that men's concerns about their wives, and the wives themselves, play an important role in a decision to have a vasectomy. Men said they had vasectomies because of "its advantages over female sterilization and temporary methods, [their] concern for their wife and her health, their desire to share responsibility for family planning, and the freedom from unintended pregnancy that vasectomy confers," the study reports.5
Research in Colombia has found that various promotional techniques can be effective, including word of mouth.6 The Asociación Probienestar de la Familia Colombiana (PROFAMILIA), the largest family planning provider in Colombia, has been a leading vasectomy promoter for nearly two decades. "Our outreach for vasectomy is constant," says Maria Isabel Plata, PROFAMILIA director. "Word of mouth is the best way to promote it. We stress quality of care. When we have happy clients, we get more clients."
Word-of-mouth promotions can be structured, sometimes involving couples. In a training course in Kenya for providers, 17 men volunteered to share their vasectomy experience. Many of these men had never spoken about their vasectomy, and a sense of solidarity emerged among the group. Some appeared in media campaigns, others volunteered at clinics to talk with men considering vasectomies, and still others worked with couples in outreach efforts. As a result of the group's work, men in the area "were much more likely to consider vasectomy and to use condoms and were less likely to believe rumors associated with other methods than were men in other regions," explains a summary of the program.7
-- William R. Finger
References
Family Health International. Final Report: A Comparative Study of the No Scalpel and the Standard Incision Method of Vasectomy in Five Countries. Research Triangle Park, NC: Family Health International, 1996.
Family Health International. Time to Azoospermia After Vasectomy: Expanded Study - Final Report. Research Triangle Park, NC: Family Health International, 1997.
United Nations, Department of Economic and Social Resources. World Contraceptive Use, 1994, poster. New York: United Nations, 1995.
Landry E, Ward V. Perspectives from couples on the vasectomy decision: a six-country study. In Ravindran TKS, Berer M, Cottingham J, eds. Beyond Acceptability: Users' Perspectives on Contraception. (London: Reproductive Health Matters, 1997) 58-67.
Vernon R. Operations research on promoting vasectomy in three Latin American countries. Int Fam Plann Perspect 1996;22(1):26-31.
Vernon R, Ojeda G, Vega A. Making vasectomy services more acceptable to men. Int Fam Plann Perspect 1991;17(2):55-60.
AVSC International. Men as Partners in Reproductive Health Workshop Report - Mombasa, Kenya, May 1997. (New York: AVSC International, 1997) 14.
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