The article by Amanda Davies and Charlotte Fleming[1] describes what
we have been practising for many years.
We have run a direct access service dealing with over 4000 patients.
The service has been well received with 96% of a sample grading it as good
or excellent.[2]
We do not see the need for a preoperative consultation and agree with
the authors that this does not add any quality to the service or th...
The article by Amanda Davies and Charlotte Fleming[1] describes what
we have been practising for many years.
We have run a direct access service dealing with over 4000 patients.
The service has been well received with 96% of a sample grading it as good
or excellent.[2]
We do not see the need for a preoperative consultation and agree with
the authors that this does not add any quality to the service or the
patient journey. Advice and information provided by the referring general
practitioner is considered adequate.
In our service, when the patient attends on the day a short
discussion takes place with the patient and with the partner if present.
This discussion touches upon complications including pain, natural
reversal rate of the procedure, postoperative seminal fluid analysis and
the need for continuing contraception after surgery. Most, if not all,
patients are adequately informed when they attend. This process aids
informed consent.
However, the need for a preoperative consultation is advised in the
following circumstances: (1) in patients who have had inguino-scrotal
surgery (e.g. for undescended testis, hernia repair, excision of
hydrocele, etc.) and (2) a repeat procedure following failure of vasectomy
or vasectomy after reversal. In these situations it is useful to know if
the vas is palpable, not surrounded by dense fibrous tissue and hence
exteriorised relatively easily under local anaesthesia.
References
1. Davies A, Fleming C. Vasectomy: replacing the preoperative
outpatient appointment with a DVD. J Fam Plann Reprod Health Care 2013.
doi:10.1136/jfprhc-2013-100584.
2. Menon NK. Patient satisfaction with a direct access vasectomy
service. Br J Fam Plann 1998;24:105-106.
I was very interested to read about Drs Partridge and Bush's
experiences with subdermal implant infections.[1] In particular the
photographic images were strikingly similar in appearance to the features
I observed in the case described in my recent letter to the Journal.[2]
It is interesting that all three cases described occurred in patients
with pre-existing eczema. This feature was not shared with my patient w...
I was very interested to read about Drs Partridge and Bush's
experiences with subdermal implant infections.[1] In particular the
photographic images were strikingly similar in appearance to the features
I observed in the case described in my recent letter to the Journal.[2]
It is interesting that all three cases described occurred in patients
with pre-existing eczema. This feature was not shared with my patient who
does not have any pre-existing dermatological condition.
In particular there seem to be marked similarities between my case
and the first two cases described by Drs Partridge and Bush in terms of
the delayed presentation, transient period of apparent improvement with
antibiotics followed by subsequent recurrence, culminating in eventual
breakdown of skin at the insertion site with partial expulsion/self-extrusion.
I agree that it would be appropriate to assess the skin at the
insertion site and also that attention be paid to maintaining conditions
so that fittings are performed by aseptic technique to minimise implant-related infections.
References
1. Partridge R, Bush J. Infections post-Nexplanon? fit. J Fam Plann
Reprod Health Care 2013;39:309-310.
2. Chaudhry F. Adverse reaction to Nexplanon?. J Fam Plann Reprod
Health Care 2013;39:231-232.
We thank Drs Chukwu and Menon[1] for their interest in our
article,[2] and are pleased to hear that their DVD is as popular with the
patients as ours is.
We also started out requiring men who had a history of previous
scrotal surgery to come for an appointment prior to their vasectomy. This
was in order to carry out an examination to check that the procedure was
likely to be possible under local anaesthetic. Ho...
We thank Drs Chukwu and Menon[1] for their interest in our
article,[2] and are pleased to hear that their DVD is as popular with the
patients as ours is.
We also started out requiring men who had a history of previous
scrotal surgery to come for an appointment prior to their vasectomy. This
was in order to carry out an examination to check that the procedure was
likely to be possible under local anaesthetic. However, we subsequently
analysed this practice and discovered that those men were no more likely
to have a failed procedure than those who had no previous history of
scrotal surgery, and so we now allow this group of patients also to bypass
the preoperative appointment.
Patients who have had failed vasectomy are seen for a consultation
prior to repeat procedure, as in Drs Chukwu and Menon's practice. Men with
a self-diagnosed testicular mass, plus those under the age of 28 years and
those on warfarin, are also required to attend for a clinic appointment
prior to being listed for their vasectomy. In addition, the DVD offers an
outpatient appointment to any patient who wishes to discuss vasectomy with
a clinician.
References
1. Chukwu A, Menon K. Comment on 'Vasectomy: replacing the
preoperative outpatient appointment with a DVD'. J Fam Plann Reprod Health
Care 2013;27 October 2013 [Epub ahead of print].
2. Davies A, Fleming C. Vasectomy: replacing the preoperative
outpatient appointment with a DVD. J Fam Plann Reprod Health Care 2013.
doi:10.1136/jfprhc-2013-100584.
While acknowledging that the article 'Embracing post-fertilisation
methods of family planning: a call to action' [1] is a personal view, the
authors appear to assume that readers of the Journal will agree and be
motivated to promote such methods. I would like to voice the view that I
and many others would find this unethical. This is a price too high to pay
to in our desire to help prevent unplanned pregnancies.
While acknowledging that the article 'Embracing post-fertilisation
methods of family planning: a call to action' [1] is a personal view, the
authors appear to assume that readers of the Journal will agree and be
motivated to promote such methods. I would like to voice the view that I
and many others would find this unethical. This is a price too high to pay
to in our desire to help prevent unplanned pregnancies.
Reference
1. Raymond EG, Coeytaux F, Gemzell-Danielsson K, et al. Embracing post-fertilisation methods of family planning: a call to action. J Fam Plann
Reprod Health Care 2013;39:244-246.
Dr Gordon is uncomfortable with a family planning method that exerts
its effect after fertilisation.[1] However, a new study, published after
our personal view article was already in press, suggests that many women
feel differently.
This study surveyed 1137 women from randomly selected households in
five European countries in 2008.[2] Overall, 41% of the respondents said
they would consider using a method that...
Dr Gordon is uncomfortable with a family planning method that exerts
its effect after fertilisation.[1] However, a new study, published after
our personal view article was already in press, suggests that many women
feel differently.
This study surveyed 1137 women from randomly selected households in
five European countries in 2008.[2] Overall, 41% of the respondents said
they would consider using a method that may work after fertilisation, and
23% would consider using one that may work after implantation. Given the
pressing importance of fertility regulation to both individuals and
society and the potential benefits of post-fertilisation methods, we hope
that readers of this Journal who respect each woman's right to make her
own reproductive decisions will advocate for research to develop such
products.
References
1. Gordon S. Comment on 'Embracing post-fertilisation methods of
family planning: a call to action'. J Fam Plann Reprod Health Care 2013; 5
November 2013 [Epub ahead of print].
2. Lopez-Del Burgo C, Mikolajczyk RT, Osorio A, et al. Women's
attitudes towards mechanisms of action of birth control methods: a cross-sectional study in five European countries. J Clin Nurs 2013;22:3006-3015.
We read with interest the article by Michie et al. in the October
2013 Journal.[1]
We are delighted that our colleagues at a sexual and reproductive
health meeting are supportive of the concept of running an abortion
service from a community setting. In Torbay we have been running such a
service for some years originally delivered by BPAS and now delivered, for
the last 12 months, by the integrated Torbay Sexual...
We read with interest the article by Michie et al. in the October
2013 Journal.[1]
We are delighted that our colleagues at a sexual and reproductive
health meeting are supportive of the concept of running an abortion
service from a community setting. In Torbay we have been running such a
service for some years originally delivered by BPAS and now delivered, for
the last 12 months, by the integrated Torbay Sexual Medicine Service
(tSMS), hosted by South Devon Healthcare Foundation Trust (SDHCFT).
The pre-abortion counselling, the medical assessment, the ultrasound
scan and the early medical abortion (EMA) service are all delivered from a
community-based health centre. The staff and the patients felt that this
was a natural extension of the integrated sexual medicine service, which
also includes sexually transmitted infection (STI) management,
contraception, a chlamydia screening service, HIV care and an outreach
service.
The only part of the abortion service that requires hospital care is
the surgical termination of pregnancy service, which is delivered by the
gynaecologists of SDHCFT and our colleagues from BPAS.
The third key message from the article was about the improvement in
contraceptive and STI management. Since the service has been taken into
the integrated service the rates of STI diagnosis, the rates of patients
having long-acting reversible contraception post-procedure, and the rates
of the use of EMA compared with surgery have all significantly increased.
In conclusion, we hope the above information confirms the notion of
the Michie et al. article that not only is a community-based service
desirable, it is also feasible and practical.
Reference
1. Michie L, Cameron ST, Glasier A. Abortion care services delivered
from a community sexual and reproductive health setting: views of health
care professionals. J Fam Plann Reprod Health Care 2013; 39: 270-275.
Following a 7-month trial on the use of Entonox for the relief of
pain or anxiety during intrauterine device (IUD) or intrauterine system
(IUS) fitting, we now offer this method of pain relief to all women
attending for an intrauterine procedure. It is available to any patient
who wishes to use it but its use is entirely optional. Entonox can be used
alongside other analgesics and there is no need for the woman to decide...
Following a 7-month trial on the use of Entonox for the relief of
pain or anxiety during intrauterine device (IUD) or intrauterine system
(IUS) fitting, we now offer this method of pain relief to all women
attending for an intrauterine procedure. It is available to any patient
who wishes to use it but its use is entirely optional. Entonox can be used
alongside other analgesics and there is no need for the woman to decide
beforehand.
Our services currently insert a minimum of 20 IUDs/IUSs per week at
two clinic sites in Central Buckinghamshire, UK. The clinics serve all
ages and client groups who mainly self-refer, as well as accepting general
practitioner (GP) referrals for emergency IUDs.
Reducing pain and anxiety for these procedures has been much debated
over the last few years. Hutt[1] and more recently Akintomide et al.[2]
have advocated an increased use of intracervical local anaesthesia.
Hutt[3] suggests that lignocaine gel is ineffective and that "...it is simply a salve to our guilty consciences".
Entonox provides pain relief and conscious sedation for a variety of
short-term procedures[4] and is licensed for such indications.[5] The
manufacturer of Entonox, BOC, expects that within a minute of
discontinuing breathing Entonox the effect has worn off so clients could
drive within 30 minutes of the procedure. This is confirmed in the Summary
of Product Characteristics (SPC).[5] Our National Health Service Trust states that clients
should not drive for 12 hours after using Entonox. We counsel women prior
to procedures and are hoping that the Trust will take a more pragmatic
stance in the future in the light of BOC's guidance and the information
within the SPC. Our current information states: "[Entonox] wears off
within a minute or two of stopping breathing it, however, please note
that: (a) it is currently a Trust policy that she should not drive herself
home if she has used Entonox so needs to arrange a lift, and (b) she
should not use Entonox if she has recently had a 'burst eardrum' or within
48 hours of SCUBA diving."
Since introducing Entonox in our clinics, we have had a steady rise
in the number of clients opting for IUD/IUS. Some state that they choose
our service "... because you have the 'gas and air'". However, some women
also state that at a previous procedure carried by their GP they had not
been advised to take any analgesics beforehand nor were they offered any
at the procedure. The clinics run a large teaching practice for both GPs
and nurses, and the many GPs we talk to who state that they never give
intracervical local anaesthesia as "women don't need it" are perhaps
unaware of the number of women who choose to go to a Level 3 service for
their next IUD/IUS in the hope of a better experience when analgesia is
available. I suggest that these women are reluctant to tell their GPs,
whom they like and trust, that the procedure was less than perfect.
Striking the balance between letting women know that Entonox is
available and worrying some who say "...if it is so painful you need 'gas
and air' I am not having one", has been something we have addressed in our
literature and by having a poster containing information and comments in
the waiting room.
The final word needs to go to one of our satisfied clients: "10 years
of contraception and gas to breathe when it's fitted, what's not to
like?".
Journal readers who would like further information on using Entonox
for procedures or who are interested in the questionnaire from which the
quotations above were taken and its audit may e-mail me direct.
References
1. Hutt S. Injectable local anaesthesia for IUD/IUS fittings J Fam
Plann Reprod Health Care 2011;37:59.
2. Akintomide H, Sewell R, Stephenson J. The use of local
anaesthesia for intrauterine device insertion by health professionals in
the UK. J Fam Plann Reprod Health Care 2013;39:276-280.
3. Hutt S. Option of local anaesthetic for IUD fittings: author's
response. J Fam Plann Reprod Health Care 2011;37:190.
4. BOC. How ENTONOX works. 2012.
http://www.entonox.co.uk/en/discover_entonox/how_entonox_works/index.shtml?style
[accessed 13 June 2012].
5. Entonox: Summary of Product Characteristics. 2013.
http://www.mhra.gov.uk/home/groups/spcpil/documents/spcpil/con1384326173333.pdf
[accessed 17 December 2013].
Congratulations are due to the authors for producing much needed
guidelines.[1] These are necessarily a consensus owing to the lack of
quality studies on pharmacological interventions. Since 2009 I have
provided a referral service for intrauterine device (IUD) problems, and
currently manage 400-500 referrals per year for failed insertion or
removal, or a history of severe pain and/or vasovagal syncope (VVS). Women
referr...
Congratulations are due to the authors for producing much needed
guidelines.[1] These are necessarily a consensus owing to the lack of
quality studies on pharmacological interventions. Since 2009 I have
provided a referral service for intrauterine device (IUD) problems, and
currently manage 400-500 referrals per year for failed insertion or
removal, or a history of severe pain and/or vasovagal syncope (VVS). Women
referred are motivated to persevere with this method despite a bad
experience. There are no data to indicate how many women are put off by a
poor experience and rule out this method of contraception and/or menstrual
control. In my experience, concerns around the fitting are the main
barrier to improving the overall low uptake of intrauterine methods in the
UK. I would strongly echo the consensus that the setting, confidence and
technique of the provider, and particularly the presence of an assistant
skilled at addressing anxiety, are key to the overall experience.
There are six points where I differ from Bahamondes et al.'s
recommended practice.
1. I am fortunate to have an electric lithotomy couch but rarely use
the leg supports, usually only where access to the cervix is particularly
difficult. My preferred position is sitting on a stool with wheels at the
side of the couch rather than with the woman at the end of the couch.
Importantly the bed is elevated enough that my legs fit in under the couch
so the cervix is comfortably at eye level.
2. The consensus view was that a tenaculum should always be applied.
I avoid this painful stimulus if fitting is possible using gel alone. A
tenaculum is essential for GyneFix. However, with framed devices it is
often unnecessary and will only increase pain. Admittedly I have the
benefit of a scanner at the bedside and routinely check the position of
any IUD. Accurate fundal placement and minimising the risk of perforation
depends on good technique but this need not include use of a tenaculum in
many cases.
3. I disagree with the authors' recommended toothed tenaculum
pictured in their Figure 1. Although rarely reported,[2] I have seen
several cases with an IUD thread exiting the cervix through a fistula, and
one case where an intrauterine system reservoir was visibly protruding
from a fistula with the thread running back into the fistula and out of
the os. It is possible a fistulous tract may be created where tenaculum
teeth penetrated the cervix with the threads then finding their way into
the tract before it heals. I would recommend use of less traumatic forceps
such as Judd-Allis or Littlewood.
4. I endorse the superiority of tapered (e.g. Bonney Barker type)
dilators over shouldered (Hegar type) dilators, but more than this there
is a technique for finding the path of least resistance. Careful bimanual
examination establishing the position of the fundus relative to the cervix
does not allow the inserter to judge the exact direction to angle the
dilator when they meet resistance. Straightening the cervico-isthmic
junction with traction on the cervix can sometimes be helpful. However
gently manipulating a dilator through 360 degrees and sometimes changing the
angle quite acutely may find a path with almost no resistance. This is
much easier with a scanner at the bedside and a uterus that is
sufficiently anteverted for simultaneous ultrasound guidance. Through use
of simultaneous ultrasound guidance I have noted that suprapubic pressure
can sometimes relax the internal os. On occasions when I have left the
sound at the point of resistance while helping the assistant focus the
image on the endocervical-endometrial canal we have noted the sound
suddenly 'fall into' the cavity. I have not tried a suprapubic warming
pack but presume that this is likely to have the same or better effect.
5. The os finder is good for stenosis of the external os. I would not
recommend its use to overcome stenosis (or spasm) of the internal os. A
tapered metal dilator would be my instrument of choice as it enables one
to find a path of least resistance when the dilator is gently rotated and
angulated at the point of resistance. One cannot do this with the os
finder as it is too flexible and too sharp.
6. The authors recommend an intracervical block for difficult
sounding. Cochrane Reviews conclude there is inadequate evidence of
benefit with local anaesthetic. However, data available on abortion under
local anaesthetic supports that deep paracervical injection combined with
a relatively high concentration of intrauterine lidocaine infusion
improves pain scores.[3] So my own practice where injection is needed is
to insert a paracervical block. My understanding of the difference between
intracervical and paracervical block is that with the former the needle is
introduced through the cervical os and with the latter the needle is
introduced a distance of 1-2 cm lateral to the os, which enables placement
of the block at a higher level. I would strongly discourage use of a
syringe with a 21 gauge needle, not only because it does not fit down the
speculum leaving room for visualisation but because the needle size is too
large for comfort. Use of a dental syringe with long 27 gauge needle is
superior. Although one cannot exclude vascular injection by checking for
backflow, in practice a slight resistance with injection should confirm
placement within tissue.
A recurring proportion of referrals are women who have had an IUD
removed followed by failed reinsertion. This supports the impression that
reflex closure of the internal os may be triggered by the stimulus of
removing a device. Personally I have found the technique of slow filling
the cavity with local anaesthetic gel, avoiding overfilling by asking the
woman to say as soon as any sensation of cramping starts, and waiting
several minutes together with care to avoid any sudden or sharp stimulus
on removal of the old device avoids this problem. A criticism of this
technique is that there is a lack of evidence. However, studies on topical
gel have generally not considered the difference between endometrial and
endocervical absorption nor the importance that 3 minutes or less may be
unrealistically short for topical absorption. Evidence to support this
practice lies in the success of managing 99% of referrals with one or more
previous failed procedures in a 30-minute one-stop outpatient appointment,
and a VVS rate of less than 0.2% (two cases in over 4 years, neither
requiring medication) despite high-risk referrals, a number of whom had
experienced severe VVS at a previous procedure. It is my personal view
that a painful stimulus is likely to be the most important cause of VVS.
References
1. Bahamondes L, Mansour D, Fiala C, et al. Practical advice for
avoidance of pain associated with insertion of intrauterine
contraceptives. J Fam Plann Reprod Health Care 2013; 40: 54-60.
2. Gonec I, Zeynep E, Vural T, et al. Cervical perforation by the
strings of a levonorgestrel releasing-intrauterine system: a case report.
Eur J Contracept Reprod Health Care, 2013; 18: 415-418.
3. Renner RM, Jensen JT, Nichols MD, et al. Pain control in first
trimester surgical abortion. Cochrane Database of Systematic Reviews 2009;
2: CD006712.
I was deeply saddened to read the opinions of Dr Rowlands in his
article entitled 'The policing of abortion services in England' in the
April 2013 issue of the Journal.[1] Although the argument is clear that
the requirement for two signatures on the HSA1 form is burdensome, and is
not seen as necessary by everyone, the article seems to miss a key point.
An overriding ethical duty for any clinician is truth telling, with...
I was deeply saddened to read the opinions of Dr Rowlands in his
article entitled 'The policing of abortion services in England' in the
April 2013 issue of the Journal.[1] Although the argument is clear that
the requirement for two signatures on the HSA1 form is burdensome, and is
not seen as necessary by everyone, the article seems to miss a key point.
An overriding ethical duty for any clinician is truth telling, with the
quality of probity reflecting this. By pre-signing blank forms for
abortion, the clinician is failing on both of these accounts. To sign
that one is satisfied that a procedure can take place in the absence of
knowledge of the patient is a clear departure from truth telling, and
raises important questions about probity. The pre-signature demonstrates
a willingness of the clinician to claim falsely that they have assessed a
patient, either in person or via professional consultation. Perhaps the
seriousness of a false claim has been underestimated in Dr Rowlands'
considerations in terms of its reflection on us as practitioners. The
need for simplification of the abortion process is stated eloquently, but
still must not be used as a justification for departure from professional
standards of behaviour.
Reference
1. Rowlands S. The policing of abortion services in England. J Fam
Plann Reprod Health Care 2013;39:121-126.
We thank Dr Kell and Ms McMahon for their comments[1] on our
article[2] and for sharing their experience of running an abortion service
from a community setting. It is reassuring to learn that both staff and
patients welcomed this service and that contraceptive provision and
sexually transmitted infection diagnosis have improved as a result. We
hope other clinicians providing abortion care services may be encouraged
to c...
We thank Dr Kell and Ms McMahon for their comments[1] on our
article[2] and for sharing their experience of running an abortion service
from a community setting. It is reassuring to learn that both staff and
patients welcomed this service and that contraceptive provision and
sexually transmitted infection diagnosis have improved as a result. We
hope other clinicians providing abortion care services may be encouraged
to consider the potential benefits of providing such services from a
community setting.
References
1. Kell P, McMahon K. Comment on 'Abortion care services delivered
from a community sexual and reproductive health setting: views of health
care professionals'. J Fam Plann Reprod Health Care
2014;doi:10.1136/jfprhc-2013-100863.
2. Michie L, Cameron ST, Glasier A. Abortion care services delivered
from a community sexual and reproductive health setting: views of health
care professionals. J Fam Plann Reprod Health Care 2013;39:270-275.
The article by Amanda Davies and Charlotte Fleming[1] describes what we have been practising for many years.
We have run a direct access service dealing with over 4000 patients. The service has been well received with 96% of a sample grading it as good or excellent.[2]
We do not see the need for a preoperative consultation and agree with the authors that this does not add any quality to the service or th...
I was very interested to read about Drs Partridge and Bush's experiences with subdermal implant infections.[1] In particular the photographic images were strikingly similar in appearance to the features I observed in the case described in my recent letter to the Journal.[2]
It is interesting that all three cases described occurred in patients with pre-existing eczema. This feature was not shared with my patient w...
We thank Drs Chukwu and Menon[1] for their interest in our article,[2] and are pleased to hear that their DVD is as popular with the patients as ours is.
We also started out requiring men who had a history of previous scrotal surgery to come for an appointment prior to their vasectomy. This was in order to carry out an examination to check that the procedure was likely to be possible under local anaesthetic. Ho...
While acknowledging that the article 'Embracing post-fertilisation methods of family planning: a call to action' [1] is a personal view, the authors appear to assume that readers of the Journal will agree and be motivated to promote such methods. I would like to voice the view that I and many others would find this unethical. This is a price too high to pay to in our desire to help prevent unplanned pregnancies.
...
Dr Gordon is uncomfortable with a family planning method that exerts its effect after fertilisation.[1] However, a new study, published after our personal view article was already in press, suggests that many women feel differently.
This study surveyed 1137 women from randomly selected households in five European countries in 2008.[2] Overall, 41% of the respondents said they would consider using a method that...
We read with interest the article by Michie et al. in the October 2013 Journal.[1]
We are delighted that our colleagues at a sexual and reproductive health meeting are supportive of the concept of running an abortion service from a community setting. In Torbay we have been running such a service for some years originally delivered by BPAS and now delivered, for the last 12 months, by the integrated Torbay Sexual...
Following a 7-month trial on the use of Entonox for the relief of pain or anxiety during intrauterine device (IUD) or intrauterine system (IUS) fitting, we now offer this method of pain relief to all women attending for an intrauterine procedure. It is available to any patient who wishes to use it but its use is entirely optional. Entonox can be used alongside other analgesics and there is no need for the woman to decide...
Congratulations are due to the authors for producing much needed guidelines.[1] These are necessarily a consensus owing to the lack of quality studies on pharmacological interventions. Since 2009 I have provided a referral service for intrauterine device (IUD) problems, and currently manage 400-500 referrals per year for failed insertion or removal, or a history of severe pain and/or vasovagal syncope (VVS). Women referr...
I was deeply saddened to read the opinions of Dr Rowlands in his article entitled 'The policing of abortion services in England' in the April 2013 issue of the Journal.[1] Although the argument is clear that the requirement for two signatures on the HSA1 form is burdensome, and is not seen as necessary by everyone, the article seems to miss a key point. An overriding ethical duty for any clinician is truth telling, with...
We thank Dr Kell and Ms McMahon for their comments[1] on our article[2] and for sharing their experience of running an abortion service from a community setting. It is reassuring to learn that both staff and patients welcomed this service and that contraceptive provision and sexually transmitted infection diagnosis have improved as a result. We hope other clinicians providing abortion care services may be encouraged to c...
Pages