A Successful Multi-Component Program for Expanding Vasectomy Services by MSI Reproductive Choices Bolivia

Initial Program Activities (July 2021-December 2021)

MSI Bolivia partnered with WVD in July 2021 to organize a provider training. WVD identified representatives from NSVI and Laval University, authors JC and ML, to serve as master trainers. The collaborating organizations met virtually on multiple occasions in 2021 to plan the training, including identifying the number of providers to train and scheduling a week-long teaching program at the MSI Bolivia La Paz clinic from November 1 to November 6, 2021. In advance of the training, MSI Bolivia assured buy-in and support from all levels of the organization and beyond. All six clinics located in the main cities of the country (La Paz, El Alto, Sucre, Cochabamba and Santa Cruz) agreed to add no-scalpel vasectomy (NSV) in their service offering.

The MSI Bolivia marketing team generated demand through an extensive and organized social media campaign across Facebook, Instagram, and TikTok, conducted one month in advance of the training. The social marketing campaign utilized humor ( Figure 3), factual medical information, and interviews with a Spanish-speaking physician practicing NSV advertising free availability of vasectomies during November 2021. Free-of-charge vasectomies were made possible through a grant from the Erik and Edith Bergstrom Foundation, Palo Alto, California, USA. Interested individuals were advised to contact the MSI Call Center via phone for further information and to schedule an appointment. Interested men were scheduled for a clinical consultation and evaluation.

Figure 2. MSI Bolivia Program Model 2021 Vasectomy Campaign.

Figure 3. Examples of social media (Facebook) advertisements for the vasectomy campaign.

In consultations among the partner institutions, it was determined that training four providers would be feasible within the one-week supervised training period. The figure was based on the number of master trainers, the feasible number of clients, and the intention that these initial four providers would train other providers within the MSI Bolivia network. The MSI clinical team pre-selected eight candidates from across the country based on clinical skills as well as training capacity. Pre-selected candidates were invited to submit a five-minute video on how they would train colleagues to perform contraceptive implant insertion. A selection committee composed of the clinical team and the senior management team reviewed the videos, evaluating both their procedural skills and their skill in training other providers, and selected the four providers to be trained. The four physicians each represented different clinics and mobile units covering Bolivia.

MSI Bolivia led the management of key logistics, including organizing physical clinic space for procedures, procuring instrument kits, and training support staff in sterilization and procedure room turnover. Vasectomy services were provided according to MSI worldwide norms, including pre-procedure counseling and informed consent.⁹ Days prior to the surgery, potential patients attended a vasectomy counseling session with providers trained on vasectomy counseling during which their questions were answered and eligibility confirmed. Due to the active COVID-19 pandemic at the time of the campaign, partners were not able to attend consultations or the procedure.

Upon arrival to the clinic, patients privately meet with their vasectomy provider who again reviewed the process and provided pre-op counseling, after which, the patient signed an informed consent form for the procedure. After the surgery, a physician provided post-op recommendations while he was resting in a recovery room.

The six-day training program involved didactic sessions, practice on vasectomy simulators prototypes (scrotal models) developed by Laval University ( Figure 4), and supervised practice on humans. The techniques taught were the mini-needle technique to perform local anesthesia,¹⁰ the NSV to isolate and expose the vas deferens,¹¹ and thermal cautery and fascial interposition to occlude the vas,¹² as recommended in international vasectomy guidelines.¹³

Figure 4. Trainee performing a simulated no-scalpel vasectomy under the supervision of her trainer.

For each vasectomy performed, the surgical team consisted of one master trainer and two trainees on a rotating schedule to ensure each trainee learned alongside both master trainers and each of their peers. One trainee would perform the vasectomy while the trainer and the other trainee observed. The trainees were evaluated daily using detailed written spreadsheets (see Appendix 1). These spreadsheets had columns for each step of the procedure, allowing the trainers to focus on the specific details needed to advance the skills of the trainees. Both the trainer and trainee used the same tool to evaluate the trainee performing the surgery, as MSI Bolivia planned that trainees would instruct their peers in the future.

The six-day training program began with one half-day of watching presentations and practicing on vasectomy simulators (scrotal models) followed by three supervised vasectomies on patients by each trainee. The five subsequent days included a one-hour session at the beginning of the day devoted to reviewing and demonstrating acquired skills on scrotal models followed by six supervised vasectomies. At the end of each training day, trainers and trainees met for 30- to 60-minute debriefing sessions. They reviewed new skills practiced during the day. They discussed what went well and what to improve based on the evaluation forms. They also planned specific skills to practice over the next days. Over the six days, each trainee completed 33 supervised cases. To support continued learning, trainees continued to work in pairs for their first 100 procedures.

MSI Bolivia held a press conference and informational event called “VasectoMITOS” (vasecto-myths, in English) to publicize the campaign, engage stakeholders, and disseminate learnings during the training week. Attendees included sexual and reproductive health advocates and organizations in Bolivia, as well as the contracted urologists already working with the organization and other vasectomy providers. The event included a panel presentation, a conversation with a vasectomy patient, promotional videos, and a reception. Other efforts to engage stakeholders included inviting family planning organizations, specialists, and urologists to observe the training at the La Paz clinic to foster cooperation.

Follow-up Program Activities (January 2022-December 2023)

Once a sufficient cadre of providers had been trained, starting in May 2022, MSI Bolivia reduced the fees charged for a vasectomy from 1500 Bolivianos (USD 215) to 850 Bolivianos (USD 122) in all their clinics nationwide. In line with World Vasectomy Day activities in November 2022, MSI Bolivia conducted another free vasectomy campaign, advertised via social media through November and half of December 2022. Similarly, in 2023, MSI Bolivia organized another campaign, this time from October through November 2023. Both campaigns were held in the cities of La Paz, El Alto, Cochabamba, Santa Cruz de la Sierra, and Sucre.

Two of the newly trained physicians in November 2021 taught NSV to seven other MSI Bolivia colleagues in 2022, and an additional four colleagues in 2023, replicating the training techniques from the original training. Trainees practiced on scrotal models, performed vasectomies under supervision, debriefed their training progress daily and were left to work in pairs supporting each other immediately after the training.

Initial Program Activities (July 2021-December 2021)

During the 2021 social media campaign, MSI Bolivia received triple the number of calls requesting appointments compared to the average number of calls received each month. A total of 884 men registered, 703 attended an initial consultation, and over 600 were scheduled for the procedure.

The social media campaign generated tens of thousands of views. The initial advertising post on Facebook had 3,600 reactions, 870 comments, and 3,700 shares ( Figure 2), while another video on TikTok generated 86,400 views and 7,973 reactions.

One hundred and thirty-three (133) men were scheduled for a vasectomy during the November 1-6, 2021 training week. Five did not present for their appointment, leading to a total of 127 vasectomies performed. During the first 2.5 days, the trainers administered the local anesthesia, and maintained a low threshold for taking over the case if the trainees faltered. According to the evaluation tool, the trainees reported increasing confidence and skill each day in anesthesia, isolation of the vas using no-scalpel technique, mucosal thermal cautery, and fascial interposition. After day four, the trainers only provided remote supervision with the two trainees working together and supervising each other. All four doctors exhibited an ability to conduct vasectomies independently with various skill levels by the end of the week. No patients suffered complications, either during the procedure or in the first days following the surgery.

Trainee feedback was overall very positive. They rated the presentations, the rotational training approach, and the practicing with vasectomy simulators very highly. Over the following weeks, the four trainees performed over 300 additional unsupervised vasectomies in La Paz, Cochabamba, and Santa Cruz de la Sierra. During this period, they worked in pairs for mutual support. The vasectomy expert trainers continued to provide support to trainees through both WhatsApp and email.

The “VasectoMITOS” event held during the training week gathered to 40 participants from various organizations and was reported in the local media. The event attendees included urologists from around Bolivia, representatives from ProMujer, CIES, Plan International, CECI, InnovaSalud, Servicio Plurinacional de la Mujer (a government agency that is part of the Ministry of Justice), Organon, UNFPA Bolivia, SEDES La Paz (state health department), and Sinergía.

Follow-up Program Activities (2022-2023)

During 2022, MSI Bolivia went from four to 11 trained providers country wide. In April 2022, two of the initially trained physicians taught NSV to two colleagues from La Paz offering mobile services to remote areas served by the La Paz and El Alto clinics. They subsequently trained two others from Cochabamba in August 2022, two more in November 2022 (one from La Paz and one from Sucre) and a final one in Santa Cruz in December 2022.

MSI Bolivia received 4,926 and 6,688 calls, and scheduled 803 and 1,390 consultations and 540 and 776 procedures during the 2022 campaign from November to mid-December and the 2023 campaign from October to November, respectively. Table 1 presents the number of vasectomies performed annually in each of the MSI Bolivia clinics from 2019 to 2023. The number of vasectomies had already increased in 2020 before availability of in-house vasectomy providers. However, compared to 2020, the number doubled in 2021, tripled in 2022, and almost quadrupled in 2023. MSI Bolivia’s own physicians performed 66% (431/643), 94% (864/918), and 100% (1135/1135) of the vasectomies provided by the organization in 2021, 2022, and 2023, respectively, Vasectomy was performed in all six of their clinics.

The 11 MSI Bolivia-trained physicians performed 2,303 vasectomies by the end of 2023. Most physicians, even the most recently trained, performed more than 100 procedures after their training. It was initially difficult to stimulate demand in remote areas served by mobile units (21 vasectomies in 2022) due to resistant cultural norms around family planning uptake generally and machismo attitudes surrounding vasectomy in particular. Targeted peri-urban campaigns in 2023 helped improve access and overcome some of the resistance, with 141 vasectomies performed in 2023.

Although both the number of vasectomies and tubectomies performed in the MSI Bolivia clinics increased between 2019 and 2023, the ratio of tubal ligations to vasectomies changed during this period ( Figure 5). From 7.1 tubectomies to one vasectomy in 2019, this ratio decreased to 1.5 in 2020 and to 0.9 in 2023, indicating that more vasectomies than tubal ligations were performed in MSI Bolivia clinics in 2023.

Figure 5. Number of vasectomies and tubectomies performed in the MSI Bolivia vasectomy clinics from 2019 to 2023.