Introduction
Vasectomy is the most effective method of male contraception, and an estimated 40 to 60 million men rely on it for birth control worldwide1. Due to its high efficacy, safety, low complication rate, and no associated serious long-term side-effects, vasectomy is an important option for couples interested in preventing pregnancy. More than 40,000 vasectomies are performed annually in Taiwan2, however little is known about the men who choose to undergo the procedure.
Black and Hispanic men have a significantly lower rate of vasectomy independently of demographic, partner, and socioeconomic factors than Caucasian men in the United States according to the 2002 National Survey of Family Growth3. In Taiwan, female surgical sterilization (tubal ligation) is performed more frequently than vasectomy. In 2012, 18 families chose tubal ligation and four chose vasectomy for surgical sterilization of a total of 1923 families according to the Ministry of Health and Welfare in Taiwan4. The National Survey of Family Growth reported that tubal ligation rates are dependent upon religion, education, parity, and race5.
Based on these findings, we hypothesized that rates of surgical sterilization in men are impacted by socioeconomic, education and parity status. Since the government in Taiwan implemented a family planning program in July 1964, the birth rate fell and the population became older. Therefore, the government encouraged families to have more children after 1998, however the birth rate has still not increased. More families practice birth control and more men choose vasectomy for contraception, although the proportion of tubal ligation in women has not increased. However, the dynamics of socioeconomic mobility change over time, and no recent studies have investigated whether a boom or downturn in the economy is related to the rate of vasectomy. Therefore, the aim of this study was to analyze the demographic,
socioeconomic, and reproductive characteristics of men who undergo vasectomy at a single institution. We collected data on tubal ligation at our institution from 2008 to 2011 from medical records.
Material and Method
From 2008 to 2011, 298 Taiwanese men received a vasectomy at our hospital. Questionnaires were administered in person or over the telephone. The
questionnaire contained six questions on gender, age, educational level, number of children, the family’s economic status, and the time from when the last child was born to the vasectomy. Six men were excluded due to other ethnicity, and 81 could not be contacted or did not complete the questionnaire. A further 49 men did not wish to participate in the study (Figure 1), and the remaining 162 men were enrolled in this study.
Trends in the economy from 2008 to 2011 were analyzed using Taiwan Monitoring Indicators published by The Council for Economic Planning and Development (CEPD)6 (http://index.ndc.gov.tw/n/en). The Taiwan Monitoring Indicators measure the current economic situation in Taiwan, and a higher score indicates a better economic situation. It is known as a "boom lights" system similar to traffic signals and
represents five different conditions. It currently consists of nine indicators such as scores of component indicators, money aggregates, stock price index, industrial production index, nonagricultural employment, customs-cleared exports, imports of machinery and electrical equipment, manufacturing sales index, sales of trade and food service, and the TIER manufacturing sector composite indicator. In accordance with changes in value of the constituent items, the CEPD publishes updated scores. The comprehensive judgment score is nine to 45 (Figure 2). A rising or falling score represents a booming or sluggish economy, respectively. We analyzed the
relationship between the seasonal number of sterilizations and the Taiwan Monitoring Indicators.
Statistical methods
Relationships between the number of seasonal contraceptive birth control surgeries (including vasectomy, tubal ligation and both) and seasonal monitoring indicators were evaluated using Pearson correlation coefficients. Statistical analyses were performed using SPSS version 17.0 (SPSS Inc., Chicago, IL, USA).
Results
The average age of the 162 men was 38.27±6.14 years (median: 37 years), and the men who chose vasectomy were well-educated (111 of the 162 above college level). Both of the parents worked in most of the families, with a family yearly income of around the average range in Taiwan (New Taiwanese dollars: 0.5-1 million/year)7.Most of those undergoing vasectomy (47.8%) underwent the procedure within 1 year after the last child had been born (Table 1).
The number of children and their gender in each family are shown in Table 2. Overall, 103 families (76%) had two children and only 19 families (11.7%) had no male children. We also found that there were 1.598-fold more boys than girls.
The number of vasectomies, tubal ligations and sterilizations and Taiwan Monitor Indicators by season are shown in Table 3. The relationships between the number of seasonal vasectomies and tubal ligations and seasonal monitoring indicators were -0.725 (P = 0.002) and -0.367 (P = 0.178), respectively. The season total number of sterilizations and seasonal Taiwan Monitoring indicators also had a negative
Discussion
Vasectomy is the most effective available method of male contraception. In Asia, approximately three quarters of the 32 million couples use vasectomy for birth control, with 20 million men undergoing a vasectomy in China and India8. We found that the men who received a vasectomy at our institute had a higher education level than average. In a study from the United States, most of the men who received a vasectomy had an education level above high school9.Previous studies have suggested that education level may allow stratification of men who undergo vasectomy5.
In the United States, a higher income was associated with vasectomy3; however, we did not find an association between family income and vasectomy. In Taiwan, well-educated parents and the middle class often plan to pursue a better quality of life and to save money10. Childcare including educational and medical costs is an economic burden as the government does not subsidize preschool childcare or after-school care11. Therefore, in households with a dual income, one of the parents may be forced to give up work to look after their children. Unintended pregnancies also incur extra medical costs12. Despite the introduction of highly effective reversible contraceptive methods, nearly half (49%) of the 6.4 million pregnancies each year in the United States are unintended13.The direct medical costs of these unintended pregnancies totaled US$5 billion, and the use of contraceptives saves nearly US$19 billion in direct medical costs each year12.
Among the men surveyed in our analysis, about half (47.8%) underwent a
vasectomy within 1 year after the last child had been born. There are three possible explanations for this finding. First, after birth, parents are likely to avoid another pregnancy. Second, when women are still breast-feeding, men have to take the responsibility of contraception. Third, men do not want their partners to suffer from the childbirth process.
In the United States, an increasing number of offspring has been shown to increase the rate of vasectomies, with the strongest increase after two or more children (OR 6.15, 95% CI 2.62–14.48)3. In our study, most families had two children (76%). This may be related to the family planning slogan of “Two's company, three's a crowd” that was used in 1964 and is still deeply rooted in Taiwanese society.
In our institution, most of the men who underwent a vasectomy already had a male child. Only 19 families had no male child, and there were 1.598-fold more male than female children. This proportion is higher than the general male to female newborn ratio in Taiwan, which was about 1.079 in 20117
was therefore influenced by already having a male child, and this is probably due to Taiwanese culture and the desire for a male heir to continue the ancestral line. This has affected the ratio of male to female births in Taiwan for many years.
Worldwide an estimated 42–60 million couples rely on vasectomy for contraception, however nearly 140 million rely on female sterilization5. In the developed world, female sterilization is approximately twice as common as vasectomy, whereas in Asia tubal ligation is eight times more common than
vasectomy. We found a far lower ratio of female to male sterilization of 1.27 (Table 3), although the female sterilization rate was still higher than the male sterilization rate.
With an increase or decrease in the Taiwan Monitoring Indicators on a quarterly basis, the number of vasectomies and total sterilizations were significantly negatively correlated (Table 3). A sluggish economic caused more men to undergo a vasectomy because in Taiwan society men have a responsibility to support the family. In
addition, the number of tubal ligations also had a trend of a negative correlation with a favorable economic condition, although without statistical significance (P=0.178). This may be because men are often the main source of income in Taiwanese families, so economic pressure influences their decision to a greater extent. However, our data may not represent the real condition of sterilization in women because of the small number of patients. We found that the total number of sterilizations was related to economic fluctuations, and this may have been because economic pressure impacted the whole family.
Existing wealth was the core economic factor rather than socioeconomic status, and the wealthy did not necessarily have more children than the poor. Deniz et al also reported that fluctuations in fertility are pro-cyclical, with a strong economy being associated with higher birth rates, and the recent recession with lower birth rates14.
The limitation of this study is that it was conducted at a single institution, although it may present the situation in Taiwan. In addition, variables such as family income could be incorrectly reported by participants. Despite this, prosperity remained a significant predictor of vasectomy. Contraceptive procedures are self-paid in Taiwan resulting in difficulty acquiring data on the total number of vasectomies or tubal ligations. Further studies are warranted to identify the reasons for these economic differences.
Conclusion
Reproductive history, partner, demographic characteristics, and socioeconomic factors are related to the utilization of vasectomy. Decisions on birth control and whether to undergo contraceptive procedures reflect economic fluctuations. A
higher number of vasectomies at one hospital may represent the economic situation at that time.
References
1. Schwingl PJ and Guess HA: Safety and effectiveness of vasectomy. Fertility and sterility 73: 923-936, 2000.
2. KAP (Knowledge, Attitude, and Practice of Contraception in Taiwan) http://www.mohw.gov.tw/cht/DOS/DisplayStatisticFile.aspx?d=11940&s=1 3. Eisenberg ML, Henderson JT, Amory JK, Smith JF and Walsh TJ: Racial differences
in vasectomy utilization in the United States: data from the national survey of family growth. Urology 74: 1020-1024, 2009
4. Ministry of Health and Welfare; http://www.mohw.gov.tw/EN/Ministry/ 5. Bumpass LL, Thomson E and Godecker AL: Women, men, and contraceptive
sterilization. Fertility and sterility 73: 937-946, 2000.
6. The Council for Economic Planning and Development (CEPD) (http://index.ndc.gov.tw/n/en )
7. Directorate-General of Budget, Accounting and Statistics. Executive Yuan. R.O.C. (Taiwan). http://www.dgbas.gov.tw/ct.asp?xItem=14616&CtNode=3566
8. Pile JM and Barone MA: Demographics of vasectomy--USA and international. The Urologic clinics of North America 36: 295-305, 2009
9. Barone MA, Johnson CH, Luick MA, Teutonico DL and Magnani RJ: Characteristics of men receiving vasectomies in the United States, 1998-1999. Perspectives on sexual and reproductive health 36: 27-33, 2004.
10. Olivera Radulović ČŠ, Aleksandar Višnjić, Ana Tasić, Roberta Marković: The
influence of education level on family planning. FACTA UNIVERSITATIS 13: 58 - 64, 2006
11. Yeh Y-c: Socioeconomic Background and People’s Childcare Policy Preference –A National Survey in Taiwan
12. Trussell J, Lalla AM, Doan QV, Reyes E, Pinto L and Gricar J: Cost effectiveness of contraceptives in the United States. Contraception 79: 5-14, 2009
13. Trussell J: The cost of unintended pregnancy in the United States. Contraception 75: 168-170, 2007
14. Deniz Dilan Karaman Örsal, Joshua R. Goldstein, The Increasing Importance of Economic Conditions on Fertility, Max Planck Institute for Demographic Research, No WP-2010-014
Figure and Table Legends:
Table 1: Socio-demographic and reproductive characteristics of vasectomies Table 2: Family composition (posterity) of vasectomies
Table 3: Seasonal number of sterilizations and seasonal Monitoring Indicators from 2008 to 2011
Figure 1: Investigation flow chart of the vasectomy patients
Figure 2: Taiwan Monitoring Indicators from 2008 to 2011; reference by Privacy and Security Policy (http://index.ndc.gov.tw/n/zh_tw)
