text: Practice Bulletin No. 133: Benefits and Risks of SterilizationObstetrics & Gynecology: February 2013 - Volume 121 - Issue 2 - p 392–404 doi: 10.1097/01.AOG.0000426425.33845.b2 College Publications Abstract Article OutlineOutline Article MetricsMetrics Female and male sterilization are both safe and effective methods of permanent contraception used by more than 220 million couples worldwide (1). Approximately 600,000 tubal occlusions and 200,000 vasectomies are performed in the United States annually (2-4). For women seeking permanent contraception, sterilization obviates the need for user-dependent contraception throughout their reproductive years and provides an excellent alternative for those with medical contraindications to reversible methods. The purpose of this document is to review the evidence for the safety and effectiveness of female sterilization in comparison with male sterilization and other forms of contraception. Abstract Background Prevalence of Sterilization Compared With Other Contracepti... Female Sterilization Timing Sterilization Approaches and Techniques Male Sterilization Clinical Considerations and Recommendations ▸ Who are good candidates for female sterilization? ▸ How safe is laparoscopic sterilization? ▸ How effective is traditional sterilization compared with ... ▸ How does the safety of female sterilization compare with ... ▸ How does hysteroscopic sterilization compare with traditi... ▸ Can patients with nickel sensitivity useEssure? ▸ Which method of tubal occlusion is mosteffective for post... ▸ Does the technique used for female sterilization affect t... ▸ How do the safety and efficacy of tubal occlusion compare... ▸ Does tubal occlusion cause menstrualabnormalities ? ▸ Are women who undergo tubal occlusionmore likely to have ... ▸ Does tubal occlusion have noncontraceptive benefits? ▸ What is the risk that a patient will regret having had st... Box 1 Components of Presterilization Counseling[Context Lin... Summary of Recommendations and Conclusions References Committee on Practice Bulletins—Gynecology. This Practice Bulletin was developed by the Committee on Practice Bulletins—Gynecology with the assistance of Alison Edelman, MD and Elizabeth Micks, MD. The information is designed to aid practitioners in making decisions about appropriate obstetric and gynecologic care. These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice. Back to Top | Article Outline Background Prevalence of Sterilization Compared With Other Contraceptive Methods According to data from the 2006-2010 National Survey of Family Growth, 38.4 million women aged 15-44 years used contraception. Sterilization remained the most common method, used by 47.3% of married couples (tubal occlusion, 30.2%; vasectomy, 17.1%) (5). In comparison, 18.6% of married couples used oral contraceptives, 15.3% used male condoms, 7.1% used intrauterine devices (IUDs), and 3.9% used injectable contraceptives (5). Rates of female sterilization increased dramatically in the 1970s, peaking at 702,000 procedures in 1977; remained stable in the 1980s and early 1990s; and decreased slightly to 643,000 procedures in 2006 (6). Back to Top | Article Outline Female Sterilization Timing Female sterilization can be performed at any time before or after pregnancy. The choice and timing of sterilization are affected by individual patient preference, medical assessment of acute risk, access to services, and insurance coverage. The timing of the procedure influences both the surgical approach and the method of tubal occlusion. In the United States, more than one half of all tubal occlusions are performed in the early postpartum period, with sterilization procedures performed after 8-9% of all hospital deliveries (6). Postpartum. Postpartum sterilization is performed at the time of cesarean delivery or after a vaginal delivery and should not extend the patient's hospital stay. Minilaparotomy after vaginal delivery is generally performed before the onset of significant uterine involution through a small infraumbilical incision. It typically is performed with regional or general anesthesia, but may be performed using local anesthesia with sedation. In most cases, epidural anesthesia placed during labor can be left in place for the procedure (7). Postpartum sterilization requires counseling and informed consent before labor and delivery (8). Ideally, consent should be obtained during prenatal care, when the patient can make a considered decision, review the risks and benefits of the procedure, and consider alternative contraceptive methods. Various obstacles, including young age and concern for patient regret, the consent process, lack of available operating rooms and anesthesia, and receiving care in a religiously affiliated hospital, prevent as many as 50% of women who request postpartum sterilization during their prenatal care from undergoing the procedure before discharge after delivery. Risk of repeat, unintended pregnancy within 1 year of delivery, which has been reported to be as high as 46.7% for women who requested but did not receive postpartum sterilization, emphasizes the importance of facilitating this requested procedure (9). In order to be an effective advocate for postpartum sterilization, the obstetrician-gynecologist needs to be proactive about identifying and overcoming barriers to accomplishing a postpartum procedure (10). Health care providers also must be familiar with any laws and regulations that may constrain sterilization, such as limitations on the patient's age, and time and procedural requirements for the consent process. Some patients have insurance coverage restricted to pregnancy and the immediate postpartum period; such women may have limited access to contraceptive options after delivery. The health care provider should inform the patient that insurance coverage for sterilization is variable so that she can discuss this issue with her insurer. In cases of intrapartum or postpartum maternal or neonatal complications, the patient and the health care provider should consider postponing sterilization to a later date (11). Postabortion. Postabortion sterilization can be performed immediately after an uncomplicated spontaneous or induced abortion with no increased risk compared with an interval procedure (12). After a first-trimester abortion or a second-trimester abortion, tubal occlusion by either laparoscopy or minilaparotomy is acceptable. With either approach, a single anesthetic may be used for the abortion and the tubal occlusion. As with postpartum sterilization, it is important to consider state regulations. Some states have enacted statutes that limit a woman's ability to consent for sterilization when seeking an abortion. Interval. Tubal occlusion can be performed as an interval procedure separate from pregnancy. A urine pregnancy test should be done before the procedure; however, this does not rule out a luteal phase pregnancy. Although not a requirement, performing the procedure during the patient's follicular phase or using an effective method of contraception before the procedure reduces the likelihood of a concurrent pregnancy and may facilitate visualization of tubal ostia for hysteroscopic procedures. Back to Top | Article Outline Sterilization Approaches and Techniques Hysteroscopy. Hysteroscopic tubal occlusion for sterilization has high efficacy and low procedure-related risk, cost, and resource requirement. Hysteroscopic techniques are not indicated for sterilization after delivery or abortion. Hysteroscopic techniques avoid entry into the peritoneal cavity and may decrease the risk of injury to abdominal organs. Unlike laparoscopic or minilaparotomy techniques, hysteroscopic sterilization is commonly performed as an office procedure, which involves the use of a paracervical block with or without oral sedation or intravenous sedation. Hysteroscopic occlusion techniques, followed by a confirmatory hysterosalpingography (HSG), have at least equal if not superior efficacy to tubal occlusion done by laparoscopy or minilaparotomy. Two hysteroscopic methods are currently approved for use by the U.S. Food and Drug Administration. Essure, approved in 2002, involves the insertion of a 4-cm long implant with a stainless steel inner coil and nickel titanium outer coil into each fallopian tube by a disposable delivery catheter; tubal occlusion occurs by an inflammatory reaction and tissue growth in response to polyethylene terephthalate fibers. Essure is generally performed with normal saline as the distention medium and is approved for use in women who are at least 6 weeks postpartum. A second method, Adiana, which involved a combination of radiofrequency energy and implant placement, is no longer manufactured because of financial reasons and is not available for use. There were no safety or efficacy concerns with Adiana. Hysteroscopic procedures require the use of an alternative method of contraception for at least 3 months after the procedure and until a confirmatory HSG indicates successful tubal occlusion. Many of the pregnancies that occurred after hysteroscopic sterilization have been attributed to inadequate occlusion, which emphasizes the importance of adherence to follow-up HSG protocols. Depending on the patient population, postoperative HSG adherence rates range from as low as 13% up to 71.1%. Patient reminders and a follow-up tracking system have been shown to improve adherence (13, 14). When considering a hysteroscopic approach to sterilization, it is recommended that patients and their health care providers discuss the need for HSG follow-up and consider whether insurance will provide coverage for the imaging procedure. The opportunity to have an office procedure with minimal anesthesia and recovery time motivates some patients to elect hysteroscopic sterilization over the more traditional laparoscopic approach (15). In early clinical trials for Essure, the successful bilateral placement rate was approximately 90%. In subsequent studies of procedures performed with the third-generation delivery catheter, the successful bilateral placement rate was 96.9% (16). No pregnancies have been reported among the 643 women in clinical trials with tubal occlusion confirmed by HSG after bilateral Essure insert placement. Of the women in clinical trials with successful placement, 3.5% had tubal patency confirmed by HSG at 3 months and 0% were patent at 6 months (17, 18). Health care providers should be aware that there is a specific HSG protocol outlined by the manufacturer of Essure that optimizes the accuracy of this follow-up testing. Laparoscopy. The laparoscopic approach is used for interval and postabortal tubal occlusion procedures and is performed as an outpatient procedure. Laparoscopy provides an opportunity to inspect the abdominal and pelvic organs, requires small incisions, is immediately effective, and enables a rapid return to full activity. The disadvantage of laparoscopy is the risk of bowel, bladder, or major vessel injury. The procedure can be performed in appropriately selected patients with local anesthetic and intravenous sedation. However, the procedure is typically performed under general anesthesia in an operating room setting. Use of general anesthesia slightly increases risk of complications, but increases the acceptability of the procedure to patients and health care providers. Tubal occlusion can be achieved using elec-trocoagulation, mechanical devices, or tubal excision. Electrocoagulation. Bipolar electrocoagulation for tubal occlusion is used exclusively with laparoscopic approaches. At least 3 cm of the isthmic portion of the fallopian tube must be completely coagulated (19). Monopolar electrocoagulation has been associated with thermal injury to the bowel and is rarely used. Mechanical Devices. Mechanical devices commonly used in the United States include the silicone rubber band, the spring-loaded clip, and the titanium clip lined with silicone rubber. Special applicators are necessary for each of these mechanical occlusion devices. The silicone band can be applied only to a fallopian tube that is sufficiently mobile to allow it to be drawn into the applicator. All of these devices are most likely to be effective when used to occlude a normal fallopian tube; tubal adhesions, thickened tubes, or dilated fallopian tubes may increase the risk of misapplication and subsequent failure. Spontaneous clip migration or expulsion is rare (20-22). Tubal Excision. Complete or partial salpingectomy may be preferable in the setting of abnormal fallopian tubes (such as hydrosalpinx), in which tubal occlusion devices may be less effective. Tubal division can be accomplished using either monopolar energy or bipolar energy and a cutting device. These techniques may be more technically difficult and more likely to cause bleeding than mechanical tubal occlusion techniques. Advantages of salpingectomy include high-contraceptive efficacy and prevention of future tubal disease, although there is some concern that salpingectomy may adversely affect ovarian function. Minilaparotomy. In the United States, minilaparotomy generally is reserved for postpartum procedures and rarely considered for patients at high risk of complications associated with laparoscopic procedures. Minilaparotomy is performed using a 2-3-cm incision placed in relation to the uterine fundus (generally infraumbilically for postpartum sterilization and suprapubically for interval procedures). Obese patients and those failing laparoscopic procedures may require a larger incision. In contrast with laparoscopy, minilaparotomy requires only basic surgical instruments and is appropriate for low-resource settings where specialized surgical equipment is not available. In randomized trials, there was no difference in major morbidity between women who underwent tubal occlusion procedures performed by laparoscopy compared with minilaparotomy (23). When sterilization is performed concurrent with cesarean delivery, any higher associated morbidity rate compared with sterilization after vaginal delivery has been attributed to the indications for which the cesarean delivery was performed (24). The commonly used techniques for tubal ligation and excision at the time of minilaparotomy and cesarean delivery include the Pomeroy, modified Pomeroy, and the Parkland methods. The Uchida and Irving methods rarely are used in the United States (25). To ensure complete transection of the tubal lumen, care should be taken to excise a sufficient section of the fallopian tube, particularly in cases of a previous failed tubal ligation or preexisting tubal disease. When an excision method is used, tubal segments should be submitted to pathology to confirm complete transection. Back to Top | Article Outline Male Sterilization Vasectomy performed as an outpatient procedure with local anesthesia has been popular in the United States since 1965. Based on data from the National Survey of Family Growth, 6.2% of reproductive-aged women reported relying on vasectomy as a birth control method (5). Compared with abdominal approaches to female sterilization, vasectomy is safer, more effective, and less expensive (26). Vasectomy is not immediately effective; an alternative form of contraception must be used until a semen analysis confirms azoospermia. Most men are azoospermic at 3 months after vasectomy, and 98-99% are azoospermic at 6 months after vasectomy (27). Back to Top | Article Outline Clinical Considerations and Recommendations ▸ Who are good candidates for female sterilization? Women who have completed their childbearing are candidates for sterilization. Preoperative counseling should be comprehensive and include a discussion of surgical technique, efficacy, safety, potential complications, and the alternatives to female sterilization. These alternatives should include long-acting reversible methods and vasectomy. Women should have ample opportunity to make a considered decision about sterilization, and they should be informed that factors, such as young age, unstable relationship, and low parity might increase the risk of regret. Women should understand the permanence of the procedure and that in the event of regret, reversal procedures are likely to be prohibitively expensive and not covered by insurance. Women should be counseled about the risk of failure, risk of regret, and alternatives (including LARC and vasectomy). In a well-informed woman, age and parity should not be a barrier to sterilization. Choice of sterilization type should involve consideration of the patient's medical health, her tolerance of office procedures, her ability to adhere to follow-up testing, the safety of abdominal surgery and general anesthesia, and any health insurance limitations. There are no medical conditions that are strictly incompatible with sterilization, but the safety of a sterilization surgery must be assessed in the context of the patient's medical conditions. The U.S. Medical Eligibility Criteria for Contraceptive Use, from the Centers for Disease Control and Prevention, provides guidance for many of these circumstances (http://www. cdc.gov/mmwr/pdf/rr/rr5904.pdf). Back to Top | Article Outline ▸ How safe is laparoscopic sterilization? Tubal occlusion via laparoscopy is a safe and effective method of permanent contraception. Overall complication rates are low, and procedure-related death is a rare event. Mortality rates in the United States have been estimated at one to two deaths per 100,000 procedures (26), with most deaths attributed to hypoventilation and cardiopulmonary arrest during administration of general anesthesia. Results from a U.S. study from 1977 to 1981 indicate that 11 of 29 sterilization-related deaths occurred in women with underlying medical conditions (28). A more recent study found no mortality among 9,475 women who underwent interval laparoscopic tubal ligation (29). A large Swiss study of 27,653 women undergoing tubal occlusion by laparoscopy or mini-laparotomy reported no intraoperative or postoperative deaths (30). Major complications from laparoscopic tubal ligation are uncommon, vary by study definition, and occur in 0.1-3.5% of laparoscopic procedures (20, 21, 29, 30). Using a standard definition of intraoperative and postoperative events, overall complication rates for laparoscopic tubal occlusion are estimated to be 0.9-1.6 per 100 procedures; unintended conversion to laparotomy is estimated as 0.9 per 100 cases (29). This complication rate did not vary significantly according to the method of occlusion used. Intraoperative complications include unplanned major surgery needed because of a problem related to the tubal surgery, transfusion, or a life-threatening event. Postoperative complications include unintended major surgery, transfusion, febrile morbidity, a life-threatening event, or rehospitalization. Use of general anesthesia, previous abdominal or pelvic surgery, obesity, and diabetes were independent predictors of complication (29). Back to Top | Article Outline ▸ How effective is traditional sterilization compared with reversible contraceptive methods? Laparoscopic tubal occlusion is far more effective than short-term, user-dependent, reversible contraceptive methods, such as oral contraceptive pills, injections, and barrier methods. Data from the 2002 National Survey of Family Growth indicate that within 1 year of starting any reversible method, 12.4% of typical users experience a contraceptive failure (31). Based on recent analysis by method, contraceptive failure occurs in the first year of typical use for 9% of women using oral contraception, patch, or ring; 18% of women relying on the male condom; 3% of women using injectable methods; and 24% using fertility awareness-based methods (32). Failure rates of sterilization are comparable with those of long-acting reversible contraception methods, such as IUDs and the etonogestrel implant. The annual failure rates for the IUD are 0.8% for the copper T380A and 0.2% for the levonorgestrel-releasing intrauterine system. The etonogestrel implant has a 0.05% reported failure rate, the lowest of any contraceptive method (32). The U.S. Collaborative Review of Sterilization (CREST), a large, prospective, multicenter observational study of 10,685 women conducted in 1996 by the Centers for Disease Control and Prevention, concluded that although sterilization via laparoscopy or minilaparotomy is a highly effective method of contraception, the risk of failure is substantially higher than previously reported (33). Analysis of CREST data found a 5-year cumulative failure rate of 13 per 1,000 for aggregated sterilization methods (including laparoscopy and laparotomy) (33), compared with a 5-year cumulative failure rate of 14 per 1,000 procedures for the copper T380AIUD (34). The 5-year cumulative pregnancy rate for the levonorgestrel-releasing IUD ranged from 5-11 per 1,000 procedures (35-37). The risk of pregnancy persists for years after the sterilization procedure and varies by occlusion technique and age of the woman (Table 1). Table 1 Back to Top | Article Outline ▸ How does the safety of female sterilization compare with intrauterine devices and the contraceptive implant? There are few medical contraindications to the use of either IUDs or the contraceptive implant (38). Long-acting methods of contraception, including IUDs and the contraceptive implant, are at least as effective as tubal occlusion and are associated with lower morbidity and mortality. Among women using IUDs for contraception, approximately 1% will experience pelvic infection within the first 20 days (39). Overall, complications with IUDs are uncommon and mainly include expulsion, method failure, and perforation. The expulsion rate is between 2% and 10% during the first year (40). Perforation occurs in 1 per 1,000 insertions or less (41). Complications associated with contraceptive implant use are rare, but include bruising and pain at the implantsite (1-3%), implant migration, and deep implant insertion that leads to difficult removal (<1%) (42). Both of these devices are placed in the outpatient setting with no systemic anesthetic, and if placed at the appropriate time should be immediately effective. Although pregnancy after a sterilization procedure is uncommon, there is substantial risk that any postster-ilization pregnancy will be ectopic. Analysis of CREST data found that one third of poststerilization pregnancies (47 out of 143 pregnancies) were ectopic (43). Pregnancies that occur in the setting of hormonal contraceptive or IUD use are also more likely to be ectopic; 20% of all IUD failures result in an ectopic pregnancy (33, 37). There have been several case reports of ectopic pregnancies that occurred in patients with the contraceptive implant (44, 45). However, overall, patients who have undergone sterilization procedures have a lower ectopic risk than noncontraceptive users. Back to Top | Article Outline ▸ How does hysteroscopic sterilization compare with traditional sterilization methods? There are no randomized studies that compare hysteroscopic sterilization to other methods of interval sterilization. Data from clinical trials indicate that Essure is a highly effective method of sterilization, but long-term data are lacking. Out of the 50,000 women who had undergone Essure procedures between 1997 and 2005, 64 unintended pregnancies were reported to the manufacturer. Most failures were attributed to patients not adhering to the use of an alternative contraceptive until tubal occlusion had been confirmed by HSG (46). Complications of hysteroscopic sterilization include tubal perforation, improper coil placement, and expulsion of the occlusion devices. In the clinical trials of Essure, tubal perforations occurred in 1-3% of women, intraperitoneal placement in 0.5-3%, and other improper placements in 0.5% of the cases. Coil expulsion occurred in 0.4-2.2% of subjects (17, 18, 47, 48). In a retrospective analysis of 4,306 office-based Essure placements, 98.5% of patients had successful coil placement and the overall complication rate was 2.7%, with vasovagal syncope being the most common. No patients had serious complications that required more than 2 hours of observation in the outpatient unit (47). One major benefit of hysteroscopic sterilization is that it can be performed as an office procedure using paracervical block and does not require entry into the peritoneal cavity (49). For this reason, major morbidity associated with general anesthesia and abdominal surgery can be avoided. This is particularly appealing for patients with significant coexisting medical disorders, obesity, or intra-abdominal adhesive disease. Several studies have suggested lower cost to hysteroscopic sterilization when compared with laparoscopic sterilization. However, if both are performed in the operating room and HSG costs are included, the cost difference is significantly reduced (50). Patients and health care providers should be prepared for the possibility that bilateral coil placement may not be possible in every patient. Visualization of tubal ostia and successful device placement may be optimized in the setting of a thin endometrium (follicular phase versus preparation with hormonal agents). A history of sexually transmitted infection has been associated with decreased success rates of device placement, likely related to a history of pelvic inflammatory disease (51). If health care providers chose to perform hysteroscopic sterilization in the operating room, it is advisable to have a contingency plan for establishing contraception in the event that device placement is not possible. Concomitant hysteroscopic sterilization and endometrial ablation has been described in the literature (52); however, device labeling explicitly precludes this practice. The formation of intrauterine adhesions subsequent to ablation may limit the ability of HSG to assess tubal patency (53). For patients desiring both procedures, a two-stage procedure should be planned with endometrial ablation performed after documentation of tubal occlusion by HSG. Back to Top | Article Outline ▸ Can patients with nickel sensitivity useEssure? An Essure insert releases a very small amount of nickel each day, less than one thousandth the amount in the average daily food intake. The reported incidence of adverse events suspected to be related to nickel hypersensitivity in patients with Essure microinserts is extremely small (0.01%). The incidence of confirmed nickel reactions is even smaller. This very low incidence of clinical reactions is consistent with data from other nickel-containing implantable devices and is reassuring (54). In 2011, the nickel sensitivity contraindication was removed from the Essure procedure instructions. Patients with nickel sensitivity are candidates for Essure and do not require preprocedure confirmatory skin testing. However, they should be counseled that microinserts do contain minute amounts of nickel, which are likely to be of no clinical significance (55). Back to Top | Article Outline ▸ Which method of tubal occlusion is mosteffective for postpartum sterilization ? Data from the CREST study indicate that postpartum partial salpingectomy is associated with lower failure rates than interval tubal occlusions done by laparoscopy (33). This lower failure rate may be because a segment of tube is removed rather than mechanically occluded or cauterized, or because a pathologist is able to confirm complete tubal cross sections. A recent systematic review of studies of the titanium clip lined with silicone rubber and partial salpingectomy by the modified Pomeroy technique concluded that the titanium clip may have decreased efficacy when used in the immediate postpartum period (56). A randomized control trial that compared the titanium clip with partial salpingectomy for postpartum sterilization concluded that the titanium clip is significantly less effective (57). Back to Top | Article Outline ▸ Does the technique used for female sterilization affect the risk of ectopic pregnancy? The risk of ectopic pregnancy varies substantially with the method and timing of tubal occlusion. Based on CREST study data, the 10-year cumulative probability of ectopic pregnancy after tubal occlusion by any method was 7.3 per 1,000 procedures (43) (Table 1). Ectopic pregnancy was not reported in the clinical trials with hysteroscopic tubal sterilization, but has been described in a case report after tubal occlusion was confirmed by HSG (58). For all methods except postpartum partial salpingectomy, the probability of ectopic pregnancy was greater for women sterilized before age 30 years than for women sterilized at age 30 years or older. Postpartum partial salpingectomy was the only method reported by the CREST study that did not have a higher 10-year cumulative probability of ectopic pregnancy in younger women (43). For all methods of tubal occlusion, the risk of ectopic pregnancy did not diminish with the length of time since the procedure. Back to Top | Article Outline ▸ How do the safety and efficacy of tubal occlusion compare with vasectomy? Vasectomy is safer than tubal occlusion. It is a less invasive surgical procedure, is performed using local anesthesia, and is protective against ectopic pregnancy. Although specific data are lacking on major morbidity and mortality related to vasectomy, serious complications are thought to be rare (59-61). Vasectomy has a failure rate of 0.15% in the first year, which is lower than the rate reported for most methods of female sterilization (31, 60). Neither female nor male sexual function appears to be affected after tubal occlusion or vasectomy (62, 63). Vasectomy failure is not associated with an increased risk of ectopic pregnancy. When controlling for pregnancy rates, tubal occlusion has a higher rate of ectopic pregnancy than vasectomy. The incidence of ectopic pregnancy is 0.32 per 1,000 women-years in women who had tubal occlusion and 0.005 per 1,000 women-years in women whose partners had vasectomy (64). By comparison, the estimated absolute incidence of ectopic pregnancy in women using no contraception is 2.6 per 1,000 women-years (64). Vasectomy-related major morbidity and mortality are extremely rare in the United States (59). Minor complications of vasectomy, such as infection at the site of incision, bleeding, hematoma formation, granuloma formation, and epididymitis, are reported to occur at rates of 0.4-10% (65, 66). In comparison with the incisional technique, the no-scalpel vasectomy technique has a lower incidence of hematoma formation, infection, and pain and has a shorter operative time (59, 65, 67, 68). Multiple large epidemiologic studies have concluded there is no causal relationship between vasectomy and both atherosclerosis disease and immunologic disease (60, 62, 69, 70). In addition, there are robust data suggesting no association between vasectomy and testicular cancer or prostate cancer (63, 71-73). The nerves involved in male erectile function and ejaculation are not affected by vasectomy, and there is no increased risk of impotence. Chronic testicular pain after vasectomy may rarely result from obstructive epididymitis or sperm granuloma. Back to Top | Article Outline ▸ Does tubal occlusion cause menstrualabnormalities ? Prospective studies that account for confounding factors, such as presterilization use of hormonal contraceptives, have found that tubal occlusion had little or no effect on menstrual patterns (74-81). An analysis of CREST data found that women who underwent sterilization were no more likely than controls to report persistent changes in their menstrual cycle length or intermenstrual bleeding (82). However, they were more likely to have beneficial changes in their menstrual cycle, including decreases in the amount of bleeding, in the number of days of bleeding, and in menstrual pain. The method of tubal occlusion did not have a significant effect on the findings. There are conflicting data describing the effect of hysteroscopic sterilization on menstrual patterns (83, 84). Back to Top | Article Outline ▸ Are women who undergo tubal occlusionmore likely to have a hysterectomy? In an analysis of CREST data, women who had tubal occlusion were found to be four to five times more likely to undergo hysterectomy over a 14-year follow-up period than those whose partners underwent vasectomy (85). Increased risk was independent of patient age and the method of tubal occlusion used, but was associated with a presterilization history of menstrual disorders or other benign gynecologic disorders, including endometriosis and uterine leiomyomas. There is no known biologic mechanism to support a causal relationship between tubal occlusion and subsequent hysterectomy. Back to Top | Article Outline ▸ Does tubal occlusion have noncontraceptive benefits ? Multiple observational trials have confirmed that laparo-scopic tubal occlusion reduces the incidence of ovarian cancer (relative risk, 0.29-0.69) (86-89). This protective effect persists after adjusting for age, use of oral contraceptives, and parity (86). Tubal occlusion maintains its protective effect in women at high risk of ovarian cancer due to BRCA1 and BRCA2 mutations (90). Recent evidence suggests that ovarian cancer may originate from the fimbrae of the fallopian tube, which leads some health care providers to remove the entire tube for sterilization (91-93). Although tubal occlusion does not protect against sexually transmitted infections (including human immunodeficiency virus [HIV]), it has been shown to reduce the spread of organisms from the lower genital tract to the peritoneal cavity and, thus, protect against pelvic inflammatory disease (94). This protection is incomplete, however, as suggested by rare case reports of pelvic inflammatory disease and tubo-ovarian abscess in women who have undergone sterilization (95-97). Back to Top | Article Outline ▸ What is the risk that a patient will regret having had sterilization, and how can the risk be reduced? Most women who choose sterilization do not regret their decision; however, information and counseling about this method of contraception should be provided with the intent to minimize regret among individual women (98-101). Although there are certain key indicators for future regret—such as young age (less than age 30) at the time of sterilization—many indicators of regret are part of individual social circumstances, which should be explored with the patient before a decision is made. Prospective analysis of CREST study data found that the cumulative probability of regret over 14 years of follow-up was 12.7% (98). However, the probability was 20.3% for women aged 30 years or younger at the time of sterilization, compared with 5.9% for women older than 30 years at the time of sterilization. A meta-analysis of studies of poststerilization regret concluded that women who underwent sterilization at age 30 years or younger were twice as likely to express regret as women older than 30 years at the time of sterilization (101). Women aged 30 years or younger at the time of their procedure were 3.5-18 times more likely to request information about sterilization-reversal and approximately eight times more likely to undergo reversal or evaluation for in vitro fertilization. In the CREST study, the 14-year cumulative probability of requesting reversal information was as high as 40.4% in women who underwent sterilization between ages 18 years and 24 years— almost four times higher than for women older than 30 years at the time of the procedure (98). Similarly, men who underwent vasectomy at young ages were more likely to have the procedure reversed than those who underwent vasectomy at older ages (38). Analysis of CREST data also showed a relationship between regret and the timing of the procedure. The cumulative probability of regret diminished steadily with increased interval between delivery and sterilization (98). Postabortion sterilization was not associated with increased regret when compared with interval sterilization (98, 102-104). Other risk factors for increased regret include having received less information about the procedure, having had less access to information or support for use of an alternative contraceptive method, and having made the decision under pressure from a spouse or because of medical indications (105-107). The number of living children is not associated with a request for reversal information. It is important to attempt to reduce the likelihood of poststerilization regret with thorough and effective counseling that takes into account known risk factors. Back to Top | Article Outline Box 1 Components of Presterilization CounselingCited Here... • Permanent nature of the procedure, not intended to be reversible • Alternative methods available, particularly long-acting reversible contraception and vasectomy • Details of the procedure, including risks and benefits of anesthesia • The possibility of failure, including ectopic pregnancy, with sterilization and other methods • The need to use condoms for protection against sexually transmitted infections, including HIV • The need to use an alternative form of contraception after hysteroscopic sterilization until hysterosalpingogram confirms tubal occlusion • Completion of informed consent process • Local regulations regarding interval from time of consent to procedure • Effect of sterilization on future health insurance coverage (eg, noncontraceptive uses of hormonal contraceptives, reversal, or infertility services) Data from Pollack AE, Soderstrom RM. Female tubal sterilization. In: Corson SL, Derman RJ, Tyrer LB, editors. Fertility control. 2nd ed.London (ON): Coldin Publishers; 1994. p. 293-317. However, patients should not be denied sterilization because of presence of such risk factors, especially young age. Both the patient and her partner, when appropriate, should be counseled (see Box 1). The choice to undergo sterilization is an individual and personal decision. It is critical that health care providers refrain from inserting their own biases or judgments about the appropriateness of a patient's decision to proceed with sterilization. Full consideration should be given to all reversible contraceptive options, particularly the long-acting reversible methods. Patients must be informed that IUDs and the implant are at least as effective as sterilization. Back to Top | Article Outline Summary of Recommendations and Conclusions The following recommendations and conclusions are based on good and consistent scientific evidence (Level A): Tubal occlusion by laparoscopy is a safe and effective method of permanent contraception. Tubal occlusion does not protect against sexually transmitted infections (including HIV). Compared with abdominal approaches to female sterilization, vasectomy is safer, more effective, and less expensive. Laparoscopic tubal occlusion is far more effective than short-term, user-dependent, reversible contra ceptive methods, such as oral contraceptive pills, injections, and barrier methods. Long-acting methods of contraception, including IUDs and the contraceptive implant, are at least as effective as tubal occlusion and are associated with lower morbidity and mortality. Although pregnancy after a sterilization procedure is uncommon, there is substantial risk that any post-sterilization pregnancy will be ectopic. Patients who have undergone sterilization proce dures have a lower ectopic risk than noncontraceptive users. The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B): Hysteroscopic occlusion techniques, followed by a confirmatory HSG, have at least equal if not superior efficacy to tubal occlusion done via laparoscopy or minilaparotomy. Hysteroscopic procedures require the use of an alternative method of contraception for at least 3 months after the procedure and until a confirmatory HSG indicates successful tubal occlusion. Postpartum partial salpingectomy is associated with lower failure rates than interval tubal occlusions done via laparoscopy. Laparoscopic tubal occlusion reduces the incidence of ovarian cancer. The following recommendation is based primarily on consensus and expert opinion (Level C): Women should be counseled about the risk of failure, risk of regret, and alternatives (including LARC and vasectomy). In a well-informed woman, age and parity should not be a barrier to sterilization. Copyright February 2013 by the American College of Obstetricians and Gynecologists. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Requests for authorization to make photocopies should be directed to Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400. The American College of Obstetricians and Gynecologists 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920 Benefits and risks of sterilization. Practice Bulletin No. 133. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:392-404. The MEDLINE database, the Cochrane Library, and the American College of Obstetricians and Gynecologists' own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1990-October 2012. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles. When reliable research was not available, expert opinions from obstetrician-gynecologists were used. Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force: I Evidence obtained from at least one properly designed randomized controlled trial. II-1 Evidence obtained from well-designed controlled trials without randomization. II-2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group. II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence. III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories: Level A—Recommendations are based on good and consistent scientific evidence. 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Every editor at IGN wishes he or she had the time to personally respond to every semi-sane comment from the message boards, but we don't. However, in an effort to raise the level of discourse, we've decided to pick out some of the most interesting comments on Peter Eykemans's recent Brink review and respond to them. The reviewer did not pick these comments out himself. This task fell to his colleague, Anthony Gallegos. The following are the original comments as they appeared on IGN.com, with the reviewer's response thereafter. Some comments may have been edited for space, but not for content.
Comment #1: I don't as a rule criticise reviews - I understand that it's a matter of opinion but I couldn't leave this alone. My basic problem is that Peter doesn't seem to understand what type of game he is reviewing. Criticising a multiplayer shooter for poor storyline and repetitive objectives is like panning an RPG for forcing the player to take on quests.
It's in effect not a criticism of Brink – but the genre of games as a whole. Multiplayer shooters are predicated on competitive team based missions not storytelling and to ignore that completely in the review is misleading. The same applies to the criticism of the ability to switch between classes rather than crafting one character. In an RPG this would indeed be a grave failing but in a shooter where you want to switch roles in a team regularly I fail to see the problem.
Secondly you can not criticise a game because 'I was often confused when I couldn't drop a turret only to remember I was a Soldier'. Being bad at the game is not the game's fault. I don't sit through Hamlet and blame Shakespeare because I can't follow the plot – that's my own inadequacy.
I'm not a multiplayer shooter fan. I can accept that this won't be my kind of game – but really I would expect a reviewer to start out with a better grasp of the type of game under consideration. All I get from Peter's review is I don't understand or enjoy multiplayer shooters, which is not a review in my book.
Contrast this with Eurogamer's excellent review, which is written by someone who gets what Brink is about.
Posted by: BenH79
Peter's Response: You bring up a solid argument, but I believe the core of your concern is incorrect. There seems to be a common misconception throughout the comments that because I use the term repetitive, or didn't simply gush about Brink, that I don't understand shooters. I love shooters and team-based gameplay.
To speak to your introduction, the influence of Brink's story is a minute detail in the greater span of the review. But regardless of whether or not story is important to the shooter genre, Brink wraps every single match, campaign and open multiplayer, in story cut-scenes. To not mention that it's bland, or exists at all, would be irresponsible. I reviewed Brink on what it brings to the table, not what a game in the genre is supposed to be about.
On the note of repetition, it's not just a single feature of the game, but the combination of many factors. Of course shooters and objective-based gameplay are repetitive by nature and definition. The reason I bring it up as a negative was actually verbalized best by another commenter on IGN. Ice-Hot suggested that: "Repetition is repetition only when it's boring. Otherwise it's called fun." This is where I'm coming from. If Brink's maps, objectives, weapons, classes, and gameplay didn't constantly feel repetitive, I wouldn't have mentioned them. If I were to complain about quests in an RPG, it would be because the quests were boring, bland and uninspired. That doesn't mean I don't understand RPGs.
Referring to the confusion over placing a turret isn't an example of being terrible at the game, but a single anecdote to represent the lack of distinction between size and classes and how the experience blends together.
Finally, I like your analogies. But complaining about Shakespeare is a discussion for another day.
Comment #2:
Sometimes I agree with IGN's reviews, sometimes I don't. But really this score is a shock for me. Not because I think this game is awesome (I have not played) but because of the way IGN's previews, interviews and sneak peeks were building it up I thought it would get at least an 8-8.5. I am now astounded by the score. I think IGN sometimes pokes the bear and asks for flaming comments with their pre-review articles. I would love if one of the editors actually addresses this for me in their new "reviewer answers comments" section. Much love IGN!
Posted by: nne05
Peter's Response: Previews are an extremely difficult task. We're invited to preview games under very specific circumstances in which the developer can control the experience and only show us one or two elements that they feel are great. Thus, we may only get a short time to demo a game rather than a full week (or more) to understand the complete package. And when we interview developers, their exciting answers are often based on best-intentions rather than final execution.
It's for this reason that previews can't be taken as a final word. They're a great way to get information about a game you're excited about, but at the same time they aren't always indicative of the final game.
If I didn't take an honest look at Brink for the product on the store shelf, then I wouldn't be doing my job. Previews and reviews are completely separate beasts.

subset: commoncrawl


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Let me start with something a little on the light-hearted side: IRL I work for a company that has recently hired a trans woman as a technician. It's a small office and we all pitch in to do minor housekeeping and keep the coffee pot full and the mugs washed. On Jessica's first day, I told her she was now responsible for sweeping and making coffee. "Why," she asked me. "Because I'm new"?
"No", I told her, 'it's because you're a woman".
It was fun to watch her reaction. And of course I was only joking! You know you are a real woman when you have to wash mugs and sweep, amirite?
I have never found transgender people to be particularly difficult to parse ideologically, because I fully believe (based on evidence) that there is such thing as a female brain and a male brain and that of course you can have the brain of one gender/sex and the body of the other, and that's a terrible affliction. It's an illness. Likely a disorder of the endocrine system. I disagree that it's a mental illness. It's a physical, medical condition that arises from serious hormonal errors, and it deserves to be treated, in whatever way the person afflicted with the illness deems best.
Having said that, perhaps going for the surgery is not the best option. I still have no good answer to a seemingly simple question: if your brain is one sex and your body is the opposite sex, why not try to make the brain match the body? Why are we focused on making the body match the brain?
I will upload this conversation as an image, but you might find it easier to click this link and then zoom on the photo. What has this person gained, exactly and how can we describe what has been done as anything other than mutilation?
For those of you with a strong stomach and morbid curiosity (like me), here is a post-op picture of the *NSFW* new genitals.
I feel like transgender people are caught in a political dungheap that makes it incredibly difficult for them to make choices about their own bodies and their own healthcare, and some of those choices can be irrevocable and devastating.
I can't think of anything I can do to help, other than to open the curtains and let the sunlight in. I think the only person who should decide what any given set of genitals look like is the person who owns those genitals – I despise infant circumcision for both boys and girls on those grounds alone – but god help us, people need correct, objective and unbiased information so they can make good choices.
Does anyone know what happened to this person? The person who wrote the post and uploaded the image? I'd be interested in finding out. Is she a cautionary tale? Does it get better?
More importantly, does she have to make coffee and sweep up at work?
Inquiring minds want to know.
Lots of love,


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Day 1
My first entry into the 30 days of robots challenge comes from one of the old DC hobby servos originally meant to go into the Altoids Drone. I'm particularly fond of the backpack on this one, made from a mouse scroll wheel's rotary encoder.
Day 2
Keeping with the theme started yesterday, day 2's robot uses the same DC servo motor, but explores the robot in maintenance; split in half at the waist and missing it's arm covering.
At some point after the challenge, it would be great to mount a small LED inside to give him a heartbeat.
Day 3
The third day and final in this concept for now, was to take the idea to a 'complete' humanoid in more pristine form. This robot is made from the same DC moor, surface-mount button and crimp terminal connectors.
Below you can see the completed set. I'll expand it further in a later project – these guys would make a great series. But for now, the creative juices need to flow again so tomorrow's robot will follow an entirely different concept.


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After all; the user never will like to consume strawberry aloe drink something that he or she supposed health benefits and lead to end up with something that is not conducive to good health and feelings that makes the most difficult and miserable life.
Benefits of aloe drink
Some of the major health benefits of drink are as follows.
- Consuming dose of 2-4 ounces of drink a day can help maintain good health.
- Principal beneficial effect of aloe drink is the detoxification of the body and the blood stream.
- It is a great help in the healing of intestinal or stomach problems.
- The drink helps the digestive tract in the body running smoothly.
- strawberry aloe drink helps dilate capillaries and can help in the growth of cells within the body.
- It is antibacterial, antiviral and antifungal agent.
- The drink taken regularly can prevent the disease that generates a sense of increased energy, strength and good health.
- One of the biggest advantages of using aloe is to regulate the healing of ulcers in the body.
Word of caution
Despite all these health benefits of drink, there are some precautions which a user has to take. First of all; you should just buy the aloe vera product that is 100% natural and without any added chemicals. Secondly; should consult their doctor before taking strawberry aloe drink or any other way of knowing whether the effects would be beneficial to their specific anatomical features. Since everyone has a different anatomical training; juice good for one may not be so good for the other.


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The other day some predictably misguided reader emailed the editorial page to accuse my cartoon of being racist because I had the temerity to depict a black man in prison. A BLACK man in prison! Imagine that! That empty charge of racism has been misused so often, it has no meaning anymore. It's the verbal equivalent of a car alarm. Nobody pays attention to it.
In the 1990s, people were scared spitless of being politically incorrect, even if it meant illustrating a lie. Once, when I was drawing a Sunday morning video comic strip for ESPN, I had occasion to draw the New York Knicks sitting on the bench. The producer insisted I draw at least one white player, EVEN THOUGH THERE WERE NO WHITE PLAYERS ON THE ENTIRE TEAM!
The bottom line back then: I could say anything or draw anything about white people, but blacks and Hispanics had to be treated special even if it was untrue. I deeply resented it and planned for the day when I could tell it like it is. Now, I draw what the majority of the population of a particular group happens to be and to hell with political correctness. If I don't know, I'll make the character white because I'm white and I reserve the right to poke fun of my own race just like any other, thankyouverymuch.
Many years ago, advertising agencies found certain things about American cultural behavior to be true. If they wanted to pitch a product to a 9 year-old, they use a 12 year-old to sell it. If they wanted to pitch a product to a girl, they used a girl. If they wanted to pitch a product to a boy, they used a boy. But, they could use a boy to sell something both sexes would like because girls would relate to the boy, but if they used a girl, boys would have nothing to do with it. That's why most of the family TV shows use 16 year-olds to play in shows that appeal to tweens. The ad agencies also found when they wanted to pitch a product to both races, they used whites. When they used a black person, white people wouldn't respond. I don't know if that's still true today, but it's a basis for discussion.
Most prisoners in the state prisons of Connecticut are black or Hispanic. Most politicians in the state of Connecticut are white. Most of the people in Hartford are minorities, but most of the folks in the suburbs and the rest of the state are white. Not for long, though. At present birth rates in the country, someday, when I draw "typical Mr. and Mrs. Connecticut," they'll be Hispanic.


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A Doll's House
Why did Mrs. Hay send the Burnell children the dolls house
Mrs. Hay brought the children a gift because she was coming to stay with the family. Etiquette dictates it is appropriate to bring your host a gift.... in this case, Mrs. Hay had the children in mind.
A Doll's House


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Hello there,
I wonder if anyone can help in this instance. I have installed XAMPP and it works very good, when we obtained or digital certificate from the CA and placed both the certificate file and the private key in ssl.crt and ssl.key and changed on ssl.conf and httpd.conf as well.
When I run lampp start
it prints out:
Starting XAMPP for Linux 1.5.0
Starting Apache with SSL (and PHP5)...
and it keeps like this forever, niether there is an error message nor correct starting.
If I try to go to http://mydomain.com, it does serve the pages, while if I try https://mydomain.com it gives file not found error. Again if I point to the default files server.crt and server.key it works fine for both http and https.
I have checked error_log file and here is the error log
[Thu Dec 22 00:30:00 2005] [error] Init: Unable to read pass phrase [Hint: key introduced or changed before restart?]
[Thu Dec 22 00:30:00 2005] [error] SSL Library Error: 218710120 error:0D094068:asn1 encoding routines:d2i_ASN1_SET:bad tag
[Thu Dec 22 00:30:00 2005] [error] SSL Library Error: 218529960 error:0D0680A8:asn1 encoding routines:ASN1_CHECK_TLEN:wrong tag
[Thu Dec 22 00:30:00 2005] [error] SSL Library Error: 218595386 error:0D07803A:asn1 encoding routines:ASN1_ITEM_EX_D2I:nested asn1 error
[Thu Dec 22 00:30:00 2005] [error] SSL Library Error: 218734605 error:0D09A00D:asn1 encoding routines:d2i_PrivateKey:ASN1 lib
It seems like there is error related to the pass phrase but what is it or how can I solve it, I have no idea.
Please if you faced this before or if you have any idea let me know. Any help will be much appreciated.
Thank you.


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Starring: Karina Cruel and new slave Flavinha brunette – film especific in farting humilhation – FEATURE FILM 50 min – Karina Cruel strikes again, now she takes the new slave Flavinha brunette and shows him all his power bossy woman, Karina has beautiful feet and claws to the extreme, her ass and beautiful, Karina can self shoot with two cameras, POV Karina shows your skills and start the new tears Falvinha slave, everyone already knows his listlessness and his cruelty time to master! she loves new girls between 18 and 23 years, this age preferred by Karina, the victim time and Flavinha brunette. this film it requires .a girl and held captive and forced to lick suck ass Karina Cruel she gets farts in the face, nose and in the mouth !! and the girl still and kept in captivity after the film and impressive … don't miss MF 2016 VIDEO !! unmissable
Other Clips By This Studio!
Check out these other hot clips from this studio!


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Prayer Ministry
We are glad you've come to Jesus for prayer. He promises to heal the brokenhearted, hear our cries, and walk with us in the midst of trials and difficulties. On top of that, the church is called to pray, support, and carry the burdens of each other - that's what family does.


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Infinite Victories: About 2 years ago, you were diagnosed with stage 4 lung cancer. With treatment, your tumor markers have been reduced by approximately 95%. What's your victory in all of this?
Dr. Thelma Chambers-Young (psychologist, minister, and wife): I've felt battered, never beaten. The real victory though, has been the connection with my Creator. The bond there has never wavered. In fact, it has only transformed into something that's stronger and more powerful than ever!
Photo by: George Young


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BlogsAbortion, Family Fri Jul 26, 2013 - 4:48 pm EST
Why you shouldn't blame the clergy that a majority of Catholics support abortion
LifeSiteNews recently reported the unsurprising findings of a poll commissioned by The Washington Post and ABC stating that a majority of American Catholics are in favor of abortion in "all or most cases." Coincidentally or providentially, LifeSiteNews published this article on the same day as the Catholic Church celebrated the 45th anniversary of Pope Paul VI's momentous encyclical Humanae Vitae. I suppose it was the latter, and I thank them for doing so.
The findings of the poll were disheartening. As a sinful, aspiring Catholic, this article provided me with a great lesson in humility and self-examination, and this is why.
As I read through the unsurprising, but equally devastating, results my anger grew stronger. What is wrong with all these Catholics? Where did the Church go wrong? Where did the pro-life movement go wrong? How is this possible and why don't they just get it?
Within seconds, my mind began to play the blame game, and naturally, my first target was the clerics of the church: Priests, bishops, and religious. "This is all their fault," I thought. Over the years, they have completely abandoned their flock. They stopped preaching the truth from the pulpit and with their own lives. They are to blame for this drastic dissent among Catholics.
Luckily, I quickly sobered up. I took a deep breath, and began to reflect more personally.
Click "like" to support Catholics Restoring the Culture!
In reality, we are all to blame. How pro-life is my family? My relationship with others? Do I always stand on the side of life in conversations with my relatives and peers? How is my relationship with my wife? My husband? My children? My parents? My relationship with my pastor? And yes, this is supposed to sound like an examination of conscience.
Instead of blaming the usual suspects, we need to look at our own lives. Clergy have an immense responsibility in the Church and they should be held accountable – but not any more accountable than husbands ought to be to their wives (and vice-versa), parents to their children, etc.
If I want more Catholics to truly believe that the right to life is above all other rights, that the inherent dignity of every human being – born and preborn – must be protected and defended at all costs and that to be Christian is to be pro-life, then I need to start with me and my immediate family. Devout and faithful priests (and there are many) definitely help, but the immediate family is the nucleus of our society, and everything starts there. This is usually the hardest place to start, but it is fundamental.
On this 45th anniversary of Humanae Vitae, we should all take the time to sit down with our family, after dinner, and read through this amazing document that was given to us by an amazing pope. We should discuss it, ask questions, seek answers, clear up misunderstandings, and relate with each other honestly by surrendering ourselves to the graces of the Holy Spirit. Afterwards, pray together for all priests and bishops and for a culture of life to be restored in our nation and around the world.
The Church and the pro-life movement have a lot of work to do and these poll results are a sobering reminder. But rather than blaming others, as I initially did, these results should motivate us to take an active role in the new evangelization and to make sure that when the next poll comes around, members of our own families will fall into the category of those who oppose abortion in all cases, not the other way around.
Red Alert! We need your help today.
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Samsung at Ulearn 2015
Not only is this tablet tough, it has the ability to be submerged in water up to one metre deep for thirty minutes, so it can handle water and more than just a sprinkling. In January 2016 I am running a teacher only day based on 'digitising camp.' The teachers I am working with will be set a series of challenges in the same way we set EOTC challenges for students that push them physically and to encourage collaboration and problem solving. These activities will be outdoors, strenuous and challenging. In addition, the teachers will have to wear tech throughout the day in order to capture their efforts, attempts and successes at meeting the challenges of the day. The teachers in their turn will use their experiences and knowledge learned about the tech to plan to 'digitise camp. ' By the end of the day the teachers will have had to capture, edit and publish, with reflections a journal of the day. As such, the Samsung rugedised tablet will form an integral part of the day.
For Ulearn however, Samsung have invited me to be on their stand for the duration of the conference to showcase what their 'ordinary' tablets can do and there is nothing ordinary about their tablets. I have my own Samsung Tab A with a 9.7 inch screen with integrated pen.
and they have kindly loaned me another tablet, the Tab A with an 8.0 inch screen, this particular model does not have an integrated pen.
A fiine nibbed stylus, integral to a tablet, is yet another winning feature that Samsung have championed for a long time. At Ulearn this year there is a thread in the breakouts about the power of the pen to communicate, a desire to return to traditional learning perhaps? However if the desire to keep the skill of writing is harnessed with a twenty-first century stylus, it can be seen more as a redefinition of learning, rather than a regression; a redefinition that Samsung has been leading for years.
With my particular focus on capturing student voice, I have been looking closely at these two devices with their native apps and the apps available on the Google Play Store, to see how these tools can really enhance the learning potential for students in the classroom using these devices. What this all means is that during the conference, whilst others may be giving products the hard sell in the trade hall, I will be on the Samsung stand running mini workshops, showcasing how easy it is to capture and share student voice using a Samsung tablet and just a few well chosen and integrated apps. I will be demonstrating how easy it is to layer different learning from one app to another in order to enable a more complex learning outcome.
So if you are at Ulearn this week, why not drop in and see how you can transform the learning in your classroom with some simple ideas and a Samsung tablet? If one of the breakout sessions you hoped to crash is full or worse still if a breakout session does not deliver what it promises, just come on down to the stand where mini workshops will be happening all the time throughout the conference. If you do not get a chance to come along to the conference, not to worry, I am hoping to capture some screen videos of some of the ideas and tools in action and post them to my YouTube channel after the event and possibly during it, if there is time. I look forward to seeing you on stand 21, just inside the main doors of the trade hall.


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You are invited to a Master Class in Lighting at Thursday 21st April from 6 to 7.30pm at OKA's flagship showroom in Chelsea.
Join us for this exclusive joint event and learn more about how to light and style your reception rooms.
Our Design Director Sally Storey will be giving expert advise on how to combine architectural and decorative lighting to add mood and atmosphere to your
reception rooms.
Cara Gillford, Interior Design Consultant for OKA, will also share her advice and design tips on creating inviting spaces that are prefect for living and entertaining.
This event is now full but we do have places for our Master Class on 16th May at our Showroom. Click here for details.


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As we approach the start of The Great British Skinny Dip, four new locations have announced that they will be holding a skinny dip event.
Leeds Naturist Group – Bramley Baths (Yorkshire)
Wyvern Sun and Swim Club – Tewkesbury (Gloucestershire)
Spielplatz Naturist Resort – St Albans (Hertfordshire)
Torbay Sun Club – Hollacombe beach (Devon)
Check back regularly to our organised events page to keep up to date with the latest events featuring in this years Great British Skinny Dip. Remember if there is still no event local to your area it's not to late to organise your own!


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The short answer is "yes," you can paint siding. But I'm wondering if it will be worth it depending on how much siding you need to paint and how it will perform over time. If you're talking about siding that covers an entire house, there are some advantages to simply replacing it. Vinyl expands and contracts significantly with changes of outdoor heat and cold, more so than any other building material. So you'd be asking your new paint coating to hold up to a lot of flexing over time. Adding a dark coating will attract more heat and will probably increase the expansion as well. I'd also be concerned about the paint "gluing" the siding panels together at the seams, then cracking loose with changes in the weather. You may even see gaps open and close with white color stripes peeking out. If painting is really your best option, you'll need to make sure you wash the siding very well, maybe even use some kind of de-glosser. The folks at my local Sherwin-Williams paint store have helped me select plastic paint (to coat thick plastic lumber) in the past, with very good results. Trust them to give you the right formula and techniques (this is important). Plan on at least three days for "curing" between coats. I expect you'll probably need at least two coats as well (hmm . . . the labor hours are adding up). But let's think a little deeper. What if you could recoup some money on future energy bills to help pay for the change in the house's exterior color? I think I'd rather pay a good vinyl siding contractor to install brand new vinyl in my favorite color, and do it under warranty, than spend at least as much money on painting labor (or try do all that work myself). While you're at it, have the installer add a thin layer of foam insulation behind the siding, or maybe upgrade to foam-backed siding. And if you don't have a nice tight house wrap under your existing siding, this would be a great time to add that vapor barrier, caulk, and paste the edges down around the window and doors to reduce air penetration. In my experience, siding replacement is a one to two-day job for an experienced installer, and it will pay you dividends in energy saving. But the siding material will cost more than paint. Painting is more labor intensive and will not hold up as well over time, but your paint materials will be less. You'll have to do the math. If you're only treating a small area for appearance (for example, to improve curb appeal to sell the house), painting is the old reliable choice. Oh, and be a good neighbor: choose a color that's in keeping with the character for your neighborhood!
How about white ALUMINUM siding? Can it be painted? (Especially since some of it has faded over time)


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Love writing on paper and on tablet computers? Then Just Mobile's AluPen Pro is just what you need. This aluminum stylus/pen hybrid has a retractable ballpoint pen on one end and a soft rubber nib on the other. It's the best of both worlds if you jot notes on classic paper and a modern tablet. It's priced at $39.95 direct from Just Mobile.
Some of our links in posts like this one are affiliate links, which means that we may receive a small commission on purchases at no cost to you.


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Building with modular construction techniques is one of the newer trends in the construction industry and it's a lot like building with Legos. This method of construction has become highly popular and will change how many hotels are to be developed in the future due to its time and inferable cost savings. So what is
Last week Marriott agreed to pay $12.2 billion, mostly in stock, for Starwood Hotels. When the deal closes, by mid-2016, Marriott will advance InterContinental Hotels Group (IHG) and Hilton Worldwide Holdings to become the No. 1 global hotel operator with 1.1 million rooms in some 100 countries and regions. This deal looks to have some positive
Hiring 3rd Party PM's in 2016 The hotel industry has changed significantly since the economic recession of 2008-2009. It has taken a few years for hotels to build profits up to what they were prior to the recession and now hotels owners are looking into new builds and renovations, which had been on hold since
Orlando, FL, Nov. 2, 2015 /PR – Beacon Bay Project Management, LLC announced today the launch of its newly revamped website. This newly redesigned website offers quick and easy access to essential information and features that offers a more comprehensive understanding of the Company's services. The website also has a portfolio section with past projects


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Internal Power Development Methods
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Mike Sigman
Location: Durango, CO
Join Date: Feb 2005
Posts: 4,123
Re: Internal Power Development Methods
Ashe Higgs
a) the clip is old and outdated but it's what i had available. since that time i've been tested and validated on our spinning hands method by my Sifu personally and so i'm quite confident that i know what i'm doing and that i can guide others in that method.
b) i can already tell your going to chase after me on this forum and try to poo-poo anything i post in an effort to assure everyone that you're the only one who knows what he's talking about. after the vitriolic PM's you can save the nice guy act for someone else.
Why not just, instead of doing the usual "go for the personal argument", see if you can logically say something other than "my Sifu validated me" stuff? If you ask many Aikido guys in re these discussions about "internal power", they'd also tell you "I got my dan ranking from a respected Shihan so that ends the discussion". Except that it didn't. If you can explain how you shifted from arm to dantien, I'd be interested in hearing it. If you want to go to personalities in order to avoid a legitimate discussion, you'll only fulfill a
held view of people from some forums (whose name I will not mention).
Mike Sigman
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Union says proposals for Sizewell C are important step on road to delivering world class jobs and skills
Plans to build a new nuclear power station at Sizewell have been welcomed by Prospect.
EDF Energy says as many as 25,000 'employment opportunities' could be created in Suffolk if project is given the go-ahead after a consultation that launched yesterday.
Prospect general secretary designate Mike Clancy said: "This is an important step on the road to delivering world class jobs and skills for Suffolk and the UK, as well as the future generation of electricity in the UK.
"Consultation with local communities and other stakeholders will be necessarily robust. Prospect believes that the boost to the local economy by the construction and then the operation of the new station as a part of a balanced energy policy is an important consideration.
"The consultation process is another example of the serious commitment by EDF Energy to investing in new nuclear in Britain."
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