Sterilization

Voluntary surgical sterilization (VSS) is the most prevalent form of contraception in the United States; 60 percent of those surgically sterilized are women who have had tubal ligation, and 40 percent are men with vasectomies. Most couples who choose surgical sterilization have completed their families, although for some individuals this choice is prompted by an inability or unwillingness to use reversible methods of birth control. Criteria once used to determine the appropriateness of sterilization based on age and parity (number of children born) are no longer appropriate, and a woman's considered, informed decision should be respected by the provider, regardless of her age, parity, and social circumstances.

TUBAL LIGATION. The most important point to be made in counseling a woman regarding tubal ligation is that the procedure must be considered permanent and should be performed only when she is sure that she desires no further children. Alternative (reversible) methods of birth control should be discussed to ensure that these methods have not been rejected on the basis of misunderstanding or other biases. Other important aspects of counseling include a description of the surgical risks of tubal ligation, failure rates, and a comparison to the various methods of sterilization available, including vasectomy for the woman's partner. If consent cannot be obtained from a severely mentally disabled woman, a legal guardian may provide consent in some cases.

Both the federal government and individual states have regulations regarding minimum age requirements and waiting periods from the time of written consent until the date that the operation may be performed if federal or state funding is to be used. For this reason, women who plan to undergo postpartum tubal ligation should receive counseling and consent before thirty-four weeks gestation.

The surgical approach to tubal ligation is primarily dependent upon whether the procedure is performed in the postpartum period, or longer than six weeks after delivery, in which case it is considered to be an interval tubal ligation. In a postpartum tubal ligation, a minilaparotomy performed within four to twenty-four hours of delivery is the preferred approach subsequent to a vaginal delivery. After receiving a regional or general anesthetic, a three-centimeter curvilinear or vertical incision is made immediately under the umbilicus. Once the peritoneal cavity has been entered, either the operator's finger can be used to sweep each tube into the incision or each tube can be grasped under direct vision. In either case, positive identification of the tube can be made by visualizing the fringelike portion at the abdominal end of each tube and by demonstrating that the nearby round ligament is uninvolved. After completion of the tubal occlusion, each excised tubal fragment must be sent for histological confirmation. In a woman delivered by cesarean section, any of the three techniques described below can be performed after repair of the uterine incision has been completed.

A number of techniques are available when there is direct access to the fallopian tubes via minilaparotomy or cesarean section. They include the following methods:

• modified Pomeroy method, in which two ligatures (sutures, "ties") are placed in the mid-

portion of each of the tubes and then the pieces of tube between the ligatures are removed. The closed ends retract, leaving a gap between the closed-off tubal segments.

• Irving method, whereby the tubal stump nearest the uterus is tucked into a tunnel made in the myometrium (muscular structure) of the large upper part of the uterus.

• Uchida method, which involves excision of a five-centimeter segment of tube, followed by burying the tubal stump farthest from the uterus within the mesosalpinx (the free margin of the upper part of the broad ligament).

While the failure rates of the Irving and Uchida techniques are exceedingly low (less than 1/1,000) in comparison to the Pomeroy method (1/250), the former take longer to perform and therefore are relegated to special cases.

Interval tubal ligation may be performed with a laparoscope (a narrow lighted tube) via a low minilaparotomy incision (a small horizontal incision, 2—5 cm long, just above the pubic hairline), the former being much more prevalent in the United States. Laparoscopic approaches ("band-aid" surgery) include either open or closed laparoscopy, and both one- and two-puncture instruments (laparoscopes) are available. While a large majority of laparoscopic tubal ligations are performed under general anesthesia, there is a growing trend to perform these procedures under local anesthesia, thereby reducing cost and avoiding the risk of general anesthetic complications, which is the most common cause of tubal ligation deaths. If local anesthesia is used, the tubes must be bathed in a long-acting local anesthetic, then banded or clipped, rather than electrocoagulated (coagulation or clotting of tissue using a high-frequency electric current).

Minilaparotomy for interval tubal ligation is performed via a three-centimeter low horizontal incision. Because of the difficulty entailed in working through a small incision, the procedure is facilitated by using a uterine elevator, an instrument placed in the vagina to lift the uterus. The procedure may be performed with general, regional, or local anesthesia. Minilaparotomy is contraindicated when the patient is obese, has an enlarged or immobile uterus, or when adnexal disease (in the areas adjacent to the uterus, e.g., ovaries and tubes) such as endometriosis is suspected. Nonetheless, minilaparotomy can be a safer, simpler, and less expensive procedure than laparoscopy, which requires more technical equipment and endoscopy experience.

If minilaparotomy is chosen, any of the occlusion techniques outlined above for postpartum tubal ligation may be used. In addition, spring-loaded tubal clips are available that can be easily applied through a minilaparotomy incision. With the laparoscopic approach, three methods of tubal occlusion are available:

• Electrocautery, with a coagulation or "blend" current, used at two or three sites along the mid-fallopian tube. Either unipolar or bipolar cautery may be used; while bipolar cautery is safer (since it is less prone to cause bowel burns), it takes longer and has a higher failure rate. Unipolar electrocautery is faster and more effective, but there is a risk of sparking between the electrode and the bowel, resulting in an unrecognized injury. Fallopian tubes occluded by electrocautery may be quite difficult to reanastomose (reconnect, in the event the woman changes her mind and wants to try to achieve pregnancy) because of extensive scarring.

• Silastic (silicone rubber) rings may be applied with a forceps-type applicator to a loop of mid-portion fallopian tube. This approach avoids the risk of electrical injury to the bowel and preserves much larger segments of healthy ends of the severed fallopian tube should later reversal be considered.

• Spring-loaded clips may be placed at a single site in the middle of the tube and can be used with double-puncture laparoscopy or at minilaparotomy.

The provider must explain that with tubal interruption alone, no organ is removed; tubal sterilization merely prevents conception. The operation is not "desexing" and will not reduce libido, vary the woman's menses, or alter her appearance. There is usually no adverse change in sexual function following tubal sterilization; on the contrary, many women who feared pregnancy before the operation report increased satisfaction in sexual intercourse and are pleased with the operative result. However, 2 to 5 percent report less frequent orgasm and a similar percentage have delayed regret that the procedure was performed.

Only hypophysectomy (excision of the pituitary gland), bilateral oophorectomy (removal of both ovaries), and ovarian damage by radiation are certain methods of sterilization. Abdominal and tubal pregnancies have occurred (rarely) even after total hysterectomy (removal of the uterus). Oophorectomy and sterilization by radiation are usually followed within four weeks by vasomotor reactions (symptoms associated with menopause such as "hot flashes") and a gradual diminution in libido or sexual satisfaction during the next six months.

VASECTOMY. Sterilization of the man by vasectomy is both less dangerous and less expensive than tubal ligation, as it is routinely performed as an office procedure under local anesthesia. Through one or two small incisions in the scrotum, the vas deferens (the tube or duct that carries sperm) is isolated and occluded and usually a small segment of each vas is removed. Neither physiologic impotence nor changes in libido result from the procedure. Sterility cannot be assumed until postoperative ejaculates are found to be completely free of sperm. Failure of the vasectomy, as manifested by pregnancy in a partner, occurs in 0.1 percent of patients. Medical risks of vasectomy include hematoma (blood clot or bruise) formation, epididymitis (congestion or inflammation of the epididymis, the coiled tubular structure where sperm cells mature), spontaneous recanalization of the vas (reconnection of the ends with restored patency) (incidence of less than 1%), and the development of a spermatocele (cystic nodule containing sperm). Atrophy of the testes very rarely results from ligation of excessive vasculature (blood supply). Vasectomy often is reversible—up to 90 percent in some reports—but requires expensive microsurgery and special skill with no guarantee of success. Pregnancy results in only about 60 percent of cases after reversal; factors that influence success include (but are not limited to) the surgeon's skill, the type of procedure used, and time interval since vasectomy.

MICHAEL S. POLICAR (1 995) REVISED

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