No, we aren't trying some form of genetic experiment! This page discusses female sterilization with men in mind. When discussing sterilization, a couple has the choice of "Him or Her". In order to make a properly informed decision, it's advisable to know about both procedures.
It's likely that women will look at web pages for women on female sterilization, and they will also look at vasectomy sites. We feel that whilst men will look at vasectomy sites, they are rather less likely to go Googling for female sterilization sites. Just to illustrate that point, this page came out of the fact that three of the senior posters at alt.support.vasectomy, and chatroom administrators on this site, our sum knowledge on female sterilization could be written on the back of a corn flakes packet! We don't feel that we are alone in our lack of knowledge, so we have put together this page that is intended to be an general overview of female sterilization that will hopefully help all of us!
General
Like vasectomy, there are different
procedures performed, but in the case of tubal occlusion the
procedure is often chosen for specific medical reasons. Unlike
vasectomy, it will normally involve a general anaesthetic, and
maybe a short stay in hospital. However, in most cases it's usual
to have the procedure done in the morning and go home later in
the day.
As with all methods of birth control, there is a failure rate, and pregnancy can occur several years after the procedure. The UK guidelines1 estimate the lifetime risk of failure to be 1 in 200. The guideline covers both male and female sterilization, and quotes the failure rate for vasectomy as being approximately 1 in 2000 where the man has semen samples analysed, and clearance has been given. Whilst men should be tested before being given the "All clear", women are not usually tested. The advice given is to continue using birth control up the first period after the operation.
Technical failure of the procedure can be down to several causes:- Recanalization, incomplete occlusion of the tube, the occlusion device can slip, the occlusion device might be in the wrong place or on the wrong anatomical structure. In addition, each occlusion device has it's own failure rate. Hulka clips and bipolar diathermy seem to have higher failure rates than other devices / methods. Age is a factor in overall reliability, with younger women being more at risk from failure. Young women are more fertile and have more fertile years remaining, therefore overall risk of failure is increased.1
Before the operation, birth control must be practiced to avoid the possibility of being pregnant, and after the operation birth control should be used up until the first period after the operation. It's normal to have a pregnancy test before the operation, but if the pregnancy is in the very early stages this may not show up. In one study, 2.6% of women had a positive pregnancy test on the day of their planned sterilization.
The RCOG1 recommends that male and female sterilization should be discussed with anyone requesting sterilization. It also recommends that women requesting sterilization should be informed that vasectomy has a lower failure rate in terms of post-procedure pregnancies, and that there are less risks related to the vasectomy procedure.
The decision
Tubal Occlusion and Vasectomy share one
thing in common - the same groups have a higher risk of regret,
and subsequently requesting reversal surgery. Like vasectomy, the
studies that look at regret have varying results. As a general
guideline, the studies tend to range between 3% and 10% of women
regret being sterilized. Also, like vasectomy good counselling
lowers the incidence of regret. In the developed world, the main
reason for regret is wanting to start a new family with a new
partner, and in the emerging world, it's often because of the
death of a child - particularly a male one.
Men and women most likely to regret being sterilized:-
Notes:-
* This doesn't mean to say that men or women
requesting sterilization under 30, or without children should be
refused sterilization, but that whoever is doing the counselling
should exercise additional care.
The procedures and
differences between them
The surgeon has to gain access to the
Fallopian tubes. There are two procedures in general use to do
this - Laporoscopy and Mini-Laporotomy. With Laporoscopy, two
small cuts are made just below the navel and lower down, or
alternatively to one side, or just above bikini line.
Mini-Laporotomy involves a slightly larger opening.
Mini-Laporotomy is mainly used if Laporoscopy is unsuccessful,
the patient is very over-weight or has had previous abdominal
surgery. It may necessitate a longer stay in hospital.
Laporoscopy has less chance of causing complications, and is
therefore usually the preferred method.
With vasectomy, the tubes are cut. In Tubal Occlusion they are
not necessarily cut. It depends upon the procedure and method of
incision. If Laporoscopy is used, then the Fallopian tubes may
simply be "crushed". Typically this will be by using a Filshie clip made of titanium and soft rubber. Like
vasectomy, tubal occlusion should be regarded as permanent
sterilization, but it is felt that as the Filshie clip destroys
less of the Fallopian tube it may be easier to reverse. If a
pregnancy occurs, it's less likely to be ectopic if mechanical
occlusion (clips or rings) has been used. However, for mechanical
occlusion to be successful, the clip has to be applied to the
right part of the tube in the correct manner. There are a variety
of clips and rings available, but according to the UK guidelines,
Filshie clips are the recommended device due to lower failure
rate, and less technical difficulty than rings when performing
the procedure. The failure rate of the Filshie clip is roughly
2-3/1000 pregnancies in women ten years post procedure.
If the surgery is being performed using Mini-Laparotomy
incisions, then there are a variety of procedures available. All
of them tie off the tubes and remove a small segment.
Reversibility is more difficult with all of the techniques.
Methods include the Pomeroy technique, the Parkland or Pritchard
technique - also known as the Modified Pomeroy procedure or
Partial Salpingectomy.
The Pomeroy technique is the most used in the UK. It's simple and
effective. A loop of tube is made, and tied with dissolvable
sutures with a cut being made at the top of the loop. After the
sutures dissolve the ends of the tubes pull apart. The advantage
is that because the sutures are rapidly absorbed, inflammation
and formation of fistulae in the tubes are decreased. The
disadvantage is that 3-4cm of tube are destroyed making reversal
more difficult.
The Parkland technique is more common in the USA. In this
version, the tubes are tied off in two places, and a small
segment removed. It's common to perform this procedure when the
patient is being sterilized whilst having a Caesarian section.
Some research suggests that in this situation it has a lower
failure rate than clips.
Other methods such as the Irving and Cooke technique that bury a
severed end in neighbouring tissue are more difficult to perform,
and not designed to be reversed.
Like the Marie Stopes method of vasectomy, Diathermy (cautery)
can be used to seal the tubes. However, the UK guideline advises
against this method, as it increases the risk of subsequent
ectopic pregnancy and is less easy to reverse than clips or
rings.
Timing
Provided that the clinician is confident
the patient has used effective contraception up to the day of the
operation and is not pregnant, Tubal Occlusion can be done at any
time of the menstrual cycle. Although Tubal Occlusion can be
performed following birth, or at the same time as a Caesarian
Section or abortion, there is an increased regret rate, and a
possible increased failure rate. In one study that compared the
regret of women who were sterilized at the time of abortion, and
women who were booked in to have the sterilization some 6 weeks
later found that 32.8% of these women did not return to have the
sterilization procedure. Another study finds that women who are
sterilized at the time of a Caesarian regretted the procedure
twice as often as those who had the procedure away from emotional
stress.
Risks
Tubal Occlusion carries a risk of ectopic
pregnancy if the procedure fails. The incidence of ectopic
pregnancy varies widely between studies and procedure methods,
but start at 4.3% of women getting pregnant after being
sterilized. The rate is higher when bipolar diathermy is
used.
There is an association with subsequent hysterectomy rates,
although there is no evidence that Tubal Occlusion leads to
problems requiring hysterectomy.
The risks of complications are higher if the patient has had
previous abdominal surgery, or is very overweight. Some studies
found that women who were sterilized young had a greater risk of
hysterectomy than women who had it done later in
life.1
Complications can happen during the surgery, but most are minor
and can be treated at the time. However, if there is any injury
to the bowel, bladder or blood vessels then the surgeon may have
to perform a Laporotomy (bikini line incision or midline cut) to
affect any repairs. Bowel injuries can happen during the
procedure. They are rare, but can be serious.
Most of the complications of Laporoscopic sterilization arise as
a result of development of air within the peritoneal cavity, or
from the blind insertion of the first trocar1. Also,
bowel injuries from trocar perforation happen - whatever
occlusion method is used.
Bowel perforations caused by diathermy burns can present some
days or up to two weeks after the procedure. If left untreated,
peritonitis and septicaemia can occur. Deaths have been reported
from unrecognised bowel burns after unipolar cautery.
Major complications are injuries to bowel, bladder or blood
vessels that require laporotomy or lead to death. The risk of
laporotomy being required varies between studies from 1.4 -
3.1/1000. The risk of death with laporoscopy is 1/12,000.
There is no evidence that having a tubal occlusion affects your
sex drive.
There is little / no evidence linked to getting heavier or more
irregular periods.
Reversibility
Reversal statistics vary between 31% to
91% of women will manage to get pregnant after tubal
reanastomosis. If the patient was sterilised with clips or rings,
they are statistically likely to be at the higher end of the
scale. Microsurgical reversal techniques have the best success
rate. With reversal there is a risk that between 0% - 7% of
pregnancies will be ectopic. The pregnancy rate post reversal
decreases with age. One study found that no women over 43 in the
study group achieved getting pregnant.
Post-tubal
syndrome
Although there are various sites on the
web devoted to this topic, there is no agreement within the
research community that the syndrome exists. Literature reviews
find that many studies into post-tubal syndrome have serious
methodological problems - recall bias, inappropriate control
groups, failure to check on past history of gynaecological
problems, psychological problems, and failure to account for the
use of oral contraceptives and IUCD's1.
Alternatives
Essure - also known as Hysteroscopic Sterilization had just been
introduced into the UK whilst the guidelines were in the final
stages of formulation. They do mention that it cannot be
reversed. They also mention that with this method, birth control
must be practiced for at least three months after the operation,
when a test called a Hysterosalpingogram (HSG for short!) is performed to
see if the tubes have been successfully blocked.
Sources
1 RCOG. UK national sterilisation guidelines 2004.
Disclaimer:- Information contained within this site is intended for the purpose of general information ONLY, and is not medical advice. For medical advice please consult a qualified Physician.