Chapter 28 Surgical Sterilization

INTRODUCTION

Procedures for performing sterilizations have become much more prevalent in recent years. Millions of couples have opted for sterilization to control their fertility, making it the most frequently used method of contraception in the United States. The demand for female sterilization is dramatically increasing, and it is now the third most common surgical procedure performed on females in the United States. Tubal sterilization is a relatively simple procedure. It is a safe, extremely effective method of permanent sterilization. This procedure may be performed on an outpatient or inpatient basis, using either an abdominal, vaginal, hysteroscopic, or laparoscopic approach, and may be performed as either a postpartum or interval operation. The choice of procedure depends on the facilities available, timing, and the experience of the surgeon.

HISTORY

The first female sterilization in North America was performed in 1880 by S.S. Lungren of Toledo, Ohio and was done at the time of cesarean section. For the next few decades, all tubal sterilizations were performed at the time of laparotomy as a concurrent procedure or at the time of cesarean section because the risk of mortality was too high to perform this operation for sterilization alone. Sterilization became better accepted with the advent of the Pomeroy method of tubal occlusion, which could be accomplished through a small incision.

In the 1970s tubal sterilization became widespread due to the introduction of minilaparotomy and laparoscopy as methods. Anderson ¹ is credited with performing the first laparoscopic electrocoagulation procedure in the United States in 1937. Steptoe² in 1967 reported the first large series of laparoscopic sterilizations, and Wheeless³ in 1973 reported the first single-puncture laparoscopic technique. These procedures allowed for interval surgery, surgery without hospital stay, reduced recovery time, less morbidity, and better cosmetic result.⁴ Sterilization is now the most commonly used method of family planning in the world.

PREOPERATIVE EVALUATION

Tubal sterilization should be available to any woman who desires permanent sterilization, assuming that she has proper informed consent (Table 28-1) and adequate knowledge regarding the procedure. The procedure should be considered purely elective. There are virtually no absolute contraindications to tubal sterilization except for gynecologic malignancy or gynecologic disease that requires hysterectomy or bilateral oophorectomy.

Table 28-1 Elements of Informed Consent for Sterilization

Review of alternative methods of permanent sterilization (e.g., vasectomy)

Indication that the procedure is considered permanent

Review of failure rate of procedure

Description of the planned operative technique

Discussion of potential surgical risks

Certain circumstances require specific mention. For example, if the patient has known extensive intra-abdominal adhesions, the potential for intraoperative morbidity may be so great as to consider another form of contraception. For the patient with a severe medical problem, it is probably advisable to consult with a specialist in the particular disease-related area or a maternal medicine specialist to determine exactly how pregnancy would affect the condition in question. Often, patients have been told by a well-meaning healthcare provider that pregnancy is contraindicated when in fact it is not. The family of a severely mentally retarded patient may request sterilization, but these are special circumstances that require discussion with the family and most often require a second opinion, an ethics committee recommendation, and, at times, a court order.

Informed Consent

Because most methods of sterilization are designed to be permanent, proper patient counseling and informed consent are important. The decision for sterilization should be made on an entirely voluntary basis after appropriate counseling on risk, benefits, and alternatives.

Various materials are available to assist the physician in counseling the patient. The American College of Obstetricians and Gynecologists (ACOG) distributes a pamphlet that discusses different techniques of sterilization as well as alternative methods for contraception. For couples desiring permanent sterilization, vasectomy should always be discussed because vasectomy is associated with fewer complications than tubal sterilization. When counseling the patient on the benefits of sterilization, it is important to include that all methods are extremely effective, are permanent, and have a low failure rate.⁵ Risks of the female sterilization procedure include risk of anesthesia, operative surgical risks, and the 1% to 3% risk of failure with an increased risk of ectopic pregnancy. It should be remembered that patients whose sterilization will be federally funded must sign a special consent document and must be at least 21 years old.

The patient’s husband is not required to give consent before the procedure is performed. Obviously, it is best if both partners have an understanding of the procedure as well as the benefits and potential risks of it. Thus, if a problem is encountered, the patient’s family is in a better position to deal with the problem.

Sterilization Regret

Anywhere from 3% to 25% of women have regret about sterilization, and 1% to 2% of these patients actually seek tubal reversal. Some reasons for regret (Table 28-2) include change in marital status, death of a child, and wanting another child after other children have gotten older. Studies have shown that there is an increased risk of regret with change in marital status, age less than 30 at the time of sterilization, psychiatric history, postpartum sterilization, poor outcome with previous delivery, and ongoing marital, financial, health, or personal problems at the time of sterilization.⁵

Table 28-2 Factors That Have and Have Not Been Associated with Regret After Sterilization

Factors Associated with Regret	Factors Not Associated with Regret
Marital status change	Religion
Family stress (e.g., death of a child)	Socioeconomic level
Desire for additional children as the “baby” grows up	Education level
Post-tubal ligation syndrome symptoms	Low parity
Postpartum procedure	Decision made with husband’s approval
Sterilization before age 30	Interval procedure

TIMING

Postpartum Sterilization

Sterilization after delivery, during the patient’s postpartum hospital stay, is a convenient, effective, and efficient way to prevent future pregnancy. In the immediate postpartum period the uterus is enlarged to the level of the umbilicus, making it convenient to perform sterilization with a small 1- to 2-cm infraumbilical incision. Any of several techniques could be used. The longest period that the patient may wait before undergoing sterilization is controversial. In some circumstances, a delay of 12 to 24 hours may be needed to assess the infant’s condition, or delays secondary to staffing patterns or availability of anesthesia may be encountered. Studies done show no increased risk of morbidity if the sterilization is delayed for the first postpartum day.^6,⁷ If it is not feasible during this time period to perform the sterilization, the patient should probably wait at least 6 weeks so that the uterine architecture will be back to normal. Before this time, the uterus may be enlarged, making laparoscopy more difficult, and there may be an increased risk of infection during the postpartum period. The patient who has a postpartum endometritis or has had premature rupture of the membranes, intrapartum fever, or manual placental removal is probably at risk of a postsurgical infection. Therefore, it may be prudent for this patient to wait and undergo interval sterilization.

If cesarean section is required and the patient desires sterilization, the two procedures should be performed concurrently. The addition of sterilization to cesarean section adds little to the operative risk of the procedure or to the postoperative morbidity. Also, performance of the sterilization procedure at the time of cesarean section or shortly after vaginal delivery allows the patient to recover from the two procedures simultaneously and therefore does not add to the patient’s hospitalization or convalescence period.

Interval Sterilization

Interval sterilization after the immediate postpartum period should be delayed for 6 or 8 weeks. Most of these procedures are performed by laparoscopy and can be done using local, conduction, or general anesthesia. Performance of the procedure during the menstrual or proliferative phase of the cycle reduces the chance of pregnancy at the time of the procedure. However, if this is not practical, a sensitive urine or serum pregnancy test can be done on the day the procedure is performed. This too has been shown to decrease the risk of luteal phase pregnancy.⁸ Finally, sterilization can be performed in conjunction with other surgical procedures, such as cholecystectomy or plastic surgical procedures.

STERILIZATION METHODS

More than 100 sterilization techniques have been described in the gynecologic literature. A discussion of the risks, benefits, technical aspects, and failure rates of each of these procedures is beyond the scope of this chapter. Therefore, only those techniques that are currently popular or are widely used are discussed. For the most part, interval sterilizations are performed by laparoscopy and postpartum sterilizations are done by minilaparotomy.

Madlener Technique

The Madlener technique involves forming a loop of tube, of which a portion is crushed at the base of the loop and ligated with a nonabsorbable suture. Occlusion but not division of the lumen is achieved (Fig. 28-1). The end result is similar to the laparoscopic placement of a Silastic band for occlusion, as described in the section on the Falope ring in this chapter. Failures are often attributed to fistula formation at the ligature site. This technique is generally of historic interest only.

Figure 28-1 Madlener technique for tubal ligation.

Irving Procedure

The Irving procedure was introduced as a technique for ligation and division of the oviduct at the time of cesarean section. At the ampullary–isthmic junction, the proximal stump is buried within the myometrium and the distal stump is buried between the leaves of the broad ligament (Fig. 28-2). As the uterus undergoes involution postpartum, the buried proximal and distal ends of the tubes become compressed and eventually obliterated. This procedure takes longer and there is often more blood loss; however, the chances of tubal recanalization or pregnancy in the proximal stump are remote.

Figure 28-2 Irving procedure for tubal ligation.

Pomeroy Method

The Pomeroy method (Fig. 28-3) or its modifications are probably the most commonly used sterilization procedures today. A knuckle of tube is grasped at the midportion using a Babcock clamp. This segment of tube, approximately 2cm in length, is then ligated at the base with an absorbable suture, preferably plain gut. This segment of tube is then excised and sent to the pathology laboratory for confirmation. The use of absorbable sutures allows the proximal and distal segments of the tube to separate, thus decreasing the risk of recanalization of the tube. The advantages to the Pomeroy method are that it is easy and quick to perform and highly effective. Its acceptance for both postpartum and interval sterilization is quite high.