Who may be sterilized?
Either partner may be sterilised usually by means of a minor operation. Sterilisation is suitable for people who have completed their family or for those who are certain that they never want to have children. The procedure should be regarded as irreversible and therefore permanent. Many surgeons only feel comfortable undertaking sterilisation for patients who have reached a certain age but will make allowance for extenuating circumstances. My own view is that sterilisation is usually not appropriate earlier than 28 30 years of age.
What does female sterilization involve?
The majority of female sterilisations involve techniques for blocking the Fallopian tubes (Figure 18.1). This prevents the sperm from reaching the egg. Human eggs are tiny (smaller than the point of a needle). If they are not fertilised the body’s natural mechanism is to destroy and remove them they do not accumulate within the blocked tube. The majority of female sterilisations are undertaken laparoscopically. The Fallopian tubes are visualised by the surgeon and a second tube is introduced into the abdomen to allow the sterilisation (Figure 18.1). At one time heating (diathermy) sealed a section of the tube but occasionally this could damage an adjacent structure such as the bowel. The majority of laparoscopic sterilisations nowadays involve the application of a clip or ring to each tube. A section of the Fallopian tube may be removed (tubal ligation) at open surgery Figure 18.2. Examples of indications for open surgery by mini-laparotomy would include previous surgery, which would make laparoscopy more dangerous or if the abdominal wall is too thick due to excess weight. When laparoscopic sterilisation is planned, it is appropriate to realise that should there be any difficulty, such as the tubes being stuck to other structures, open sterilisation could be required. Laparoscopic sterilisation can usually be undertaken as a day case whereas open sterilisation requires one or two extra days in hospital.
ESSURE PBC (PERMANENT BIRTH CONTROL)
1 June 2001
A new method of contraception has been developed for those women seeking permanent contraception without the need for a general anaesthetic and major surgery.
The method is called the Essure pbc (permanent birth control) system and comprises an inner wire surrounded by a larger coil or wire with a layer of synthetic fibre between.
The device is loaded into a standard hysteroscopy tube and the majority of insertions can be safely and comfortably performed under local anaesthesia.
The inserter device flattens the coiled spring so that the device can be inserted through the cervix and uterine cavity and into the entrance of the fallopian tubes. About 5-10 mm of the device remains within the uterine cavity but as the inserted device is withdrawn the coiled spring uncoils and lodges firmly in the tube. This is then repeated on the other side.
The presence of the synthetic fibre encourages the growth of fibroblasts (a cell found in connective tissue, which can form collagen fibres) into the device so that in time the sections of the fallopian tubes where the device lies are completely and irreversibly blocked.
The advantages of this form of permanent contraception are the fact that it leaves no scars, and that it can be performed under local anaesthetic with less post-operative side effects than could be expected from conventional tubal ligation procedures, that is, from having your tubes tied.
According to FPA Health, the Essure pbc system represents a new and exciting option for women re questing permanent sterilisation. Outpatient hysteroscopic sterilisation using the Essure system without sedation or general anaesthesia is a successful and safe procedure associated with high rates of patient satisfaction. If practical, women should be scheduled to have their procedures in the proliferative phase of the menstrual cycle to optimise successful placement of Essure devices, especially if the uterus is clinically enlarged.
Hysteroscopic placement of tubal microinserts for sterilization may occasionally be associated with intractable pelvic pain requiring removal of the devices.
Seven hundred seventy women with known parity were recruited to participate in a prospective, multicenter study. Bipolar, low-level radiofrequency energy delivery and porous silicon inserts were used. The inserts were placed bilaterally in the fallopian tube lumen. Subsequent bilateral occlusion was assessed with hysterosalpingography. Overall, bilateral placement success was achieved in 611 of 645 women (95%). Bilateral occlusion was confirmed in 570 of 645 (88.4%). The 1-year pregnancy prevention rate as derived with life-table methods was 98.9%.
How failsafe is female sterilization?
No method of sterilization is completely guaranteed. Ectopic pregnancy has been reported even after hysterectomy (the end of a Fallopian tube had opened into the top of the vagina). Figures vary according to the method of sterilization but the average failure rate is about 1 in 200.
How quickly does female sterilization work?
The operation provides immediate protection. You can make love as soon as you feel ready. It must be stressed that contraception is required before the operation. If there are sperm in the female genital tract before the sterilisation, fertilisation could occur. If you have an IUCD that is to be removed at the time of sterilisation, you should abstain or use a barrier method for at least seven days before the sterilisation. If an embryo has been conceived and it is above the sterilisation point, the pregnancy could implant in the Fallopian tube (ectopic pregnancy) which is dangerous. If the embryo is below the sterilisation point, an ongoing pregnancy within the uterus would not be prevented by the operation.
How will I feel after female sterilization?
It may take a day or two for the effects of the anaesthetic to disappear completely so that you will need to take things easy for at least a few days. There may be some discomfort at the small incision sites but mild pain relief such as paracetamol is probably all that will be required.
Laparoscopic sterilization will have no effect on your hormones so that your sex drive and enjoyment of intercourse should not be diminished.
What are the risks of female sterilization?
Even with the greatest care and surgical skill, there are risks with any surgical procedure. When surgery is performed within the abdominal cavity, blood vessels and organs such as the bowel may be inadvertently injured. The majority of female sterilisations are performed with . There is a one in a thousand risk of complications occurring.
Sometimes it may not be possible to visualise the Fallopian tubes adequately and your gynaecologist may decide to transfer from a laparoscopic approach to an open procedure.
How will female sterilization affect my periods?
Many women find that their periods seem to be heavier some time after they were sterilized. Usually this occurs because they had been taking the pill before they were sterilized and the pill had been masking the problem. Others would have developed period problems later in life even if they had not been sterilized. The question as to whether sterilization is a cause of heavy periods remains unresolved although research tends to show no difference in the incidence of period problems following sterilization whether the female or male partner has the operation.
Is my partner’s consent required before I am sterilized?
There is no legal requirement, in the UK, for you to have consent for sterilisation from your partner.
My family is complete. What are my birth control options?
Firstly, there may be no good reason to stop taking the pill. If you are healthy, not overweight, do not smoke, do not have high blood pressure and you have not had a blood clot problem (thromboembolism –surgery risks), there is no medical reason to stop the pill. If you stop taking the pill when you are sterilised, your periods are likely to change back to how they were before the pill was taken. If they were troublesome before, they are likely to cause you problems again .
- You could stop the pill for a few months and use a barrier method to see what your periods are like before you have a sterilisation operation.
- The LNG-intra-uterine system provides excellent contraception and may reduce period problems. Failure rates with Mirena are lower than with sterilisation.
- Hysterectomy would provide sterilisation and you would no longer have periods. This operation may be a reasonable option particularly if your womb is enlarged with (Endometrial ablation could be performed at the time of sterilisation if you have heavy periods, no obvious structural problem with your uterus and you do not want to have a hysterectomy. Ablation seems to improve periods in about 80% of cases.
Every operation carries a small risk . The specific risks for vasectomy are bruising and pain. This may be helped by wearing tight fitting underpants for seven days and nights after the operation. There have been reports of a possible link between prostate and testicular cancer and vasectomy but this risk remains unproven.
Following vasectomy, there will still be sperm above the cut in the vas deferens and it will take between 2-4 months for them to disappear. Semen analysis will be arranged about three months following the operation. Intercourse can recommence as soon as the man feels comfortable but additional contraception is essential until there have been two semen tests showing absence of sperm.
Female sterilization and vasectomy compared.
These are compared in
Table 18.1 A comparison of female sterilisation with vasectomy.
|Usually performed under general anaesthetic.||Usually performed under local anaesthetic.|
|requires admission to hospital usually for one day only.||Performed in the clinic.|
|Effective immediately.||Takes about three months to be effective.|
|Failure rate 1:400||Failure rate 1:1000 – 7000|
|More risks than vasectomy.||Operative risks minimal.|
|Best considered as irreversible.||Also best regarded as irreversible.|
Which one of us should be sterilized?
You should consider together all the options carefully. Above all you must be absolutely certain that your family is complete. The argument that sterilisation is the most effective contraception is no longer valid as the LNG-intra-uterine system is associated with a lower failure rate than female sterilisation. From a medical point of view vasectomy is easier and associated with fewer complications than female sterilisation.
One partner may be many years older than the other or have a medical history that would contraindicate parenting a child so this partner may feel that he or she is the least likely ever to regret the operation. There may be an anatomical problem making sterilisation particularly hazardous for one partner.
Is it possible for sterilization to be reversed?
Sterilisation should not be regarded as temporary contraception. You should not contemplate sterilisation unless you are absolutely certain that your family is complete.
Doctors, perhaps more than many others, are well aware that life does not always follow an individual’s aspirations. At least six times each year, I see a woman who re quests reversal of sterilisation. The notes always document that at the time of counselling before the sterilisation she was absolutely certain that her family was complete. The most common reason for the re quest for reversal is a change of partner. Clearly the younger the individual at the time of sterilisation, the longer the time for the sterilisation to be regretted.
There is sometimes a possibility for sterilisation to be reversed but surgery is by no means always successful. Reversal of female sterilisation is only possible when small sections of the Fallopian tubes have been blocked. If all, or a large parts, of the tubes have been removed, reversal would not be possible. If just one clip has been applied to each tube, reversal is successful in about 70% of cases. Medical insurance companies and most purchasing authorities in the NHS are unlikely to fund reversal of sterilisation.
If reversal of sterilisation fails there are still other possibilities. For the woman, pregnancy may still be possible by IVF (24). For the man, donor insemination (sperm from an anonymous healthy donor with similar physical characteristics) could be inseminated into the female partner. Another option is for sperm to be retrieved from above the sterilisation sight by surgical aspiration. Individual sperm can be injected into individual eggs (ICSI 25) obtained during IVF.
Members of a support group, provide each other with various types of help and information for a particular shared difficulty.
The support may take the form of providing relevant information,
- relating personal experiences,
- listening to others’ experiences,
- providing sympathetic understanding and
- establishing social networks.
A support group may also provide ancillary support, such as serving as a voice for the public or engaging in advocacy.
Support groups maintain interpersonal contact among their members in a variety of ways.
Support groups also maintain contact through printed information rich newsletters, telephone chains, internet forums, and mailing lists.
Support groups offer companionship and information for people coping with diseases or disabilities. Support groups may not be appropriate for everyone, and some find that a support group actually adds to their stress rather than relieving it.
You may find that several general women’s health sites may help you . The following are more specialised Web sites on topics found in this
The Family Planning Association (FPA) provides information about contraception and details of local clinics:-
2-12 Pentonville Road
London N1 9FP
Tel:- 020 7837 4044