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  • Nathan Riley, MD

Obgyno Wino Podcast Episode 15 - Benefits and Risks of Sterillization

"Your vision will become clear only when you look into your heart. Who looks outside dreams. Who looks inside awakens." - Carl Jung

2016 Red Blend from Rabble Wine Company

PB#208 - Published January 2019

Five Pearls

  1. Female sterilization techniques are safe, easy and effective

  2. Male sterilization techniques are even safer and easier

  3. Pregnancies that occur in the setting of female sterilization failure are more likely to be ectopic (though absolute risk of pregnancy, ectopic or otherwise, is still exceedingly low)

  4. Counseling for patients desiring sterilization postpartum should begin early and continue throughout pregnancy; likelihood of regret should be a mainstay of counseling

  5. Alternatives to sterilization should always be provided


Sterilization: come again?

- fallopian tubes are either occluded or removed altogether (or vas deferens snipped in the male)

- of the 38.4 million using contraception in our country, this is actually the most common method used (~50% married couples, roughly 1/3 are vesectomies)

- 20% of married couples rely on oral contraceptives; 15% on male condoms; 7% on IUDs

- Female sterilization techniques peaked in the 1970s and rose through the 90s, then dropped slightly in early 2000s

Counseling

- safe and effective, and it's a great alternative for those with medical contraindications to reversible methods

- requires thorough discussion around risks, benefits, and alternatives

- should be considered irreversible, though there are techniques for reversing certain techniques (e.g. reanastomosis), but they carry low success rate and are often cost prohibitive

- safety of surgery must be considered in setting of patient's co-morbidities

- IUDs and implants are safe in almost everybody

- IUD risks: 1% chance of infection, 2-10% chance of expulsion, 0.1% chance of uterine perforation

- Implant risks are negligible apart from mild bruising and bleeding at placement site

- risk of regret is higher in women under 30; risk decreases as youngest child increases in age


Timing of sterilization


Postpartum

- (>50% of procedures, ~10% before leaving the hospital after a delivery)

- regional or general anesthesia or by reactivating functional epidural

- ideally consent should be obtained prior to presentation to the hospital

- this is not a decision that should be made in emotional environment around delivery: up to 50% of women ultimately do not decide to proceed with sterilization while hospitalized for a delivery even after they underwent counseling for sterilization during their prenatal care (risk of repeat, unintended pregnancy within 1 year of delivery for this cohort is also close to 50%)

- patient needs time to deliberate (with your help) over the risks, benefits, and alternatives to sterilization

- familiarize yourself with the laws and regulations of your state, they are in place to prevent compulsory sterilization or procedures without consent of patients

- some patients may be restricted to intrapartum or postpartum sterilization by their insurers

- in the case of intrapartum or postpartum maternal or neonatal complications, best to postpone until a later date


Postabortion

- OK after uncomplicated spontaneous or induced 1st or 2nd trimester abortion

- again, review state regulations

- laparoscopic or mini-lap approach


Interval

- any sterilization procedure performed apart from postpartum or postabortion

- need a urine pregnancy test, though this won't rule out a luteal phase pregnancy

- best to perform procedure during patient's follicular phase if patient wasn't using a reliable method of contraception prior


How To Be Reasonably Certain that a Woman Is Not Pregnant (per the CDC website)

Techniques


Vasectomy (for the men)

- outpatient procedure performed under local anesthetic

- safer, more effective, and less expensive than female sterilization techniques

- not immediately effective, thus use of an alternative form of contraception is required until a semen analysis confirms azoospermia (usually by 3 months; 98-99% are azoospermic at 6 months)

- not associated with sexual dysfunction or CVD risk

- counseling for young men, in particular, should include potential for regreting having had the procedure

Maybe it's time for men to sack up and join the Clippers

Hysteroscopy

- currently no approved hysteroscopic methods in the U.S.

- Essure® was a great option for women with preclusions to surgery

- outpatient procedure under local anesthetic in which nickel-titanium coils were inserted into the fallopian tubes

- legal battles for years over lawsuits from women that reported headaches, nausea and vomiting, mood and anxiety disorders among other complaints - Bayer discontinued device manufacturing in December 2018

- the FDA continues to "believe that the benefits of the Essure® device outweigh its risks"

- for patients that have it in place, OK to keep it there; if they are experiencing symptoms that might be attributed to the device, removal is possible (hysteroscopic removal or laparoscopic salpingectomy or cornuectomy), though likelihood of seeing a resolution of their symptoms is unclear per the available research

Essure® had a fun run.

Laparoscopy

- pros: small incisions, short surgery, quick recovery, immediately effective

- cons: risk of bowel, bladder, and major vessel injury

- generally performed under general anesthesia (risky), but in select patients local w/ sedation may be possible

- historically, mortality is 1-2 per 100000 procedures, with most deaths attributable to general anesthia (e.g. hypoventilation and cardiopulmonary arrest); more recent data suggest even lower mortality rates, perhaps attriubtable to surgeons becoming more experienced with laparoscopic techniques

- low major complication rates (intraop or postop: unplanned major surgery, transfusion, life-threatening event, febrile morbidity, or rehospitalization): 0.9-1.6 per 100 procedures w/ no variation between methods

- unintended conversion to laparotomy rate 0.9 per 100 procedures

- unclear association between history of tubal occlusion and subsequent hysterectomy


a. Electrocoagulation: bipolar instrument used to achieve tubal occlusion through electrocoagulation of at least 3 cm of isthmic portion of tube; monopolar instruments out of favor due to higher risk of thermal injury

b. Mechanical devices: silicone rubber bands, spring-loaded clips, or titanium clips placed on isthmic portion of tube

- these methods are less effective if fallopian tube is immobile, such as in the presence of adhesions, or otherwise abnormal (i.e. edematous, dilated)

- spontaneous clip migration or expulsion is rare

c. Salpingectomy or "ligation": obviously the least reversible of the bunch; no significant increased risk in length of hospital stay, re-admissions, blood transfusions, or post-op complications, infections, or fever compared to other laparoscopic approaches, possibly a decreased risk in ovarian cancer (esp if you are careful to remove fimbriae)

Recall: Ovarian cancer sucks. Highest mortality across all gynecologic cancers. Epithelial ovarian cancers are super-aggressive and comprise 90% of ovarian cancer as well as 90% of deaths from ovarian cancer. Available evidence suggests that epithelial ovarian cancer originates in the fallopian tube. This theory might explain why a lower ovarian cancer rate (relative risk 0.29-0.62, albeit still low absolute risk) has been seen through multiple epidemiologic studies in women who underwent salpingectomy and even non-excisional sterilization methods. See CO#774 March 2019 for further reading.

Mini-laparotomy

- affordable in low-resource setting due to minimal equipment needs

- larger incision required (2-3 cm below umbilicus) when compared to laparoscopic approach, but no difference in major morbidity

- can also be performed at time of c-section; any higher morbidity when compared with postpartum tubal after vaginal delivery has been attributed to indications for which the c-section was performed

- great for obese patients or those with other preclusions to laparoscopic surgery

- techniques: modified Pomeroy or Parkland (other methods are rarely used in the U.S.)

- submit tube segments to pathology to ensure complete transection

Fun fact: Pomeroy and modified Pomeroy techniques are the same apart from the type of ties used. The original was described using chromic. Its more contemporary cousin employs plain gut ties for more rapid absorption.

Pomeroy method of tubal ligation

How well do these methods work?

- Risk of failure across all reversible methods w/in 1 year of starting? 12%

  1. fertility awareness-based methods: 24%

  2. male condom: 18%

  3. oral contraceptive: 9%

  4. injectable methods: 3%

  5. copper T380A (Paragard): 0.8%

  6. Essure® (3-year): 0.48% (assuming 3 month confirmatory HSG) g. levonorgestrel-releasing IUS (Mirena): 0.2%

  7. etonogestrel implant (Nexplanon): 0.05%

- CREST study looked at 5-year failure rates

  1. aggregated sterilization methods (both laparoscopic and those by mini-lap): 1.3%

  2. copper T380A (Paragard IUD): 1.4%

  3. levonorgestrel-releasing IUS (Mirena IUD): 0.5-1.1%

- failure after sterilization carries higher risk of ectopic pregnancy in the event of failure

- 33% risk of ectopic if pregnancy occurs post-sterilization

- 20% risk of ectopic pregnancy secondary to IUD failure

- Important: still overall lower absolute risk of both pregnancy and, as such, ectopic pregnancy for both sterilization and IUD


So which sterilization method works best?



- clips may be less than effective than partial salpingectomy in the immediate postpartum period

- apart from postpartum partial salpingectomy, probability of ectopic pregnancy was higher for women <30 years compared to women >30 years of age

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