Guest Author - Dr. Denise Howard
Permanent sterilization should be considered as a birth control option in those who have completed their childbearing or in those who have no desire for fertility. The word “permanent” must be emphasized. Even though there are cases where permanent sterilization has been reversed it is important to have the expectation that this is not reversible. There are methods available that are equally effective but not permanent if there is any doubt.
Permanent sterilization entails the cutting or blocking of the fallopian tubes to prevent the egg and sperm from meeting. This avoids fertilization. This is an option in men also. It is called a vasectomy. In women there are many different techniques which have evolved and become more refined over time. Currently tubal occlusion can be performed laparoscopically, immediately post partum or with a hysteroscopic approach.
Immediately following delivery, a small incision can be made beneath the umbilicus. The uterus is still enlarged, so the fallopian tubes can be grasped through this small incision. A portion of the tube is removed and it is then tied to control bleeding. Laparoscopy is a technique using a camera and a small incision in the umbilicus and another in the lower abdomen. Clips or bands can be placed on the tube to obstruct it. The tubes can also be burned during laparoscopy utilizing a method called electrocoagulation.
The newest method is performed via a transcervical route. The Essure procedure, approved for use in 2002, entails placement of a coiled microinsert in the proximal portion of each tube by going through the uterine cavity using a hysteroscope. The implant is 4 cm with a stainless steel inner coil and a nickel titanium outer coil. Over time the body scars leading to complete obstruction of the tube.
At 3 months 96% of women will have complete obstruction and 100% by 6 months. This procedure is done without an incision and can be performed in a doctor’s office. It is just as effective as the traditional sterilization techniques as long as appropriate follow up is completed. The major disadvantage is the need for radiologic confirmation of obstruction 3-6 months after the procedure. Interval contraception is required. This procedure is indeed permanent as tubal reversal is impossible.
Permanent sterilization is attractive because it is simple, effective and minimally invasive. The success rate is generally greater than 99% but various depending on a number of factors. A failure of 5.5 per 1000 procedures in the first year is one reported rate. If failure occurs then the risk of a tubal or ectopic pregnancy is approximately 32%. Overall the risk of an ectopic pregnancy is much lower in a sterilized woman than a non-sterilized one. Failure of tubal sterilization maybe attributed to different causes. Tubal reanastomosis or recanalization can also occur. Failure of equipment and surgical error are also other possibilities.
Not all procedures are created equal. The pregnancy rate for postpartum partial salpingectomy is 6.3 pregnancies per 1000 procedures at 5 years. The hysteroscopic implant is the lowest with 1.64/1000 while the bipolar coagulation pregnancy rate is 16.5/1000.The silicone band has a rate of 10/1000 while the spring clips rate is 31/1000. The greatest risk after this procedure is that of ectopic pregnancy. In general the rate is 7.3 ectopics per 1000 procedures whoever this risk is highest in those who had bipolar coagulation with rate of 17 ectopics per 1000 procedures.
Tubal occlusion is an excellent choice for women who have completed their childbearing, especially in those who may not be good candidates for other birth control methods. One other important, rarely discussed benefit of tubal occlusion is the decreased risk of ovarian cancer.
It is important to discuss the risks and benefits of permanent sterilization with your doctor. Since not all methods are equal, it is also wise to discuss the method she will utilize. Serious thought should be given to having it done immediately postpartum if you are certain that you have completed childbearing. Discussion of other available contraception should be apart of this counseling visit. Being informed will allow you to make the choice that is most appropriate for you.
I hope this article has provided you with information that will help you make wise choices, so you may:
Live healthy, live well and live long!