Technical failures in female sterilization using the tubal ring: a case-control analysis.

To delineate characteristics of women predisposing to sterilization technical failures, we performed an analysis of 20 technical failures that occurred during tubal ring procedures and 80 control ring procedures matched on planned surgical approach and study site. None of the women had recently been pregnant (interval procedures). The odds ratios (ORs) were elevated for women wearing an IUD in the three months prior to sterilization (OR = 5.0, 90% confidence interval [CI] 2.2, 11.2) and for women with a history of spontaneous abortion (OR = 4.3, 90% CI 1.8, 9.8). A history of pelvic inflammatory disease (PID) and/or current evidence of PID was strongly associated with technical failure (X2 = 25.0, p less than 0.001). The combined effect of any two of these three factors increased the risk synergistically. We examined these factors prospectively and confirmed the elevated risks (relative risk [RR] = 5.0, 5.5 and 22.7 for recent IUD wearing, spontaneous abortion history and history/evidence of PID, respectively). The prospective analysis also found that previous abdominal surgery is associated with technical failure (RR = 6.7).

PIP: To delineate characteristics of women predisposing to sterilization technical failures, we performed an analysis of 20 technical failures that occurred during tubal ring procedures and 80 control ring procedures matched on planned surgical approach and study site. None of the women had recently been pregnant (interval procedures). The odds ratios (ORs) were elevated for women wearing an IUD in the 3 months prior to sterilization (OR=5.0, 90% confidence interval CI 2.2, 11.2) and for women with a history of spontaneous abortion (OR=4.3, CI 1.8, 9.8). A history of pelvic inflammatory disease (PID) and/or current evidence of PID was strongly associated with technical failure (X squared=25.0, p less than 0.001). The combined effect of any 2 of these 3 factors increased the risk synergistically. We examined these factors prospectively and confirmed the elevated risks (relative risk RR =5.0, 5.5 and 22.7 for recent IUD wearing, spontaneous abortion history and history/evidence of PID, respectively). The prospective analysis also found that previous abdominal surgery is associated with technical failure (RR=6.7).

Laparoscopic tubal sterilization: postoperative follow-up and late gynecological complaints.

PIP: In a 7 year study, 322 women between 31-45 years old who submitted for laparoscopic tubal sterilization were questioned on specific gynecological complaints. 4 techniques including coagulation with tubal resection, double coagulation without resection, silastic rings, and spring-loaded clips were the surgical procedures used. After accounting for combination-pill use and abdominal complaints previous to sterilization, 7.1% of the women complained of menorrhagia, 6.2% complained of dysmenorrhea, and 8.7% complained of vague abdominal pain. The incidence of menorrhagia and dysmenorrhea occurred equally for each sterilization technique. Postoperative complaints may be due to hyperplasia of stroma with endometrial biopsies indicative of a persisting proliferation phase.^ieng

Interval mini-laparotomy: an alternative to laparoscopic sterilization?

PIP: The criteria for assessing female sterilization techniques are safety, effectiveness, and economy. Comparison is made between interval minilaparotomy and laparoscopy. The equipment necessary and surgical techniques followed for both these procedures is described. The operative equipment necessary for laparoscopy is extensive. The mini-laparotomy requires only some type of instrument for elevating the uterus. There are no distinct contraindications for use of the mini-laparotomy while there are 3 clear and 2 relative contraindications against laparoscopy. These are: cardio-respiratory decompensation, sickle hemoglobinopathy, hernias, peritonitis, and intestinal obstruction. The complications which are unique to laparoscopy derive from the necessity to create the pneumoperitoneum in that procedure. Comparison of complications experienced and subsequent pregnancies with both procedures is made though a literature search; the comparison involves several laparoscopic studies and 1 large mini-laparotomy study. Results of the comparison are tabulated.^ieng

[Transverse laparotomy by supre-pubic detachment of the recti muscles in gynecologic surgery. Apropos of 266 cases]. / Laparotomie transversale par désinsertion sus-publenne des droits en chirurgie gynécologique. A propos de 266 cas

The authors have studied 266 case histories where supra-pubic detachment of rectus muscles was used according to Cherny's method. This allowed aseptic gynaecological surgery to be carried out in all its forms by a true transverse incision. The advantages are great : it is aesthetic and the incision can be enlarged if necessary indefinitely. This means that surgery can be carried out easily and explains the great rarity of intra-abdominal complications. On the other hand two relatively rare complications do occur with this incision : peritoneal haematomata and lateral herniations. Details have been given of the methods necessary to avoid these complications.

PIP: 266 cases in which suprapubic detachment of the recti muscles was performed according to Cherney's method were studied. This method, which is described and compared with other methods, allowed aseptic gynecological surgery to be performed in all its forms by a true transverse incision. This technique offers great advantages, both from an esthetic viewpoint and because, if necessary, the incision can be enlarged indefinitely. Thus, surgery can be performed easily, which explains the great rarity of abdominal complications. Conversely, 2 relatively rare complications do occur when using this incision: peritoneal hematoma and lateral inguinal hernia. The techniques required to prevent the occurrence of such complications are described in the report. There is a single formal contraindication, in case of septic lesion; if, however, such lesions are found unexpectedly during the operation, the appropriate technique to be followed is described. The incision should be avoided in the case of patients suffering from obesity and blood disorders, because of the risk of hematoma.

Current status of sterilization.

About 50 per cent of child bearing women in Australia are being sterilized. The selection of patients for the procedure requires careful counseling in order to avoid the risk of regret. Factors increasing the risk of regret are enumerated. Laparoscopy is the most popular method for sterilization, but mini laparotomy is a reasonable alternative for patients not having access to skilled laparoscopists. Clips and rings provide a greater chance of successful reversal of sterilization, and are recommended for use in younger women. The sequelae of sterilization are slight, with failure of technique, infection and temporary regret being the commonest. Serious psychological or physical sequelae are rare. If reversal is required the microsurgical technique is recommended.

PIP: About 50% of women at childbearing age in Australia are requesting sterilization, usually for the following reasons: 1) increasing age; 2) achievement of the desired family size; 3) difficulty coping emotionally and physically with children; 4) financial difficulty; 5) difficulty with other methods of contraception; and 6) anticipated physical hazards with further childbearing and the absence of the desire to conceive. Nevertheless, counseling should precede the operation and a written document, which may be of value if legal proceedings are afterwards initiated, should be secured. Laparoscopy is done in two-thirds of the cases. 4 methods are available: bioplar and unipolar diathermy, clips, and rings. The advantages and disadvantages of each are weighed in terms of effectiveness and reversibility. The author proposes that if the failure rate for the clip is established to be the same as for the more radical methods of sterilization, then it can be accepted as the main laparoscopic technique. Similarly, the author reviews the effectiveness and the techniques of laparotomy and minilaparotomy. The article concludes with a review of the sequelae of sterilization and sterilization reversal, in which microsurgical reversal is commended as the more accurate and less damaging procedure as well as having the greatest chance of success.

[Sterilization as a contraceptive method]. / Sterilizatsiiata kato kontratseptiven metod.

PIP: Sterilization has been recognized as an efficient method of contraception and has been used worldwide in recent years. Indications and contraindications for the sterilization of men and women are described as well as the legal and ethical aspects of the problem. The authors describe the most modern surgical methods utilized: conventional laparotomy, minilaparotomy, colpotomy, and vasectomy, and also discuss the biological and side effects of the manipulations. The advantages of the method are also discussed. (Authors' modifeid)^ieng

[Aortic perforation following electrocoagulation of the tubes]. / Aortenperforation nach Elektrokoagulation der Tuben

PIP: In the course of a sterilization by tubal electrocoagulation, the patient suffered perforation of the abdominal aorta, causing a large hematoma and danger of bleeding to death. The aorta was repaired with a Teflon patch and the patient recovered, but the potentially fatal incident occasioned a review of the legal status of sterilization and of its complications. In the Dohrn case (1964), the Federal Court of Justice determined that voluntary sterilization is nonpunishable under German law. However, sterilization has increased less in Germany than, e.g., in England or Japan, and in 1969 the German Doctors' Conference declared sterilization permissible only for medical, genetic-eugenic, or pressing social reasons. As for complications, electrocoagulation of the tubes - involving anesthesia, inhibition of respiration by means of Trendelenburg's position, introduction of carbon dioxide into the abdomen, and manipulation of instruments through incisions - must be considered a complex procedure. Among 11,956 published cases described by 29 authors between 1969-1974, the complication rate was 1.71%; probably the actual rate is higher. 3 fatalities - from heart failure, peritonitis, and suffocation - were reported. In addition, there were 117 hemorrhages (.98% of the cases reported), 22 burns or mechanical injuries of the gastrointestinal tract (.19%), 26 perforations of the uterus (.22%), 44 infections (.37%), 25 skin burns (.21%), and 24 cases of skin or organ emphysema (.2%). Mechanical injuries carry the danger of perforation of organs over time, and the injuries reported included 13 perforations of colon, ileum, or stomach, requiring laparotomy and excision. Complications under electrocoagulation are reported to be less severe than in conventional operations; nevertheless, electrocoagulation should never be performed as an outpatient operation, and follow-up to check for delayed complications is advisable. Contraindications are poor general health, severely reduced respiration, and such conditions as anatomical anomalies, tumors, endometriosis, and obesity.^ieng

[Empirical contraindications to the sterilization of women]. / Empirische Kontraindikationen zur Sterilisation der Frau.

PIP: The results of a follow-up study of 2000 women who underwent sterilization between 1964 and 1971 are presented. 95% of the women were satisfied with the operation. Sterilization should not be performed if a woman unconsciously considers the ability to conceive as integral to her womanhood. Sterilization should only be performed because of incapability to use oral contraceptives or the IUD, if the patient is psychologically prepared for it. The most important condition for undergoing sterilization is the fulfilled desire to have children. Sterilization should not be used to stabilize an unstable marriage, or as a reaction to an abortion, the birth of a deformed child, or due to pressure from a third party.^ieng

An invisible incision for postpartum tubal ligation.

PIP: Tubal ligation was performed on 80 women with flattened postpartum navels using the Mark-Webb 1968 technique to reduce the size of the incision. Those women who were obese, had chronic coughs, or smoked were not used. A semilunar incision from 3 to 9 o'clock in the umbilicus and a transverse incision in the exposed fascia were used. The peritoneum was incised vertically. The operation is best performed immediately after delivery and is most suitable for non-obese patients. No wound infections or hernias occurred. The invisible incision enhanced cosmetic appeal to the women and was not a constant reminder of sterility.^ieng

Laparoscopic sterilization - what are the problems?

PIP: The problems which may arise in the course of laparoscopic sterilization are discussed. The overall mortality rate from laparoscopic procedures has been put at 20-30 per 100,000 procedures. Previous abdominal surgery is no longer regarded as an absolute contraindication, and extremely obese patients can now be operated upon with modified instruments. The reported morbidity for the procedure has ranged from 1%-6%. The most common major complications are emphysema, cardiac and respiratory difficulties, organ perforation, burns, and hemorrhage. Techniques for avoiding these complications are described. The overall failure (pregnancy) rate for the procedure has ranged from 0%-2%. Causes for failure and surgical techniques to assure complete sterilization are given. It is now considered safe to perform laparoscopic sterilization in the early postpartum period, though procedures for introducing a pneumoperitoneum and the tubal site for coagulation must be slightly modified. Bleeding and hypotension are the most frequent complications in postpartum patients. Laparoscopic sterilization in conjunction with abortion is being more commonly performed. The average hospital stay for postabortion sterilization patients without complications is 2.4 days. Outpatient cases have been reported where the shortest stay was 9 hours.^ieng

Tubectomies in rural areas of Jaipur district.

PIP: In Jaipur district, 1065 cases of tubectomies were performed from 1974-1975, of which 1000 were performed vaginally and 65 through the abdomen using the Pomeroy and Viennese Method. The majority of patients were between 25-34 years old and had 4 or more children. Post-operative side effects included menstrual disturbance (25% of the patients), backache (25%), leucorrhea (18%), low abdominal pain (20%), and sexual dyspareunia (2.1%). Complications included: 1) rectal injury; 2) ruptured cystic ovary; 3) bleeding; 4) spinal headache; 5) febrile convalescence; and 6) distension of abdomen. 2 deaths from peritonitis and paralytic ileus occurred because the patients did not seek help soon enough. There are no sterilization failures at present.^ieng

Interval tubal sterilization in obese women--an assessment of risks.

Obesity is considered to be a complicating factor in most surgical procedures, but very few studies have investigated whether this is true for tubal sterilization. We used a large international data set to investigate the effect of obesity on tubal sterilization. Each of the 159 women delineated as obese (greater than 50% above the mean ideal weight) was matched with a woman of normal weight on important provider variables such as center, operator, and type of surgical procedure. Incidences of anesthesic, surgical, and early postsurgical complications were comparably low and of a mild nature for both the obese and the nonobese groups. Incidence of surgical difficulties was higher, and as a result, the technical failure rate was also higher and the surgical time longer for obese women than for nonobese women. However, none of these surgical difficulties or technical failures led to serious consequences. The difference in surgical times was small and is probably of little practical significance. It appears that the surgical difficulties of tubal sterilization in moderately obese women can be easily overcome.

[Contraception at 40 years of age]. / La contraception à 40 ans.

PIP: Until recently, most 40-year-old women considered their families complete and wanted no more children. At present, however, with more women working, easier contraception, and more frequent divorces, many 40-year-old women are ambivalent about their future childbearing plans. Their fertility is in decline, but some form of contraception is still necessary. At all ages from puberty to menopause, contraceptive choice is related to ambivalence in desire for a child, body image, and the contraceptive method itself. For a psychologically well-balanced and healthy woman of 40 wanting no more children, almost any method of contraception may be acceptable. Women this age fearing loss of fertility and aging may come to desire another child. Couples with 2 children of the same sex or working women wanting a family "eventually" may realize they can defer their decision no longer. Women who do not feel comfortable unless they are pregnant or caring for a small child by this age may have several children and are usually considered good candidates for sterilization. They in fact should probably not be sterilized because of the likelihood of psychological complications or psychosomatic problems. IUDs are probably the best choice for such women. Good tolerance of contraception depends on the sexual adjustment and mutual understanding of the couple. As to the choice of method, oral contraceptives (OCs) are controversial because of the increase of vascular risks with age. Smoking, metabolic disorders, and hypertension are absolute contraindications. OCs may however have protective effects against endometrial and ovarian cancer, and the increased surveillance provided to women on OCs is an argument in their favor. Progestin-only pills combine contraception and therapy for some mammary or uterine pathologies. IUDs may be a good choice although local problems such as fibromas may limit their use.^ieng

Sterilization by laparoscopy.

Today, female sterilization is most easily accomplished by single-puncture laparoscopy and, ideally, is carried out under local anesthesia. In experienced hands, electrocoagulation offers slightly fewer failures if a large portion of tube or two segments are destroyed. Fulguration of a small portion of tube, bands, or clips offer a better chance of reversal. It is extremely important that the operator be familiar with and use proper equipment, along with following a rigid format, if complications are to be kept to a minimum. The underlying theme for this article, and all of the articles published, shows that, regardless of the method employed to interrupt the tubes, the complication and failure rates are usually more a function of the experience of the operator than of the method employed.

PIP: This discussion of sterilization by laparoscopy reviews the following: indications and contraindications; preoperative patient preparation; anesthesia; the procedure; preparation and draping; tubal interruption (unipolar electrocoagulation, bipolar electrocoagulation, silastic bands, and Hulka clips); pregnancy rates; complications (electrothermal burns, bleeding, infection); and reversibility. The major indication for laparoscopy should be permanent sterilization. There are no absolute contraindications. Each surgeon needs to establish his/her own limitations. Conditions such as previous multiple abdominal surgical procedures, known adhesions, and serious medical disease increase the risk of complications and fall under a classification of relative contraindications. Each patient should have a complete history, physical examination, and Papanicolaou smear before the laparoscopy. The surgery may be performed any time throughout the menstrual cycle. Currently, female sterilization is most easily accomplished by single puncture laparoscopy and, ideally, is performed under local anesthesia. In experienced physicians, electrocoagulation offers slightly fewer failures if a large portion of tube or 2 segments are destroyed. Fulguration of a small portion of tube, bands, or clips offer a better chance of reversal. In regard to the reported statistics for pregnancies following sterilization, there is a wide variation in the results. Pregnancies after laparoscopic sterilization by any method occurs for 2 reasons and in 2 ways. Luteal phase pregnancies, which occur before the procedure is performed, are reported with an average rate of 2.4/1000 cases. In an effort to reduce these, some surgeons insist on good contraception before surgery and limit the operation to the preovulatory time of the menstrual cycle. The procedure may fail because the method may fail or may be performed incorrectly. Assuming the tube has been burned, banded, or clipped correctly, failures may occur because of uteroperitoneal fistual formation or recannulization of the tube. This may occur if less tube is destroyed or if it is not separated. If the failure is secondary to the operator, there will be more intrauterine pregnancies. If it is due to the method, the incidence of ectopic pregnancies will usually be higher. With proper training, operator failures should be eliminated. Loffer and Pent report no failures in 2249 cases; the author has had none in 5500 cases. The complication as well as the failure rates are usually more a function of the operator than of the method used.

Vaginal ligation under local anaesthesia--a simplified technique.

PIP: A new technique of vaginal ligation for sterilization is described which can be performed under local anesthesia and requires minimal hospital stay. The procedure is based on the principles of culdoscopic ligation but does not use the culdoscope itself. The method has been used on 62 patients with no postoperative complications. The procedure is safe, requires only 5-8 minutes operating time, and the patient can be released from the hospital on the same day. Careful handling of the tissues and proper patient selection insuring a freely mobile uterus are important factors in the operation's success.^ieng

Laparoscopy.

PIP: Laproscopic sterilization techniques and the diagnostic use of laparoscopy are discussed. In a series of 1000 laparoscopic sterilizations by the 2-incision technique, there was a total failure rate, surgical and operative, of .4%. In a similar series with the 1-incision technique and electrocagulation only, the total failure rate was 1.6%, though the complication rate was considerably reduced. The high failure rate was attributed to incomplete transection resulting in recanalization. The failure rate with a single-incision, 3-burn technique was .25% in a series of 2000 patients, and complications were few. Tubal occlusion with hemoclips has produced poor results (failure rate: 8-27%). The results with silastic bands, however, have been comparable to those for electrocoagulation, but with fewer complications. Means by which the cost of laparoscopic equipment may be reduced are discussed. Laparoscopy can be helpful in the diagnosis of infertility-endocrinology, ectopic pregnancy, pelvic pain, pelvic inflammatory disease, adnexal masses, and the retrieval of foreign bodies in the pelvic region. Contraindications to laparoscopy are reviewed. It is concluded that laparoscopy is a safe and effective means of sterilization on an outpatient basis, and is of value in the diagnosis of gynecologic disorders.^ieng

[Laparoscopic sterilization for medical indication (author's transl)]. / Esterilización laparoscópica por indicación médica.

PIP: 35 patients between 20-40 were sterilized for strictly medical reasons, mostly cardiopathies and nephropathies. Patients with cardiac problems had parity over 2-3; patients with nephritic problems had parity over 1; nulliparous patients were sterilized to prevent hereditary diseases. The technique used was bilateral tubaric coagulation, followed by double tubal section. No complications were reported, except 1 tubal pregnancy 2 months after sterilization.^ieng

[Tubal ligation by culdoscopy in a simplified surgical procedure: study and follow-up of 214 cases]. / Ligadura tubarica con el culdoespeculo en un sistema de cirugia simplificada: estudio y seguimento de 214 casos.

PIP: 214 patients, of average age 32 and of median parity 4.5, were sterilized by tubal ligation using a modified Madlener method. The surgical procedures were greatly helped by the use of a new piece of equipment invented by the author, a culdoscope of special design, allowing a larger view of the operative field. Peridural anesthesia was employed in 88.8% of cases; general anesthesia in 3.2% of cases, and only for patients with psychological problems. The procedure lasted an average of 17 minutes; there were a few cases of immediate bleeding or pain, but no serious complications. Long-term side effects had usually to do with changes in libido. There were no pregnancies. 81.7% of patients were followed up to 3 months after sterilization; 95% of them were very satisfied with the procedure, and most declared to have chosen culdoscopy over other sterilization methods for esthetical reasons. The only contraindication to tubal ligation performed in this manner would be pelvic infection complicated by adnexitis.^ieng