Sterilization is still the most widely used method of contraception in couples over 50 years old in the UK. As long-acting and reversible methods such as the Mirena, Implanon and the newer copper IUDs are increasingly recognized as being not only highly effective but also acceptable, they are likely to challenge female sterilization as the method of choice for women who have completed their family. Another important point to note is that in many areas of the UK reversal of sterilization is not available on the National Health Service.
Any person undergoing sterilization must be willing to accept that it is permanent. The family planning provider has the responsibility to ensure that the person considering sterilization has real expectations from the procedure, with regard to permanence, failure rates (in comparison with other methods) and complications. This means that the doctor or nurse giving family planning advice must have a good understanding of all currently available long-acting methods of contraception.
Vasectomy is the most effective established method of contraception currently available, with a failure rate ranging from 1:2000 to 1:10 000 after two azoospermic samples. It is suitable for men who have completed their family and, rarely, for those who have decided not to have children. It is usually carried out under local anesthesia and has very few contraindications. Briefly, the procedure can be described in the following way: After anesthetizing the skin, the vas deferens is identified and immobilized through the scrotum. After that, the scrotum is opened. In conventional vasectomy the surgeon uses a scalpel to make two incisions in the scrotal skin, one over each vas deferens. The incisions are 1-2 cm long. The vas is brought out into the open. About a 1 cm portion of the vas is removed and both ends are ligated. The entry incisions are then closed with sutures. In a ‘no-scalpel’ vasectomy, the scrotum is entered bluntly with a special sharp hemostat rather than a scalpel. This creates a small puncture wound that does not need suturing. Fewer complications and less pain are reported with the ‘no-scalpel’ vasectomy. There has been much discussion and research into a possible link between vasectomy and prostatic cancer but such a link has now been disproved, reinforcing the safety of this important method of contraception. Reversal should be discussed before the surgery, in regard to both its availability and success rates. Reversal of sterilization defined as the presence of sperm in the ejaculate is successful in 70-92% of cases depending on the technique, the surgeon’s experience, the time that has elapsed since the vasectomy and the type of vasectomy procedure. Reversal of sterilization defined as pregnancy rate is much lower, with rates between 25-80% being reported. There is also inter-surgeon variation in success rates.
Vasectomy is not immediately effective, because of the length of sperm survival. The vas distal to the vasectomy contains viable spermatozoa for weeks after the operation. Patients must be aware of this and receive advice about effective interim contraception. About 20 ejaculations are needed to clear the remaining sperm. Clearance is delayed by abstinence from ejaculation. It is usual to carry out semen analyses at 12 and 16 weeks post vasectomy. After two consecutive negative semen analyses one month apart the vasectomy can be regarded as being successful. If the samples fail to clear, then early reanastomosis or an additional unidentified vas is present and re-operation may be required. Men who seek a vasectomy should be advised that:
(1) Vasectomy is not castration and does not affect sexual ability or cause impotence.
(2) After vasectomy, the man continues to ejaculate because sperm contribute by only 10% to the volume of the ejaculate.
(3) Vasectomy does not cause prostatic cancer or early atherosclerosis.
The complications of a vasectomy procedure are listed in Table Complications of vasectomy. Sperm granuloma is a small nodule that forms when sperm leak out of the vas deferens or the epididymis, inducing an inflammatory reaction. Post-vasectomy pain syndrome is defined as chronic pain in the testis following a vasectomy. Conservative treatment with non-steroidal anti-inflammatory medication, sitz baths or spermatic cord block may help.
Table Complications of vasectomy
|(a)||pain (significant in 8%)|
|(3)||Post-vasectomy pain syndrome (3-8%)|
|(4)||Possible psychologic effects/regret|
*Early failure is defined as pregnancy occuring within six months after the operation or before azoospermia is docmented. Late failure is defined as pregnancy occuring after this period
The convenience and efficacy of this method have made it the most commonly used single method in women over 40 who have a completed family. Recent data from the USA indicate that the failure rate of female sterilization is higher than previously thought: at around one in 200 over 10 years. Failure rates are highest in women sterilized under the age of 35 or at the time of Cesarean section, in the puerperium or at the time of termination of pregnancy. There may also be more regret in those having sterilization in association with a recent pregnancy. The risks of sterilization are small but quantifiable (see Table Complications of female sterilization). Sterilization is particularly suitable for women who:
(1) Have completed their family;
(2) Find no other long-term method acceptable;
(3) Have no gynecologic condition that requires hysterectomy;
(4) Have no conditions that make the procedure dangerous (for example, obesity).
Table Complications of female sterilization
|Mortality||1-2 per 100 000|
|Damage to bowel or vascular tree||1 in 1000|
|Ectopic pregnancy rate||10% of failures|
Sterilization is usually carried out under general anesthesia. It is effected by applying clips or rings to the isthmus of the fallopian tubes. Diathermy is rarely used now because of the risk of damaging intra-abdominal organs. Partial salpingectomy (modified Pomeroy technique) requires a mini-laparotomy and is particularly useful in countries where laparoscopy is not available, and it can also be done as a day case. An important risk is that of ectopic pregnancy should failure occur, and a woman who has previously been sterilized and who is pregnant should have a scan at four to five weeks’ gestation to locate the pregnancy.
There is usually a delay between the decision to be sterilized and the actual operation; an effective interim contraceptive is required because some women become pregnant while waiting for the procedure to be done. In addition, a sterilization carried out in the luteal phase of the cycle carries a theoretical risk of an ectopic pregnancy if a fertilized ovum is still within the tube distal to the clip.
After laparoscopic sterilization, women can expect some abdominal discomfort and shoulder pain for up to a week. Women who have been using a method that makes menstruation lighter (such as the COC pill) or absent (such as depo-medroxyprogesterone acetate) and are opting for sterilization should be advised that their periods may appear to get heavier when that method is discontinued — and in some cases this could be unacceptable.
As with the reversal of vasectomy, the success of the reversal of female sterilization varies depending on the amount of tube damaged by the initial procedure and the surgical technique used for the original operation.