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Sterilisation of Women - How, Why, Two Detailed Case Studies. Is It A Good Birth Control Measure?

Sterilisation in women is the most requested contraception technique worldwide. It is a permanent method of birth control and involves blocking or cutting the fallopian tubes. This is a minor surgery carried out under general anaesthesia or sometimes under local anaesthesia. It is a very effective method of contraception with a success rate of more than 99%.

The technique, timing and setting of the operation have progressively changed since the early 1970’s and the advent of minimally invasive surgery. The most appropriate method of female sterilisation in a particular family is often determined by local situations and constraints. According to Cochrane review, the decision which method to choose should be a multifactorial one, depending on the setting, the surgeons experience and the woman’s preference.

How Sterilisation can prevent pregnancy?
As sterilisation procedure involves blocking the fallopian tubes it occludes the pathway for eggs to reach the tube to the sperm and get fertilised. As the ovaries are not affected by sterilisation therefore menstrual cycles are not altered.

How is Female Sterilisation done?
This can be performed by the following techniques –
1) Occlusion of Fallopian Tubes which is carried by either applying titanium clips over the tubes or by applying silicone rings after making a small loop in the tube  or by inserting a titanium microinsert into the fallopian tubes.
2)  By cutting a part of the tube after tying a loop (tubectomy).

These techniques can be used through the following different approaches
1) Laparoscopy– This is most commonly used, safe and convenient method. In this one or two  small cuts are made near the belly button and a laparoscope (a narrow tube with light source and camera) is introduced through which surgeon examines the internal organs and carries out sterilisation procedure.
2) Minilaparotomy – a small incision is given in lower abdomen near pubic hairline. This is done in those case where laparoscopy is not possible.
3) Hysteroscopic Sterilisation – carried out by introducing a hysteroscope (a narrow tube with light source and camera) through vagina and cervix. A guidewire is used to insert a titanium microinsert into fallopian tube through the hysteroscope under local anaesthesia.

Why is Sterilisation done?  

Since it’s a permanent method of contraception it is recommended for those women who have completed their family and don’t desire to have more children. Therefore counselling of the couple is very important. It is recommended that the woman should be married, be above 22 years of age and below 49 years and the couple should have at least one child.

Is it a good birth control measure?

Female sterilisation is a safe procedure and has very low rate (2%) of complications which when diagnosed immediately can be treated effectively. Both the procedures (tubectomy and tubal occlusion) have a small risk of failure rate which is less than 1 pregnancy per 100 women in first year after sterilisation. Thus it is an ideal method for those who have completed their family.

1st Case Study:
Date SV, Rokade J, Mule V, Dandapannavar S. Female sterilisation failure: Review over a decade and its clinicopathological correlation. Int J App Basic Med Res 2014; 4:81-5

Summary:
We hereby present a summary of a retrospective analysis carried out by Date et al in 2014 in which they present their findings on the failure rate of various types of sterilization techniques done during the period of 10 years from April 2002 to March 2012.

During the period 140 women have reported to the institution as tubal sterilization-failure making an average of 14 cases/year.

The sterilisation techniques that were covered in the study included mini laparotomy (minilap), laparoscopic (Lap TL) and lower segment cesarean section (LSCS) tubal ligation. These constitute the majority of sterilisation types that are performed in India. Minilap failure constituted 59% followed by Lap TL  - 38% and LSCS - 3%. The Sterilisation-failure interval was <1 year in 22 (15.71%) cases, 1-5 years in 80 patients (57.14%), 6-10 years in 30 (21.43%) and >10 years in eight patients (5.71%). The longest documented sterilisation-failure interval was 20 years in our study presented with ruptured ectopic.

A greater proportion of early failures (<1 year) were mainly due to initial non-occlusion of tube due to improper procedure compared with late failures where tubal regeneration leading to spontaneous tubal reapproximation associated with tubal reanastomosis and recanalization or formation of tuboperitoneal fistula were likely. When failure due to improper procedure was further analyzed 78% contribution was from occlusive methods with laparoscopy. In resectional methods with minilap, failure was prominently due to spontaneous luminal regeneration.

The authors concluded that female sterilisation-failure is well-known and proven entity and no age, method and interval is failure free. Although, it is not completely preventable, failure due to improper procedure can be avoided if we will follow standard guidelines for tubal ligation. Proper counseling of patient regarding chances of failure and early reporting if menses are delayed can help in diagnosing failure in early gestation and to reduce related morbidities.

2nd Case Study:
Female sterilisation: a cohort controlled comparative study of ESSURE versus laparoscopic sterilisation. Duffy S, Marsh F, Rogerson L, Hudson H, Cooper K, Jack S, Hunter D, Philips G. BJOG. 2005 Nov;112(11):1522-8.
 
Summary:
The study compared patient satisfaction, discomfort, procedure time, success rate and adverse events of hysteroscopic (ESSURE, Conceptus Inc, San Carlos, USA) versus laparoscopic sterilisation.

A 2:1 ratio of ESSURE placement to laparoscopic sterilisation was undertaken. Laparoscopic sterilisation was carried out under general anaesthesia in the day surgery unit whereas all ESSURE procedures were carried out in a dedicated outpatient facility. All patients completed a self-assessment diary on days 7 and 90 post-operatively. Patient satisfaction, tolerance and discomfort were measured.

All women who underwent laparoscopic sterilisation had the procedure successfully completed whereas the overall bilateral device placement rate for ESSURE was 81%. Patient satisfaction with their decision to undergo either ESSURE or laparoscopic sterilisation was high with 94% of the ESSURE group being ‘very’ or ‘somewhat’ satisfied at 90 days post-procedure versus 80% in the laparoscopic sterilisation group. At 90 days post-procedure 100% of women in the ESSURE group were ‘very satisfied’ with their speed of recovery versus 80% in the laparoscopic sterilisation group. The procedure time (defined from the time of insertion of the hysteroscope or laparoscope to its removal) took significantly longer for ESSURE than laparoscopic sterilisation. Eighty-two percent of women in the ESSURE group described their tolerance of the procedure between ‘good and excellent’ compared with only 41% of the laparoscopic sterilisation group. Only 31% of the ESSURE group reported moderate or severe pain following the procedure compared with 63% of the laparoscopic sterilisation group. Only 11% of patients had problems immediately post-operatively in the ESSURE group compared with 27% in the laparoscopy group. Finally, in the more medium term (three months post-operatively), patients still had an advantage in terms of post-procedure adverse events in the ESSURE group (21% vs 50%).

This study provides evidence that ESSURE can be performed in the majority of women and, when successful, is associated with a greater overall patient satisfaction rate than laparoscopic sterilisation. However, the devices cannot be bilaterally placed in all cases and some women do not tolerate the procedure awake. Visit for further info- http://www.sciivf.com

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