Population Reports

Population Reports SERIES C NUMBER 7 MAY 1976 STERILIZATION Department of Medical and Public Affairs, The George Washington University Medical Center, 2001 S Street, N.W.. Washington. D.C. 20009 Tubal Sterilization This report on tubal sterilization methods was prepared by Judith Wortman, R.N., on the basis -Review of Methods- of published reports and articles, unpublished papers, personal interviews, and correspon dence. SUMMARY The assistance of the following reviewers is ap preciated: Elizabeth Connell, William Droege mueller, Jaroslav Hulka, Theodore King, R. T. Widespread demand for simple, effective, and inexpensive Ravenholt, Ralph Richart, John Sciarra, and J. female sterilization procedures which can be performed Joseph Speidel. Frances G. Conn is Executive on an outpatient basis has encouraged both medical Editor. Comments and additional updated mate practitioners and researchers to evaluate existing meth rial are welcome. ods of tubal occlusion and to develop new ones. Recent research has concentrated on: • modification and improvement of older methods of ciated with a higher rate of infection than abdominal tubal occlusion, such as ligation and fulguration; approaches. Finally, methods which interrupt (cut • application of clips and bands to the tubes; through) the tubes are associated with higher morbidity • introduction of chemicals and plugs into the tubes. (e.g . bleeding) than those in which tube continuity is Invention of equipment such as endoscopes and spe maintained. cially-tailored cannulae which now permit a variety of Potential for reversibility may be a factor in selecting a approaches to the tubes has contributed to the develop particular method of tubal occlusion. Experience in both ment of new methods of tubal occlusion. As a result, the developing and developed countries indicates that most tracjitionallarge abdominal incision for sterilization (Iapa women desiring sterilization prefer a permanent method, rotqmy) has been replaced by a tiny abdominal incision but many, particularly in the younger age groups, might (mihilaparotomy) or punctu re (Iaparoscopy) and by trans welcome a means of sterilization that could be reversed. vaginal (colpotomy, culdoscopy) or transcervical ap proaches (hysteroscopy, blind delivery) which require no Although some plugs offer potential for reversibility be incision. cause theoretically they may be withdrawn from the tube, reversibility has not been adequately assessed by tests in These approaches permit occlusion of any part of the humans. In animal experiments, the tubal epithelium is fallopian tube. For example, the infundibulum (distal, sometimes destroyed beyond repair when plugs are re fimbrial end of the tube) can be excised, buried, plugged, moved. Clips or bands, on the other hand, destroy a or capped; the ampulla or isthmus (middle of the tube) can narrow segment of tube, but there is virtually no expe be tied, cut, excised, fulgurated, clipped, banded, or rience with reversibility. Reversal would require a second buried; and the interstitial portion of the tube (near the operation to cut out the crushed section of tube and uterotubal junction) can be coagulated or blocked with chemicals or plugs (see Fig. 1). The choice of approach and the method of tu bal occlusion CONTENTS often depend upon the physician's prior training, degree of skill, and knowledge regarding the safety and effective Ligation ......................... .. ...... C-74 ness of the various methods. Endoscopic approaches, for Fulguration ........ .. .... .. .. .. .... C-78 example, generally require more training and skill than Clips . .. ................ ... ............ , C-82 other approaches, while most transcervical approaches Bands....... ... ... .... .... ........ ,. C-84 are still considered experimental and are less effective Chemicals .... .... ... ....... .......... C-86 than those performed by other approaches. Likewise, Solid Plugs. .. C-89 cautery and some chemicals are associated with a higher Other Tubal Occlusion Methods ......... C-91 risk of damage to structures adjacent to the tubes Bibliography .. ... ..... .. ....... .. .. ... C-91 than ligation, clips, bands, or plugs. Methods performed through the vaginal cul-de-sac (e.g. colpotomy) are asso- Part 1 of 2 parts-May 1976 mailing C-73 Ligatic 1 techniques can be classified into one or a comt i nation Jf the following categories according to the exte 1t Population Reports is published bi-monthly at of acti n on the fallopian tubes: 2001 S Street NW., Washington, D.C. 20009, USA, by the Population Information Program, Science • sim Ie ligation; Communication Division, Department of Medical • liga on and crushing; and Public Affairs of the George Washington • liga on, division, and burial; University Medical Center and is supported by the • liga on and resection; United States Agency for International Develop • liga on, resection, and burial. ment. Helen K. Kolbe, Project Director. Second class postage paid at Washington, D.C. SIMPL : LIGATION. Simple ligation is seldom performf! d today lecause of the high failure rate asso iated with Its use. F rst proposed by Lungren (USA) in 1880 (90), simple ligatio preceded other ligation methods by almost t 10 anastomose (join) the two remaining ends. Ligation is the decad s. In 1895, DLihrssen (The Netherl nds) used a procedure most often reversed successfully, but the same doubl!' ligature on each tube in an effort to prevent t 1e operative procedure for anastomosis is required. The use failure associated with single ligatures (119). Howevl!r, of cautery makes reversibility virtually impossible to subse uent investigations have shown that hydrosalpir1x achieve because a large segment of tube is destroyed. (colle! ion of fluid) frequently develops between the t'tlO Likewise, most chemical methods are not reversible be ligatul )S and, as a result, reports of double ligation have cause the epithelium is permanently damaged. disapf eared from the literature. In one of the few recent report on simple ligation, Purandare (India), who p r Comparisons of the effectiveness of the various tubal forms colpotomy for interval sterilization and laparotor y occlusion procedures are difficult to make. In many cases, for p erperal sterilization, uses nonabsorbable lin ,n there are insufficient data and investigators do not con threac to tie the tubes at the junction of the lateral 0 e sider life tables or the Pearl Index' in computing failure th ird 0 ld medial two-thirds of the tubes. Purandare recog rates (see Population Reports, Series H, Number 4, Janu nizes I Ie possibility of failu re with his tech nique and ac ks ary 1976). Thus, there is no basis for comparison among up tht, procedure by abortion. He has not r ecently p b studies and only estimates can be made from published lished ailure rates orthe percentage of abor ions requir ,d information. amon the total number of procedures perf rmed. While great strides in knowledge about tubal physiology tv ljor Advantages Major Disadvantage and in biomedical engineering have been made, more • sirr )Ie to perform; • high failure rate (up to 20 research is needed to determi ne the practical ity, effective • 10'11 morbidity; percent). ness, and applicability of the newer methods of tubal • higll potential for rever occlusion, such as use of chemicals. Until then, traditional sibl ity. methods (e.g., ligation) are likely to remain popular. Ligation and Crushing MADl ::: NER TECHNIQUE. This technique, first reported LIGATION in 19 ), is easier to perform and results in less bleedi 19 than I lore extensive ligation procedures (144). However, like si 1ple ligation, the failure rate is higher than forthc se Tubal ligation (tying the fallopian tubes) to prevent pas technq ues in which tubal continuity is interrupted. In the sage of sperm and ova is one of the oldest forms of tubal Madl ~ 1er technique, the midsection of the tube is picked occlusion. Nearly a century of experience with this me up to )rm a loop, and the base of the loop is crushed wit a thod has eliminated the least effective techniques and the clam~ and ligated with nonabsorbable suture matel ial outcome of most of those remaining is now predictable. (e.g., ;ilk, cotton) (see Fig. 2) . In a modification of t lis Traditionally performed through a large 10 cm (3-4 techn .:Jue adopted by some practitioners, ~ he top of 'he inches) abdominal incision (laparotomy), today the tubes loop i cut off. are ligated through a 2.5 cm abdominal incision (minilapa rotomy) or a 3-5 cm vaginal incision (colpotomy). The amount of skill required to perform ligation, the approach ul 'us interstitial isthmic-ampullary used, and effectiveness vary according to the type of ligatio"1 procedure performed (see Table 1). Major Advantages Major Disadvantage • only average skill is re • most effective proce infundibLlum quired for most proce dures are usually irre dures; versible; • only simple instrumen • the procedures per tation is required ; formed via laparotomy • morbidity is usually low. require hospitalization. 'Failure rates per 100 woman years are computed using the Pearl Fig 1. Anatomy of fallopian tube in relation to the uterus formula: an ovary. No. of pregnancies x 1200 No. of months of exposure C-74 Like simple ligation, the Madlener technique may be performed by the abdominal or vaginal route. Recently its performance on an outpatient basis was reported in Tai wan where Ou uses a "one finger technique" which in volves inserting a finger through a minilaparotomy

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