Part four

Surgical Methods

Female Sterilization: Tubal Occlusion

Healthy women may remain fertile until their late 40s, and healthy men are fertile all their lives. Most couples have all the children they want long before they lose their fertility. As a result, they face a good many years in which they have to use some effective form of birth control. Many couples choose sterilization as a solution. As a result, voluntary sterilization is one of the most common contraceptive methods used in the United States. Either partner can be sterilized to end the possibility of conception.

Female sterilization involves permanently closing off (occluding) the fallopian tubes to prevent sperm from reaching an egg. This is done surgically.

One of the most effective contraceptive methods available, female sterilization has a failure rate of less than 2 percent in preventing pregnancy over a 10-year period. The risk of pregnancy is even smaller for women age 28 and older. The greatest failure risk occurs among women under age 28, who tend to be more sexually active and more fertile.

If you have your tubes "tied," you will continue to produce female hormones and to menstruate as usual, and your sexual functioning is unaffected. The surgery will not change your skin, breasts, or weight, nor does it affect the vagina, uterus, or ovaries. An egg cell is still released by the ovaries every month and enters the nearby fallopian tube. The egg cell stops, however, where the tube has been closed off, disintegrates, and is absorbed by the body.

Sterilization surgery can be performed with a local anesthetic or under general anesthesia. At some medical centers the most commonly used methods—laparoscopy and minilaparotomy—are performed on an outpatient basis, using a local anesthetic and mild sedatives. Both these procedures usually take less than 30 minutes. When local anesthesia is used, most women are able to go home after an hour or two of resting in the recovery room. If a general or spinal anesthetic is used, it may be necessary to stay in the clinic or hospital a bit longer.

The type of surgery used depends on when the procedure is done, on your health and medical condition, and on the policies and preferences of the surgeon, the medical center, and the patient. If the sterilization is performed immediately after childbirth, a minilapar-otomy is preferred because this approach is easiest when the uterus and tubes are high in the abdomen, as they are right after a childbirth. It is called a minilaparotomy because the incision is less than 2 inches long. When tubes are tied at another time, the surgical technique used is most often a laparoscopy.

If you are overweight, have adhesions from previous abdominal surgery, or have an abdominal abnormality, you are likely to need a somewhat more complicated procedure. You should choose a skilled gynecologist/surgeon and a fully equipped medical center. Although it may be possible to carry out the operation with local anesthesia, general anesthesia should be available in case it is needed. Just which technique will be used depends on the preferences and experience of the patient and surgeon.

METHODS AND TECHNIQUES

Two methods are used to reach the fallopian tubes in order to close them.

IN A NUTSHELL

FEMALE STERILIZATION

Sterilization is a permanent form of birth control. For women, being sterilized means that the two tubes that carry eggs from the ovary to the uterus are tied shut, or cut, or blocked in some other way. This prevents sperm from reaching the egg to fertilize it. It is extremely effective.

Having your tubes tied does not affect your hormones. It does not change your menstrual cycle or your feelings about sex. Only the tubes are changed. Your vagina, uterus, and ovaries remain the same. Your breasts, skin, and weight are not affected.

Sterilization surgery usually takes about 30 minutes. If a local anesthetic is used, you can go home after an hour or two of rest at the clinic. If a general anesthetic or spinal is used, the recovery time may be somewhat longer.

The surgery is done through very small incisions in the belly that require only one or two stitches. It can be done in the hospital right after having a baby, or at any time.

Because it is permanent, this method of birth control is not advised for young women whose lives may change so they want to have another child. It is important to think about this very carefully and not to make a decision without getting counseling. Good clinics, hospitals, and doctors who perform sterilizations always offer counseling.

Sterilization does not protect against STDs of any kind.

Minilaparotomy

In a minilaparotomy, an approximately 2-inch incision is made low in the abdomen, often just above the pubic hair, where it will not be very obvious. Using an instrument placed in the uterus via the vagina, the surgeon gently pushes the uterus and fallopian tubes up to the abdominal wall to make it easier to reach the tubes through the incision. The surgeon then uses a special hook, a forceps, or a finger to reach in and lift out a loop of fallopian tube.

The tube is closed off by the application of a high-frequency electric current (electrocoagulation), a plastic ring, or a special spring clip. Some surgeons use a suture to tie the tube in a loop, and then remove the loop itself. After both tubes have been closed off or tied and replaced in the abdomen, the incision is shut with a few stitches.

The minilap is the method favored when women have a tubal occlusion right after childbirth. As we mentioned, this is a good time to perform an occlusion, from a surgical point of view. The uterus and tubes are high in the abdomen and easier to reach. A minilap cannot be done if a women is very overweight, however. The extra layers of fatty abdominal tissue require a larger incision, and the procedure becomes a regular laparotomy (abdominal surgery).

Laparoscopy

Laparoscopy is the method most frequently used today in the U.S. and Europe for female sterilization. When performed by a surgeon experienced in the technique, it is extremely safe. Today it is often done as an outpatient procedure, which can reduce its cost.

Instead of requiring a conventional incision, laparoscopy is performed through one or two punctures into the abdomen. A hollow needle is inserted into the site to inflate the abdomen with gas, usually nitrous oxide or carbon dioxide, which expands the abdominal cavity and lifts the wall of the belly away from the structures within it. The needle is then withdrawn and a sharp-pointed trocar is used to make a puncture into the abdomen for the long, slender

ISSUES TO CONSIDER BEFORE STERILIZATION

• Vasectomy (male sterilization) is simpler, safer, and less expensive than female sterilization. If both vasectomy and sterilization are equally acceptable to a couple, vasectomy is the medically preferred procedure.

• It is not a legal requirement to have the permission of a spouse in order to undergo sterilization.

• Persons who wish to be sterilized must be legally competent to make this decision, which usually means being over age 21 and mentally competent. If federal funds are paying for sterilization, after signing a consent form for voluntary surgical contraception, women (and men having vasectomies) must wait 30 days before having the surgery. These include sterilizations paid for by the U.S. Department of Health and Human Services (Medicaid) or performed in U.S. Public Health, military, or Indian Health Service facilities.

laparoscope. The laparoscope wand contains a light source for illuminating the inside of the abdomen and a lens through which the surgeon can view it. There are many variations of this technique, and your surgeon may use a procedure that is slightly different.

If the operation is a single-puncture laparoscopy, the operating instruments enter the abdomen through the operating channel of the laparoscope (Figure 12.1). They are used both to grasp and close each fallopian tube in turn, guided by the surgeon's view through the scope. In a double-puncture approach, the operating instruments are inserted in the second incision, while the surgeon uses the scope at the original incision to guide their movements.

After the tubes have been closed with silicone rubber bands, electrocoagulation, spring clips, or a suture tie, the organs in the abdomen are inspected through the scope to make sure there has been no injury or bleeding caused by the procedure. The laparo-scope then is removed, the gas expelled from the abdomen, and the incision closed with a suture or two. The only protective covering needed for each tiny incision is a small bandage. If any gas remains, it may cause some abdominal or shoulder discomfort, but it dissipates in a few days.

Occlusion Methods

Probably the most common technique for closing off the fallopian tubes during laparoscopic sterilization is electrocoagulation. A high-frequency electric current is applied very briefly to the narrow, middle section of the tube. The current heats the tissue, causing scars to develop at the site, permanently blocking the tube. It also kills the nerves at the site, so there is less discomfort after the surgery. Safest, most effective, and most commonly used is bipolar electrocoagulation. The bipolar instrument looks like a tiny set of tongs. The current passes down one tong, through the tissue of the tube, and up the other tong, effectively limiting the burned tissue to the small area held between the tongs.

The method most frequently used during a minilap is ligation, using a suture to tie each tube and then removing the section of the tube between the ties. Many surgeons prefer the Pomeroy technique,

Tube is tied and cut

C Tube is cauterized

Tube is clipped

Tube is banded

FIGURE 12.1 Laparoscopy and Various Tubal Ligation Methods

View through scope

Tube is tied and cut

C Tube is cauterized

Tube is clipped

Tube is banded

FIGURE 12.1 Laparoscopy and Various Tubal Ligation Methods in which the tube is tied tightly in a loop and then the loop portion is snipped off.

The oviducts also can be blocked by pinching them shut with mechanical devices, such as metal or plastic clips or small, silastic rings that are like strong, long-lasting rubber bands. These devices fasten tightly around the fallopian tube, holding it in an immovable grasp. Eventually the pinched tissue dies, forming a permanent seal. These clips and rings have the advantage of damaging only the tissue in their immediate vicinity. They are likely to cause several hours of postoperative cramping, however, because of the pressure put on the tube.

Although most tubal occlusions have been performed as hospital inpatient procedures, there now is an increasing trend for these to be outpatient procedures. When done in an outpatient setting, it is important that the clinic or other facility have formal ties with a nearby hospital, in case an emergency occurs during the procedure. Certain conditions discovered during the surgery—such as adhesions from undiagnosed endometriosis—can make it necessary to stop the operation and repeat it later at a full-facility hospital. Insurance plans frequently cover the cost of sterilization.

Local Versus General Anesthesia

Local anesthesia for laparoscopic sterilization is effective in preventing pain. Local anesthesia is particularly appropriate for a minilaparotomy or a laparoscopy, because these procedures cause little trauma to the tissues and take a short time to execute. Short-term, general anesthesia, which means the patient sleeps, also is used.

Local anesthesia involves injecting a drug into the area being treated to interrupt the function of the pain-carrying nerves, making the area insensitive to pain. You are awake but usually given a sedative for relaxation and relief of anxiety. The use of local anesthesia has several advantages: (1) it avoids risking the complications that can occur with general anesthesia; (2) for most patients it means a shorter recovery time and less time at the clinic or hospital; and (3) it may reduce the cost of the operation.

Using a local anesthetic means the gynecologist must make changes in how he or she executes the surgery. Having you awake but sedated makes it necessary to perform the surgery more gently. Furthermore, the physician must be in continual communication with you, telling you what is being done and what sensations or discomfort to expect as the fallopian tubes and other organs are manipulated. Occasionally, you will have to be warned not to move. A local anesthetic eliminates the pain, but you may still experience some discomfort.

General anesthesia, by contrast, induces a loss of consciousness and sensation, usually by injected or inhaled drugs. You feel nothing, which helps the surgeon carry out the procedure with dispatch. Nevertheless, general anesthesia is associated with many possible complications: low blood pressure, irregular heartbeat, heart attack, airway obstruction, allergic reactions, brain damage, and death. Although these reactions are rare, general anesthesia should be used only when necessary.

Epidural and spinal blocks are forms of regional anesthesia. With these techniques, the nerves are anesthetized where they branch from the spinal cord. These can be used for childbirth and abdominal surgery, and some gynecologists now use them for sterilization.

Each type of anesthesia has its advantages and disadvantages. Discuss them all with your gynecologist/surgeon. If you prefer a local, you may have to make some inquiries to find a clinic or hospital that favors this method or offers a choice, although it is more widely used today because it is less expensive. In some communities, however, you may find that the only available gynecologist prefers using general anesthesia.

EFFECTIVENESS AND REVERSIBILITY

Sterilization is extremely effective and should be considered permanent. It is possible to repair occluded fallopian tubes so that they can function again, but this is major surgery and does not always work.

Failure Rate

As we noted, female sterilization is more than 98 percent effective over a 10-year period. Failures happen because an occluding device did not work properly, for example, a spring clip that does not exert sufficient pressure, or because electrocoagulation was not complete. A channel also can re-form in an incompletely sealed tube, allowing eggs or sperm to pass through and meet. Failure also can occur if the surgery is not performed carefully or a structure other than the tube was occluded.

Reversibility

Never contemplate having a tubal occlusion with the idea that someday you might want to have it reversed. Life situations can change unexpectedly and unpredictable events can lead to the desire for a child. Divorce and remarriage, a change in career plans, an alteration in your emotional or financial status, or the death of a child can create a strong wish to reverse an occlusion. Women under the age of 30, particularly, are advised against a tubal occlusion, because younger women are more likely to experience life changes.

If there is even the slightest chance that you might want a child in the future, use a reversible type of contraception.

Because of the possibility of regret after an irreversible procedure, careful counseling is important before sterilization. Counseling is available from physicians and family planning clinics, and no tubal occlusion should be performed without it.

Tubal occlusions can be reversed only under the best of circumstances. Reversal does not always lead to pregnancy, because delicate microsurgery is necessary to reverse the blockage of the tubes.

Sterilization procedures that destroy too much of the tube or remove the fimbria, the part of the tube that collects the released egg cell, make a reversal impossible. And it is not unusual for a surgeon to start a reversal procedure only to find that, in addition to the deliberate scarring caused by the occlusion method, the woman's tubes have been harmed by the adhesions and scarring of undiag-nosed pelvic inflammatory disease or endometriosis.

For a reversal to be successful, you need to have healthy fallopian tubes that were damaged minimally during sterilization. To become pregnant, you also need to be ovulating and have a fertile partner.

Chances for reversing a sterilization are best if a clip or silastic band was used to occlude the tubes. The most effective method, electrocautery, causes more extensive destruction, making it the most difficult to reverse. Some clinicians prefer to occlude the narrowest part of the tube whenever possible, in order to preserve the greatest amount of tissue—just in case the patient someday wants to have her sterilization reversed.

Although microsurgery techniques have increased the possiblity of reversing a tubal occlusion, success rates for this surgery are modest, and the expense is high. Because of age, irregular ovulation, and other fertility problems, a high percentage of sterilized women are not good candidates for a reversal attempt. Before having such an operation, you and your partner should be tested for other fertility problems, and you should have an examination by laparoscopy to determine the condition of your tubes and whether a reversal of the occlusion is feasible.

POSSIBLE COMPLICATIONS

Major complications as a result of female sterilization are infrequent. In the United States, the fatality rate is 4 per 100,000 procedures, mostly from complications from the use of general anesthesia.

Surgical Complications

Complications from the surgery itself can include infection and internal bleeding as the result of an instrument piercing a major blood vessel. Laparoscopic instruments can puncture organs or the intestines and can perforate the uterus. In rare instances, inflating the abdomen leads to a gas bubble in the blood system, which can be immediately fatal. Electrocoagulation instruments, if not managed carefully, can burn tissues other than the fallopian tubes.

Major complications—including injuries that require further surgery to repair—occur in just under 2 out of every 1,000 patients. The overall rate for major and minor complications is approximately 6 percent of the laparoscopies performed.

After having a tubal occlusion, be alert for such symptoms as fever, severe or persistent pain in the abdomen, or bleeding from the incision. These could indicate an infection or an injury that occurred as a result of the surgery. Complications can be minimized if they are treated right away, so bring such symptoms immediately to the attention of the gynecologist who performed the operation. Injuries made by the instruments usually require laparotomy to repair.

The risk of complications from laparoscopy is influenced considerably by the skills of the surgeon. The clinician who performs any sterilization surgery, particularly laparoscopy, should have special training in it. Furthermore, experience plays an important part— gynecologists who do fewer than 100 laparoscopies each year have a much higher rate of complications.

Ectopic Pregnancy

Although tubal occlusions rarely fail, if you become pregnant after being sterilized, there is a considerable chance the embryo will lodge itself in the fallopian tube. Anytime you feel any signs of pregnancy after sterilization, such as morning sickness, tender breasts, or no menstrual period, contact your physician for a pregnancy test.

If the pregnancy is ectopic, you may develop these symptoms:

• Sudden, severe, or persistent abdominal pain or cramping, often on one side.

• Unusual vaginal bleeding or spotting, along with abdominal pain, especially if this occurs after an unusually light period, or a late or missed period.

• A spell of faintness or dizziness (an indication of internal bleeding) together with any of the preceding symptoms.

If you have these symptoms and cannot reach your doctor, seek help at the nearest hospital emergency room. A pregnancy in a fallopian tube may rupture at any time, creating an emergency situation.

Although ectopic pregnancy is a potential complication of sterilization, 100,000 women who have had a tubal occlusion will experience fewer ectopic pregnancies than an equal number of unsterilized women who use no contraception.

WHEN TO HAVE A TUBAL OCCLUSION

From a surgical point of view, the easiest time for a woman to be sterilized is immediately after childbirth, when the uterus and fallopian tubes are still high in the abdomen and easier to reach than when they are in their usual lower position. In the past, when sterilizations required hospitalization, this seemed a logical time for the procedure—the woman was already in the hospital; the surgery did not extend the hospital stay; the operation was easier; and so the cost was less.

Today, however, most sterilizations do not need to be performed in a hospital, and many women feel that immediately after childbirth is not a good time to have any additional discomfort and pain.

Psychologically, too, while you are pregnant or soon after you have had a baby may be poor times to decide on sterilization. You may be under particular emotional and physical stress at these times and preoccupied with other important issues—especially those relating to the new baby. The decision to have a tubal occlusion should be made when you are able to think clearly about your life. Although you do not need the consent of your spouse in order to be sterilized, it is a good idea to include your partner in the decision-making process.

A tubal occlusion also can be performed immediately after an induced or spontaneous abortion. Because your tubes and uterus are not as enlarged as they are after a full-term pregnancy, either a minilap or a laparoscopy can be used.

Caution must also be exercised regarding sterilization immediately after abortion. Abortion can be an emotional, stressful event. It is not the best time for deciding on a method of contraception that is permanent. Do not choose to be sterilized if you are feeling under any sort of pressure—from yourself or others—to do so.

HAVING A TUBAL OCCLUSION

You can change your mind anytime before the surgery. If you are the least bit uncomfortable with your decision to be sterilized or you are not totally certain about the prospect of having no more children, cancel or postpone the procedure.

Choosing a Practitioner

The most obvious person with whom to discuss the possibility of a tubal occlusion—after your partner—is your obstetrician/gynecologist. Nevertheless, do not assume automatically that he or she should perform the surgery. The more frequently a clinician performs a particular procedure, the safer it will be, so you want to seek out a physician who performs many sterilizations. It is perfectly all right to ask where he or she was trained in laparoscopy and how often he or she now does sterilizations.

If there are not many medical resources where you live, or you are not satisfied with them, call your nearest Planned Parenthood clinic or the gynecology department of the closest medical school or

ARE YOU A GOOD CANDIDATE FOR STERILIZATION?

A tubal occlusion may be right for you if you are sure you do not want to be pregnant at any time in the future—for example, if you have health problems that can make pregnancy unsafe, if you do not want to pass on a hereditary disease or disability, or if you have all the children you want. Sterilization may also be the answer if you and your partner cannot use or do not want to use the reversible contraceptive methods currently avail-

teaching hospital and ask for the names of several doctors who are experienced in sterilization. Many hospitals offer this operation, often on an outpatient basis. Some hospitals can offer sterilization because they receive public funds to provide family planning care to low-income families. If you choose a clinic outside a hospital, make certain it has an arrangement with a nearby hospital to provide emergency backup.

This chapter provides only a general outline—each gynecologic surgeon has her or his own approach to tubal occlusion. When you have chosen a surgeon, before your first appointment write down your questions and ask for a step-by-step description of the procedure. Do not be afraid to ask questions, particularly about the possible risks of this surgery. If you want more information after your first visit, ask for it. Sterilization is an important step and should not be undertaken until your questions have been answered to your satisfaction. Make sure you receive the counseling that is a vital part of the process.

Today, before most operations take place, you are asked to sign an informed consent document. In general, the document for a sterilization covers these points: (1) the exact type of operation being performed, including its risks and benefits; (2) the availability of alternative, reversible methods of birth control; (3) the fact that a successful sterilization will prevent you from ever having more children; (4) the failure rate that is possible with this procedure; and (5) the fact that you can change your mind about having the surgery without losing your insurance or medical or financial benefits. The last point is important when the tubal occlusion would be paid for by public funds.

Before and After the Operation

If you are using birth control pills, mention this to your surgeon in case you need to discontinue them before surgery. In this case, be sure to use another contraceptive method until the surgery is complete. If you are pregnant at the time you are scheduled for sterilization, the pregnancy most probably will continue unless you choose to have an abortion as well as the sterilization. An abortion can be performed at the same time.

Do not eat or drink anything 8 hours before the operation. Take a bath or shower just before you go to the hospital or clinic, and thoroughly wash your abdomen, navel, and pubic area.

Arrange to have someone accompany you home afterward. Because your reflexes will be slowed down, it is not safe for you to drive for some hours after having general anesthesia or the sedatives used with local anesthesia. Plan to have someone with you for the first 24 hours after the surgery.

Plan to rest for at least 24 hours after the procedure and avoid any heavy work or lifting for at least 7 days, to give your body time to heal. Build as much flexibility and rest into your schedule as possible—some women recover more slowly than others from the effects of surgery and anesthesia. It may be a good idea to schedule sterilization surgery for a Thursday or Friday, to gain the weekend days for extra rest.

If you have a minilap or laparoscopy with local anesthesia, you may feel ready to go home as early as an hour after the procedure. If you have general anesthesia, you need to stay a little longer. After such a brief operation, most women recover from general anesthesia after 4 or 5 hours; rarely is an overnight stay in the hospital necessary. If the operation is performed immediately after childbirth, your hospital stay may be lengthened by a day.

If you have general anesthesia, you are likely to feel nauseated, weak, and tired until the next day. Your throat will be sore from the endotracheal tube put into your windpipe.

POSTOPERATIVE DANGER SIGNALS

Although some pain at the site of the incision and some abdominal discomfort are to be expected, any sign of an infection at the incision, any abdominal pain that is not relieved by mild pain medication, or any pain that lasts longer than 12 hours should be brought to the attention of the physician who performed the surgery.

Other symptoms of possible complications include the following:

• Chest pain, shortness of breath, coughing, or feeling faint.

• Fever with a temperature over 100.4 degrees Fahrenheit.

• Blood or fluid coming from the incision after the first day or two.

• Moderate or heavy vaginal bleeding.

After a laparoscopy, you may experience pain in a shoulder— this is caused by the gas used to inflate your abdomen. Although much of the gas is removed after the surgery, enough can remain to cause discomfort for a few days. These effects fade as the gas is absorbed by your body over the next couple of days.

Although the area of the incision is likely to be painful, the discomfort almost always can be relieved by taking a non-aspirin type of pain medication such as acetaminophen. Take one or two tablets every 4 to 6 hours as long as you need pain relief. You may have an occasional feeling of discomfort or aching in your lower abdomen as a result of the manipulation of the uterus or tubes. This usually disappears after a few days.

Some women experience menstrual problems after a tubal occlusion. This effect has been studied by several groups of researchers—with conflicting results. It does appear that some women experience shorter menstrual cycles, greater blood loss, and irregular bleeding after their tubes have been tied. These changes did not happen immediately—most were not noticeable until almost 2 years had passed. Women in the study who had abnormal cycles before sterilization were most likely to have menstrual changes after the procedure.

Tubal occlusion does not protect you against sexually transmitted diseases, including AIDS. Although you are safe from pregnancy, if you are not in a mutually monogamous relationship, you or your partner still need to use a barrier method of contraception, preferably a condom, for STD protection.

COST

The cost of a tubal occlusion varies, depending on the setting in which it is done and on the physician who performs it. The cost ranges from $1,200 to about $3,000. (A high cost does not necessarily guarantee a better quality procedure.) Medicaid, most insurance plans, and most health maintenance organizations pay for sterilization.

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