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By Laura Sech, MD, Family Planning Fellow, Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine ; Penina Segall-Gutierrez, MD, MSc, Adjunct Associate Professor of Family Medicine and Obstetrics and Gynecology, Keck School of Medicine, University of Southern California ; Emily Silverstein, MD, Research Project Manager, Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine ; Daniel R. Mishell, Jr., MD, MSc, Endowed Professor of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California

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Patient Education

In the US, one third of couples attempting to prevent pregnancy, particularly if the woman is > 30, choose sterilization with vasectomy or tubal ligation. Sterilization should be assumed to be permanent. However, if pregnancy is desired, reanastomosis may restore fertility in 45 to 60% of men after vasectomy and in 50 to 80% of women after tubal ligation. Also, in vitro fertilization may be used successfully.

Male Sterilization (Vasectomy)

For this procedure, the vasa deferentia are cut, and the cut ends are ligated or fulgurated. Vasectomy can be done in about 20 min; a local anesthetic is used. Sterility requires about 20 ejaculations after the operation and should be documented by 2 sperm-free ejaculates, usually obtained 3 mo after the operation. A back-up contraceptive method should be used until that time.

Mild discomfort for 2 to 3 days after the procedure is common. Taking NSAIDs and not attempting ejaculation are recommended during this period.

Complications of vasectomy include hematoma ( 5%), sperm granulomas (inflammatory responses to sperm leakage), and spontaneous reanastomosis, which usually occurs shortly after the procedure. The cumulative pregnancy rate is 1.1% at 5 yr.

Female Sterilization

In this procedure, the fallopian tubes are cut and a segment is excised or the tubes are closed by ligation, fulguration, or various mechanical devices (plastic bands, spring-loaded clips). Alternatively, the tubes can be occluded. Sterilization that uses mechanical devices causes less tissue damage and thus may be more reversible.

One of several methods may be used; they include

  • Laparoscopy

  • Hysteroscopy

  • Minilaparotomy

Tubal ligation can be done during cesarean delivery or 1 to 2 days after vaginal delivery via a small periumbilical incision (via laparoscopy). Laparoscopic methods of tubal sterilization are traditionally done as an interval procedure (unrelated to pregnancy), usually > 6 wk after delivery and in the operating room; a general anesthetic is used. The cumulative failure rate of tubal sterilization is about 1.8% at 10 yr; however, certain techniques have higher failure rates than others. Postpartum procedures have a lower failure rate than some laparoscopic methods.

For hysteroscopic sterilization,clinicians, using hysteroscopic guidance, occlude the lumen of the fallopian tubes by inserting microinserts with coils. The coils consist of an outer layer of a nickel/titanium alloy and an inner layer of stainless steel and polyethylene terephthalate (PET). The PET fibers stimulate an ingrowth reaction that occludes the tubes.

Advantages of hysteroscopic sterilization over tubal ligation include the following:

  • It can be done in a clinic as an outpatient procedure.

  • It does not require incisions or cutting, clipping, or burning of the tubes.

A comparative disadvantage is that after microinserts are placed, sterility is delayed for up to 3 mo because the reaction that occludes the tubes takes several weeks. Often, clinicians recommend that women use another contraceptive method for 3 mo after the procedure. Women should choose a method (eg, depot medroxyprogesterone) that stabilizes the endometrium and allows visualization during hysteroscopy. This method can be used until tubal occlusion is confirmed by hysterosalpingography 3 mo after sterilization. If women are allergic to radiopaque dyes, ultrasonography can be used to confirm tubal occlusion.

Minilaparotomy is sometimes used instead of laparoscopic sterilization, usually when women want to be sterilized soon after delivery of a baby. It requires a general, regional, or local anesthetic. It involves a small abdominal incision (about 2.5 to 7.6 cm) and removal of a section of each fallopian tube. Compared with laparoscopy, minilaparotomy caused more pain, and recovery takes slightly longer.

After laparoscopic or minilaparotomy sterilization, clinicians recommend that women do not place anything in the vagina (eg, tampons, douches) and that they do not have sexual intercourse for about 2 wk.

Adverse effects of female sterilization are uncommon. Some of these complications include

  • Death: 1 to 2/100,000 women

  • Hemorrhage or intestinal injuries: About 0.5% of women

  • Other complications (eg, infarction, failure of occlusion): Up to about 5% of women

  • Ectopic pregnancy: About 30% of pregnancies that occur after tubal ligation

Key Points

  • Tell patients that sterilization should be considered permanent, although reanastomosis can restore fertility (if desired) in about half of men and even more women.

  • For men, the vasa deferentia are cut, then ligated or fulgurated; sterility is confirmed after 2 ejaculations are sperm-free, usually after 3 mo.

  • For women, the fallopian tubes are cut; then part of the tubes is excised, or the tubes are occluded using microinserts or closed by ligation, fulguration, or mechanical devices such as plastic bands or spring-loaded clips; procedures used include laparoscopy, hysteroscopy, and minilaparotomy.