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Permanent Contraception

(Sterilization)

By

Frances E. Casey

, MD, MPH, Virginia Commonwealth University Medical Center

Last full review/revision May 2020| Content last modified May 2020
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In the US, one third of couples attempting to prevent pregnancy, particularly if the woman is > 30, choose permanent contraception with vasectomy or tubal ligation.

This form of contraception is meant to be and should be assumed to be permanent. If pregnancy is desired, reanastomosis may be considered, but live birth rates after such procedures are

  • After vasectomy reversal: About 26% (1)

  • After permanent contraception procedures in women: A small percentage when the tubes are closed and 0% when the tubes are removed

In vitro fertilization may be used successfully.

General reference

  • 1. Lee R, Li PS, Schlegel PN, Goldstein M: Reassessing reconstruction in the management of obstructive azoospermia: reconstruction or sperm acquisition? Urol Clin North Am 35 (2):289-301, 2008. x. doi: 10.1016/j.ucl.2008.01.005.

Male Permanent Contraception (Vasectomy)

For this procedure, the vasa deferentia are cut, and the cut ends are ligated or fulgurated. Vasectomy can be done in about 20 minutes; 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 months 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 nonsteroidal anti-inflammatory drugs (NSAIDs) and not attempting ejaculation are recommended during this period.

Complications of vasectomy include

  • Hematoma (≤ 5%)

  • Sperm granulomas (inflammatory responses to sperm leakage)

  • Spontaneous reanastomosis, which usually occurs shortly after the procedure

The cumulative pregnancy rate is 1.1% at 5 years after vasectomy.

Female Permanent Contraception

For permanent contraception in women, the fallopian tubes may be

  • Cut and a segment is excised

  • Closed by ligation, fulguration, or various mechanical devices (plastic bands or rings, spring-loaded clips)

  • Completely removed

Pregnancy rates are higher with spring-loaded clips than plastic bands. Procedures that use mechanical devices cause less tissue damage and thus may be more reversible than closure by ligation or fulguration. Complete removal of the fallopian tubes may reduce the risk of ovarian cancer.

The following methods may be used:

  • 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).

Permanent contraception by laparoscopy

Laparoscopic procedures used to provide permanent contraception for women are traditionally done as an interval procedure (unrelated to pregnancy), usually > 6 weeks after delivery and in the operating room; a general anesthetic is used.

The cumulative failure rate of these procedures is about 1.8% at 10 years; however, certain procedures have higher failure rates than others. Postpartum laparoscopic procedures have a lower failure rate than some other laparoscopic procedures.

Permanent contraception by hysteroscopy

Until recently, hysteroscopy using coiled microinserts could be done to provide permanent contraception for women. As of December 31, 2018, the devices used in this method were removed from the US market. Thus, this method is no longer being used in the US.

For permanent contraception using hysteroscopy, clinicians, using hysteroscopic guidance, occlude the lumen of the fallopian tubes by inserting microinserts with coils through the vagina and uterus and into the fallopian tubes. 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 this procedure 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 months because the reaction that occludes the tubes takes several weeks. Often, clinicians recommend that women use another contraceptive method for 3 months 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 months after the procedure. If women are allergic to radiopaque contrast, ultrasonography can be used to confirm tubal occlusion.

Minilaparotomy

Minilaparotomy is sometimes used instead of laparoscopic procedures, usually when women want to permanent contraception soon after delivery of a baby.

Minilaparotomy 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 causes more pain, and recovery takes slightly longer.

Complications

Complications of permanent contraception in women are uncommon. They include

  • Death: 1 to 2/100,000 women

  • Hemorrhage or intestinal injuries: About 0.5% of women

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

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

Complications of permanent contraception by hysteroscopy may also include pelvic pain, abnormal uterine bleeding, and inflammatory disorders.

Key Points

  • Tell patients that vasectomy or tubal ligation should be considered permanent, although reanastomosis can sometimes restore fertility.

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

  • For women, the fallopian tubes are cut or removed; then part of the tubes is excised, or the tubes are closed by ligation, fulguration, or mechanical devices such as plastic bands or rings; procedures used include laparoscopy and minilaparotomy.

Drugs Mentioned In This Article

Drug Name Select Trade
PROVERA
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