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Surgical sterilization is a safe, highly effective and permanent form of contraception. In 1995, almost 30 per cent of contraceptive users in the United States used tubal sterilization.

Regrets After Sterilization

This occurs in approximately three to 25 per cent of women. However, only about one to two per cent of women who have undergone sterilization seek a tubal ligation reversal. The most common factor associated with regret is change in marital status. Some studies also report an association between regret and marital discord at the time of procedure.

Timing Of Sterilization

Sterilization can be performed after childbirth, after an abortion, or in conjunction with other surgical procedures like the removal of the gallbladder. Sterilizations after delivery of children are performed immediately after delivery or within 24 hours but can be done up to seven days later. Further delay increases the risk of infection and the difficulty due to involution which is the process by which the uterus achieves pre-pregnancy size and structure.

Other Contraception

Contraception should be used at least one month before sterilization and continued to the next cycle to prevent pregnancy.

Complications

The mortality rate of tubal sterilization in the US is one to four deaths per 100,000 procedures and in developing countries 4.7 per 100,000 procedure. These rates are mainly due to anaesthetic complications

Complications such as wound infections, hematoma (collection of blood), and perforation of the bladder, uterus, or intestine occur in 0.4 to one per cent of procedures. In a multi-center study done of 9475 women, the complications during and after surgery were found to be less than one per cent. Independent predictors of having complications were diabetes, use of general anaesthesia, previous abdominal or pelvic surgery and obesity.

Major complications are related to general anaesthesia, sepsis(infection) and bleeding. Serious sepsis can result from unrecognized thermal bowel injury during unipolar coagulation (a procedure done during surgery to close off blood vessels).

Outcome

Pregnancy is uncommon after tubal sterilization. The risk appears to be related to age and the type of procedure. In a large, long-term study of 10,685 women who underwent tubal sterilization and were followed for 8 to 14 years, there were 143 sterilization failures. The cumulative 10-year probability of pregnancy was 18.5 per 1000 procedures; it was highest after clip sterilization, and lowest after unipolar coagulation and postpartum partial salpingectomy (36.5, 7.5, and 7.5 per 1000 procedures, respectively). The risk of pregnancy was highest among women sterilized at a young age.

There was a Canadian study of the 10 year cumulative probability of pregnancy after 311,960 sterilization procedures. This study reported a rate of 18.5 per 1000 procedures.

Ectopic Pregnancy

If pregnancy does occur, there is a risk that it will be an ectopic pregnancy. One-third of post sterilization failures are ectopic. In the same Canadian study, the 10-year cumulative probability of ectopic pregnancy was 7.3 per 1000 procedures. This time again, the risk was related to age and the type of procedure performed. Women under 30 years at the time of sterilization were almost twice as likely as older women to have a subsequent ectopic pregnancy. Bipolar coagulation resulted in the highest probability of ectopic pregnancy (17.1 per 1000 procedures at 10 years after sterilization), postpartum partial salpingectomy the lowest (1.5 per 1000 procedures at 10 years after sterilization).

Postablation Tubal Sterilization Syndrome

Postablation tubal sterilization syndrome refers to the development of severe, cyclic, unilateral or bilateral pelvic pain usually occurring five to ten months after an endometrial ablation performed in a woman with a previous tubal sterilization procedure. This is a newly described entity still under study. Endometrial ablation is done when there is a suspicion of endometrial cancer. Endometrium is the inner lining of the uterus.

Summary

  • Surgical sterilization is safe (complication rate less than one percent) and effective (overall 10-year probability of pregnancy 18.5 per 1000 procedures, but varies with type of procedure).

  • Pregnancies occurring after tubal ligation are more likely to be ectopic. The rate of ectopic pregnancy is higher than that in women using other forms of contraception, but lower than in women not using any form of contraception.

  • The procedure should be considered permanent. Reversal may be successful, but requires major surgery, is costly, and may not be covered by medical insurance. Regret after sterilization may be related to young age, conflicted feelings at the time of surgery, or a subsequent change in marital status

  • Laparoscopic sterilization techniques and sterilization by minilaparotomy have comparable safety and efficacy. The choice of method should be based upon the clinical situation and patient and physician preference.

  • Women who have undergone tubal ligation are less likely to develop ovarian cancer and pelvic inflammatory disease, but may have a slightly higher rate of future hysterectomy

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