Is sterilisation the correct contraception choice?
Manish Gupta and Dr Kirsten Duckitt examine the latest guidelines
Sterilisation can be an empowering event for a woman or man when carried out at the right time in a person's life. But its success should not detract us from giving all the information we can to the patient so they make an informed choice.
The Royal College of Obstetricians and Gynaecologists has recently updated its evidence-based guideline for male and female sterilisation. This article examines aspects relevant to GPs and their patients.
What needs to be discussed?
As well as the usual history and examination, everyone who requests sterilisation must be counseled regarding other long-term, reversible methods of contraception. This should include information on the advantages, disadvantages and relative failure rates of each method (see table top right). Women in particular should be informed that vasectomy for their partner is safer and more effective than tubal occlusion.
At this point it is a good idea to remind people that contraception still needs to be used up until the next period following the procedure for women. For men, they or their partners will need to use effective contraception until azoospermia has been confirmed by semen analysis at least eight weeks after the vasectomy. In the UK this is usually confirmed by two separate post-vasectomy samples. This is to confirm that there is clearance of stored spermatozoa and to ensure there is no evidence of early recanalisation.
The other areas that must be discussed before proceeding are the intended permanency of the procedure, likely failure rate, the procedure and any common complications.
It may also be useful to dispel various common myths that accompany both female sterilisation and vasectomy. Men and women who are under 30 or childless require careful consideration on the part of the practitioner because of their increased regret rate.
Both methods are intended to be permanent. Reversal is possible but not usually funded by the NHS.
Trials report that reversal of tubal occlusion has a success rate of 31-92 per cent, with an ectopic pregnancy rate of up to 7 per cent, depending on the original method used to occlude the fallopian tubes. IVF is an alternative to reversal but may be more costly if a pregnancy is not achieved on the first cycle.
Success rates of vasectomy reversal operations vary from 52-82 per cent, depending on time elapsed since vasectomy, type of vasectomy and type of reversal. It is possible to extract sperm from the male genital tract and use this for intracytoplasmic sperm injection.
For all methods of tubal occlusion the failure rate over a woman's reproductive lifetime will be about one in 200. Failures occur just as commonly 10 years after the procedure as in the first year. The longest period of follow-up data available for the most common method used in the UK, the Filshie clip, suggests a failure rate after 10 years of two-three per 1,000 procedures.
The age at which a woman is sterilised influences failure rates – women who are sterilised under the age of 34 have a higher chance of failure as they will still be fertile for many years. This failure rate is higher than that for the levonorgestrel-releasing IUS, yet many people still think of female sterilisation as the most effective method.
Vasectomy has a failure rate after clearance has been given of one in 2,000. The commonest causes are operative failure, early unprotected intercourse and spontaneous recanalisation.
Procedure for tubal occlusion
Tubal occlusion is usually performed via laparoscopy as a day case under general or, more rarely, local anaesthesia. Mini-laparotomy may be necessary if the woman is obese or the laparoscopic approach proves difficult due to previous surgery. Local anaesthesia should be applied to the tubes as it lessens post-operative pain from local tissue necrosis.
Filshie clips or tubal rings are the best methods when laparoscopy is used: they have the least chance of failure. Filshie clips are most commonly used in the UK as they cause the least post-operative pain and are associated with the most success if reversal is required, because they damage the least amount of tube.
At mini-laparotomy or, at the time of Caesarean section, a modified Pomeroy technique – where a piece of the tube is removed by looping the tube with a suture and cutting off the top – is used.
Tubal occlusion should usually be performed as an interval procedure rather than in association with a pregnancy because of increased failure rates and regret. If it is going to be done at the same time, discussion should take place at least one week before the Caesarean.
Procedure for vasectomy
Trials suggest vasectomies should be performed by the no-scalpel approach, rather than conventional surgery, because it takes less time and has a significantly reduced rate of complications from bleeding, haematoma formation, infection and pain. It is similar in efficacy to the sharp scalpel approach and men seem to find it more acceptable.
Clips should not be used to ligate the vas as they have an unacceptably high failure rate. Diathermy or fascial interposition must be used as an adjunct to merely dividing the vas – otherwise failure rates are unacceptably high due to early recanalisation.
Vasectomies are nearly always performed under local anaesthesia, which makes them more attractive than tubal occlusions. General anaesthesia is used for the more complicated cases when there has been previous surgery or a varicocoele or hydrocoele is present.
There is no association between tubal occlusion and heavier or irregular periods, but women should be warned that if they are changing from using the oral contraceptive pill their periods might become heavier or more uncomfortable, purely for the reason that they will be reverting to their normal periods rather than Pill withdrawal bleeds. This is one reason why a levonorgestrel-releasing IUS may be preferable to tubal occlusion.
There is no increase in the risk of testicular cancer, prostate cancer or cardiovascular disease after a vasectomy. Neither operation affects libido.
Sterilisation is unusual in that a surgical procedure, with all its attendant risks, is performed at the request of an individual for social reasons. The intended permanency of the procedure means we must ensure the patient has all the information they need to make an informed choice.
Manish Gupta is specialist registrar and Kirsten Duckitt is consultant obstetrician and gynaecologist, John Radcliffe Hospital, Oxford
As with any laparoscopic procedure, women should be made aware that the risk of laparotomy for complications of laparoscopy is approximately one-two per 1,000. If the procedure fails, the resulting pregnancy has a 30 per cent chance of being ectopic. It is important that women are told this so they do not delay seeking advice if they think they may be pregnant at any time in the future.
Chromic testicular pain can occur after vasectomy. This may develop months or years after the procedure. The incidence of chronic post-vasectomy pain ranges from 12-52 per cent, depending on the study population. This is likely to represent an overestimate, since most of the studies involved questionnaire surveys, to which men with complications may be more likely to respond. Although pain may occur quite commonly, however, only a small minority of men questioned – between 0.9 and 5.2 per cent – sought help or said it affected their quality of life.
Popularity of sterilisation
lSterilisation is the commonest method of contraception worldwide
lMale and female sterilisation procedures are commonly the subject of litigation
lIn 1999, 47,268 tubal occlusions and 64,422 vasectomies were performed in England
lIn 2001, 10 per cent of women aged 16-49 in England had been sterilised
lIn 2001, 15 per cent of men aged 16-64 in England had had a vasectomy
lA new patient information leaflet can be downloaded from the Good Practice/Patient Information section of the RCOG website: www.rcog.org.uk This may be useful before the hospital visit, as some hospitals don't see women before the procedure but send out an information pack and health questionnaire instead. The surgeon's first discussion with the patient may be at the time of the operation.
lThe complete guideline and short version are available from the Good Practice/Sterilisation section of the RCOG website: www.rcog.org.uk
lThe Family Planning Association has useful information for patients and doctors at www.fpa.org.uk
lTwo published Cochrane reviews cover female sterilisation techniques; three more are in the pipeline on vasectomy techniques and IVF versus tubal reanastomosis for reversal of sterilisation: www.nelh.nhs.uk