Sterilization has become a popular choice of contraceptive for millions of men and women in the United States as well as in many countries worldwide. This procedure is indicated in those requesting sterilization and who clearly understand its permanence and its difficult and often unsuccessful reversal. A woman should be counseled regarding alternative contraceptive choices (American College of Obstetricians and Gynecologists, 2007).
Female sterilization is the contraceptive method selected by 28 percent of couples in the United States (American College of Obstetricians and Gynecologists, 2003). And for women aged 35 to 44 years, surgical sterilization was their most commonly reported form of contraception (Bensyl and associates, 2005; Huber and Huber, 2009).
Sterilization is usually accomplished by occlusion or division of the fallopian tubes. This can be performed at any time, but at least half are performed in conjunction with cesarean or vaginal delivery and are termed puerperal (MacKay and associates, 2001). Nonpuerperal surgical tubal sterilization is usually accomplished via laparoscopy in an outpatient surgical center. Hysteroscopic or minilaparotomy approaches to occlusion are also available.
Puerperal Tubal Sterilization
For several days after delivery, the fallopian tubes are accessible at the umbilicus directly beneath the abdominal wall. Wall laxity allows easy repositioning of the abdominal incision over each uterine cornu. Thus, puerperal sterilization is technically simple, and hospitalization need not be prolonged. Some prefer to perform sterilization immediately following delivery, although others wait for 12 to 24 hours (Bucklin and Smith, 1999). At Parkland and the University of Alabama Hospitals, puerperal tubal ligation is performed in the obstetrical surgical suite the morning after delivery. This minimizes hospital stays but allows the likelihood of postpartum hemorrhage to diminish. In addition, the status of the newborn can be better ascertained.
Various techniques are now used to disrupt tubal patency. In general, a midtubal segment of fallopian tube is excised, and the severed ends seal by fibrosis and reperitonealization. Commonly used methods of interval sterilization include the Parkland, Pomeroy, and modified Pomeroy techniques (American College of Obstetricians and Gynecologists, 2003). Irving and Uchida techniques or Kroener fimbriectomy are rarely used because they involve increased dissection, operative time, and chance of mesosalpingeal injury. With fimbriectomy, unfavorably high failure rates stem from recanalization of the proximal tubal portion (Pati and Cullins, 2000).
A small infraumbilical incision is made. The fallopian tube is identified by grasping its midportion with a Babcock clamp, and the distal fimbria is identified. This prevents confusing the round ligament with the midportion of the tube. A common reason for sterilization failure is ligation of the wrong structure, typically the round ligament. Therefore, identification and isolation of the distal tube prior to ligation is required. Whenever the tube is inadvertently dropped, it is mandatory to repeat this identification procedure. Surgical steps are outlined for each method in Figures 33-1 and 33-2.
Parkland method. A. An avascular site in the mesosalpinx adjacent to the fallopian tube is perforated with a small hemostat. The jaws are opened to separate the fallopian tube from the adjacent mesosalpinx for approximately 2.5 cm. B. The freed fallopian tube is ligated proximally and distally with 0-chromic suture. The intervening segment of approximately 2 cm is excised, and the excision site is inspected for hemostasis. This method was designed to avoid the initial intimate proximity of the cut ends of the fallopian tube inherent with the Pomeroy procedure. (From Hoffman, 2008, with permission.)
Surgical sterilization: Pomeroy method. Plain catgut is used to ligate a knuckle of tube to ensure prompt absorption of the ligature and subsequent separation of the severed tubal ends. (From Hoffman, 2008, with permission.)
Puerperal sterilization fails for two major reasons. First, surgical errors include transection of the round ligament or only partial transection of the tube. Thus, both tubal segments are submitted for pathological confirmation. Secondly, a fistulous tract or spontaneous reanastomosis forms between the severed tubal stumps.
In their first report, investigators from the Collaborative Review of Sterilization (CREST) study described follow-up of 10,863 women who had undergone tubal sterilization from 1978 through 1986 (Peterson and colleagues, 1996). The failure rates for various procedures are summarized in Figure 33-3. Specifically, with the Parkland method, during four decades, the failure rate has been less than 1 in 400 procedures. It is readily apparent that puerperal sterilization is highly effective, with a short- and long-term failure rate that is better than those of most interval procedures.
Data from the U.S. Collaborative Review of Sterilization (CREST) shows the cumulative probability of pregnancy per 1000 procedures by five methods of tubal sterilization. (Data from Peterson and co-workers, 1996.)
Nonpuerperal (Interval) Surgical Tubal Sterilization
Techniques for surgical nonpuerperal tubal sterilization, including modifications, basically consist of:
ligation and resection at laparotomy, as described earlier for puerperal sterilization
application of a variety of permanent rings, clips, or inserts to the fallopian tubes, by laparoscopy or hysteroscopy
electrocoagulation of a tubal segment, again usually through a laparoscope.
In the United States, laparoscopic tubal ligation is the leading method of interval female sterilization (American College of Obstetricians and Gynecologists, 2003). The procedure is frequently performed in an ambulatory surgical setting under general anesthesia. In almost all cases, the woman can be discharged within several hours.