Sterilisation

Original article by Tom Leach | Last updated on 7/6/2014
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Introduction

  • Can be controversial in some cultures
  • Should only be undertaken in stable relationships where the couple is certain they do not want any more children
 

Epidemiology

Rates falling in developed countries
UK is unusual as the number of men receiving the operation is greater than the number of women

  • 18% of men between 18-69 have had a vasectomy
    • Only 64% of these were done on the NHS
    • 95% of female sterilisations are performed on the NHS
 
It is unlikely that anyone with the following situation will be sterilised:
  • Under 30
  • No children
  • Not in a long-term relationship
 
Counselling is usually given to all parties. It is not necessary to have the partners permission, but it the patient is encouraged to involve them in the decision making process.
 

Reversal

Is possible, but is less likely the longer the patients has been sterilised. It not usually available on the NHS.

The procedure should be treated as irreversible – and discussed as such with the patient. For example, you should point out that if unseen circumstanced were to occur, whereby their current children were to become ill or die, they would be unable to have further children.
Instances where couples are likely to express regret:

  • Under 25
  • Fewer than 2 children
  • Unstable relationship
  • Vasectomy during a partner’s pregnancy
  • Tubal ligation at C-section
  • Sterilisation at TOP
 

Failure

Like all surgery, there is a small proportion of operations that fail.
 
Choosing – vasectomy or female sterilisation
Vasectomy is:
  • 30x less likely to fail
  • 20x less likely to result in complications
  • Less invasive
  • Performed under local anaesthetic, and thus is a more minor procedure. Usually a day case.
 

Threat of pregnancy to the mother

Some diseases pose a risk to the mother’s life if she were to become pregnant, for example Primary pulmonary hypertension. In this condition, pregnancy could be fatal, and hormonal contraceptives may be contra-indicated. It would be in the woman’s best interest to be sterilised.
  • It is not a good idea to perform vasectomy on the partner in these instances, as it could be possible that the man would be widowed, and left infertile.
 

Female sterilisation

Tubal occlusion / Tubal ligation / Salpingectomy
 

Efficacy

Efficacy rates vary from 99.2 – 99.5%. The Filshie clip is thought to be the most effective.
  • The ‘lifetime failure rate’ – is about 1 in 200
  • If the surgery fails, there is an increased risk of ectopic pregnancy
Failure of the procedure can be immediate, or years later.
It can be done laparoscopically (usually local anaesthetic) or as open surgery (general anaesthetic).
 

Procedure

  • Usually carried out at the isthsmus (the bit next to the uterus)
  • The ovaries and uterus are left intact
    • Ovulation may still occur, but the ovum is absorbed by surrounding tissues
  • May be laparotomy or laparoscopy.
  • Salpingectomy – is a particular procedure where the tubes are cut, and then sutured over.
  • Clips – some surgeons prefer to clip, rather than suture the tubes. The clip inhibits blood flow to the clipped area, and the region typically undergoes fibrosis and scarring which help to block the passage.
  • Rings – similar to a clip
  • Cauterization
  • Usually performed under general anaesthetic – however in some situations – e.g. directly after a caesarean, may be performed under local. 
 

After Surgery

  • Women can consider themselves infertile straight after the procedure – but there is a risk of pregnancy in the menstrual cycle immediately prior to the surgery.
 

Complications

  • Laparoscopic surgery may need to be converted to open surgery if there are complications.
    • This is more likely in obese patients, and in those with previous abdominal surgery
  • Advise patients to seek urgent medical advice if they have vaginal bleeding, or abdominal pain, to rule out ectopic pregnancy
  • Associated with increased need for hysterectomy
  • Not associated with increased risk of heavy, irregular periods
 

Male sterilisation

Vasectomy

Efficacy

0.3% if there is:

  • Ligation of the vas, PLUS
  • Cauterisation of the ends, PLUS
  • Insertion of a fascia between the two ends

Around 1% if cauterisation only is used
Late failure occurs in 0.2% of cases

 

Surgical technique

  • The vas is palpated, and moved as close to the scrotal skin as possible. Local anaesthetic (lidocaine 1-2ml) is administered.
  • Through a small inscision in the scrotal skin, the vas is identified and clamped in two places, about 5cm apart
  • A small segment (e.g. 1cm) is removed and sent for histology to confirm it is actually the vas deferens.
  • Of the two ends, the testicular end is tied back on itself to reduce the risk of anastomosis, and the top end is also occluded, with non-absorbable stitching.
    • Some surgeons may insert an artificial fascia between the two ends to further reduce the risk of anastomoses
  • Suture up the skin
 

Alternative methods

  • Cauterisation of the vas
 

Measuring success

  • There needs to be two negative sperm count samples 1 month apart, taken after a minimum of 20 ejaculations.
 

After surgery

  • Normal ejaculation and orgasm occur, however, there is no sperm in the ejaculate.
  • May be painful, and men advised to take several days off work, and not do anything too strenuous for 1 week
 

Complications

Bleeding

  • Mild – 1:400
  • Major – 1:1000

Infection – 1:100
Epididymitis – 1:100
Persistent pain – 1:1000
perm granuloma – 1:500

  • This is a tender scrotal swelling at the proximal end of the cut vas, and will require excision.
 
Vasectomy does NOT cause: