The Committee on Practice Bulletins-Gynecology of the American College of Obstetricians and Gynecologists (ACOG) has released a practice bulletin on sterilization. “ACOG Practice Bulletin No. 46: Benefits and Risks of Sterilization” appears in the September 2003 issue of Obstetrics and Gynecology.
Sterilization accounts for 39 percent of contraceptive method use by U.S. women of reproductive age (15 to 44 years of age) and their partners. Of those, 28 percent had tubal sterilization, and 11 percent have partners who had a vasectomy. In comparison, 27 percent of the same population use oral contraceptives, 21 percent use male condoms, 3 percent use injectable contraceptives, 2 percent use diaphragms, and 1 percent use intrauterine devices (IUDs).
The bulletin lists methods of surgical sterilization, including laparoscopy, minilaparotomy, and transcervical and transvaginal approaches. Methods of occlusion, including electrocoagulation, mechanical methods (e.g., silicone rubber band, spring-loaded clip, and titanium clip lined with silicone rubber), ligation methods, and chemical methods, also are discussed. According to ACOG, tubal sterilization may be recommended as a safe and effective method for women who desire permanent contraception. Women should be counseled that tubal ligation is not intended to be reversible; therefore, those who do not want permanent contraception should be counseled to consider other methods of contraception. The risk of sterilization failure persists for years after the procedure and varies by method, age, race, and ethnicity. The younger a woman was at the time of the procedure, the more likely she was to have had sterilization failure.
The ACOG bulletin notes that vasectomy, when compared with tubal sterilization, is safer, less expensive, and appears to be as effective. The no-scalpel vasectomy technique has a lower incidence of complications than the incisional technique. In addition, there are no associations between vasectomy and prostate or testicular cancer, or any other long-term health problem.
To reduce future regret, the patient and her partner, when appropriate, should be counseled. According to ACOG, components of presterilization counseling should include discussion of the permanent nature of the procedure, alternative methods available, reasons for choosing sterilization, screening for indicators for regret, details of the procedure (risks and benefits of anesthesia), possibility of failure or ectopic pregnancy, the need to use condoms for protection against sexually transmitted diseases, completion of informed consent process, and local regulations about the waiting period from time of consent to procedure.
Regarding tubal sterilization, the following recommendations from ACOG are included in the bulletin:
Physicians should advise their patients that neither tubal sterilization nor vasectomy provides any protection against sexually transmitted diseases, including human immunodeficiency virus infection.
Physicians should advise their patients that the morbidity and mortality of tubal ligation, although low, is higher than that of vasectomy, and the efficiency rates of the two procedures are similar. Vasectomy is a less invasive surgical procedure and is performed using local anesthesia. Tubal sterilization involves entry into the peritoneal cavity and usually is performed under general or regional anesthesia.
Physicians should counsel their patients that tubal sterilization is more effective than short-term, user-dependent reversible methods.
Physicians should counsel their patients that failure rates of tubal sterilization are comparable with those of IUDs.