12/1/2018 - Tera Howard, MD
Mentor: Todd Jenkins, MD
Editor: Abimbola Famuyide, MBBS
Female permanent sterilization is the most common form of contraception in the United States and is used by nearly half of all married couples. Laparoscopic sterilization is performed under general anesthesia as an outpatient procedure. It allows for inspection of the abdomen and pelvis and can be useful in patients presenting with concurrent pelvic pain. It is immediately effective and patients can return quickly to normal activity.
Before undergoing laparoscopic sterilization, the patient should be counseled about its permanent nature and the risk of regret, in particular when performed on patients under 30 years of age. Surgical complications occur in 0.9-1.6 per 100 cases and include bowel or bladder injury from electrocautery, unintended conversion to laparotomy, and blood transfusion. Deaths from laparoscopic sterilization are rare and are most frequently related to risks of general anesthesia from hypoventilation or cardiopulmonary arrest. Although 5-year cumulative failure rate from laparoscopic sterilization is less than 1%, one third of post procedure pregnancies are ectopic in location. Long term, patients may experience changes in menstrual pattern attributable to advancing age and or discontinuation of hormonal contraception. Tubal ligation does not change menstrual pattern.
Alternatives to laparoscopic sterilization include all forms of contraception, especially male sterilization and long acting reversible contraception (LARC) methods. Vasectomy is safer, more effective, and less expensive than female sterilization. LARC methods are at least as effective as female permanent sterilization and in some cases more effective. An adequately counseled patient should never be denied a sterilization procedure solely based on age or parity. Once fully counseled, patients can be offered laparoscopic sterilization separate from a pregnancy (interval sterilization) or concomitantly with a first trimester or a second trimester abortion. For interval sterilization, it is important that the patient is on a reliable form of contraception leading up to the procedure or that the procedure is performed during the follicular phase of the menstrual cycle. Otherwise, the patient may have a luteal phase pregnancy.
Laparoscopic sterilization can be achieved by complete occlusion of a segment of the fallopian tube using mechanical devices such as the spring clip, silicone band, silicone lined titanium clips, bipolar electrocoagulation, or by partial or complete tubal excision. Mechanical methods should be performed on normal fallopian tubes. For silicone band application, the tubes have to be long enough to be drawn into the applicator device. Bipolar electrocautery is preferred to monopolar energy because of lower risk of thermal bowel injury. A 3 cm section of the isthmic portion must be completely coagulated for optimal efficacy. Partial or complete salpingectomies are suitable for patients with peritubal or tubal pathology. Observational studies suggest ovarian cancer risk reduction following partial or total salpingectomy in both women with average cancer risks and in those with BRCA 1 and BRCA 2 mutations. Salpingectomy also reduces the risk of pelvic inflammatory disease. Concerns regarding loss of ovarian function following salpingectomy are unsubstantiated.
- American College of Obstetricians and Gynecologists. ACOG Practice bulletin no. 133: benefits and risks of sterilization. Obstet Gynecol. 2013 Feb;121(2 Pt 1):392-404. doi: http://10.1097/01.AOG.0000426425.33845.b2.
- Stuart GS, Ramesh SS. Interval female sterilization. Obstet Gynecol. 2018 Jan;131(1):117-124. doi: 10.1097/AOG.0000000000002376.
- Abstracts of publications from the Collaborative Review of Sterilization (CREST), available at https://www.cdc.gov/reporductivehealth/contraception/index.htm
Initial Approval: November 2018
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