SURGICAL METHODS OF CONTRACEPTION

SURGICAL METHODS OF CONTRACEPTION

Sterilization for women and men 

What we need to understand

Sterilization with reference to family planning means permanent prevention from getting pregnant. For this to happen; the individual needs an operation. For women it is called tubal ligation or occlusion, for men it is called vasectomy. The partners need to consider it very carefully because it is permanent. Sometimes a single woman feels she never wants to have a baby and has a sterilization fairly young. I feel they need to think about it seriously. It can be reversed, however the success rate cannot be predicted. It also depends on the method of tubal ligation and what method was originally used.  If they were burned or totally removed it cannot be reversed.

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Before the advent of so many methods of contraception, sterilization was very common. In countries like India, when India was trying to control its population the public was encouraged to use sterilization or vasectomy; if they did so they were given a transistor radio as a gift. It was unfortunate that many young men had a vasectomy in the greed of a transistor radio without understanding its serious consequences. Now since we have long term reversible contraceptives such as, intrauterine devices or hormone implants, the frequency of operative contraception has gone down.

VASECTOMY

It is an operative method of contraception for men. The tube called vasdeferens carrying the sperm from the testicles to the penis is cut and tied so that when ejaculation occurs, there are no sperm and the partner cannot get pregnant. This takes few months as the residual sperm will still be there. They are stored in the Epididymis as shown in the diagram below. A test is performed on your ejaculate before you are cleared for sexual relations and that there is no sperm. The sperm in your body is naturally absorbed, and there is no build up.  There may be infection or bleeding as a result of the operation but it is rare. Before you decide to have this operation performed, a man needs to think very carefully about the fact that he will no longer be able to produce any offspring however we now have the medical technology to freeze sperm should a child be desired. A vasectomy can be reversed however the results are uncertain. A vasectomy is simple and has less extra complications; it can be done under local anaesthesia.

TUBAL OCCLUSION

If you decide to have a tubal ligation, you and your partner should discuss that this is what you want. You may also discuss the alternatives with your doctor, maybe one of these appeals to you. Make sure you never want a baby or another baby. It is better if you are, older than thirty years of age. Research has shown that women often regret if they had a tubal ligation very young. The frequency of divorce also complicates matters further. In modern times the tubal occlusion is almost always performed by keyhole surgery called, laparoscopy. In developing countries where there are no surgeons who can do it or there is no equipment, as this is expensive, it is done by open surgery. Give yourself time to think about it. Keep up with your regular contraception until the very last day or to the last tablet.

There are two ways, how tubal ligation is performed.

 OPEN METHOD

This means that you belly is cut open. This is like any other surgical operation. The operation is explained to you and your partner. You have to be very sure that you want this done. In some countries they coerce to have this done by giving you money or electronic, goods. In my view it is safe if you have a good marriage, you have three children and you are above thirty years of age. After the basic things are decided, you go to the operating theatre after having given the, consent. The operation is generally done under general aesthesia by an anaesthetist. The surgeon then makes a cut near the bikini line, which is about 3-4 cms long. He then identifies the tubes and blocks them.  Different methods are used by different surgeons to block them. The urinary bladder which lies in this area is always emptied, to prevent it from being injured. The belly is then closed by sutures that do not need to be removed. Generally you can go home the same day or the next day. This operation is called mini laparatomy. It is done when you are not pregnant and using a proper contraceptive. I had an incidence when a woman who had sex the night before her operation was due, thinking this cannot do any harm, She did not turn up for her six weeks visit in spite of my requests finally when she arrived, she was twenty weeks pregnant. It was worked out that she became pregnant the night before, as she did not use the condom that night which was her normal usual contraceptive. It is best to do tubal ligation soon after a period (Proliferative phase of menstrual cycle) when the woman is not likely to get pregnant .Tubal ligation can be done at the time of caesarean section, however the failure rate of these tubal ligations are slightly higher than the ones done when you are not pregnant. Also the other problem can often be that if the baby is found to have a serious medical condition and he can die, than it can be a disaster. I am not very keen on doing tubal ligation during the time of a caesarean section or at the time of an abortion, as at that time one may not be emotionally ready.

There are several methods of Tubal ligation usually named after the Surgeon who described them. There are different parts of the tube shown in the picture below.

It is best to lift up the tube in a tissue forceps, make sure this is the part of the tube where the blood supply is least. This protects the ovaries from their blood supply being compromised. The tube is then compressed, tied and cut. About one cm loop of the tube is cut and sent to pathology. This confirms that the tube was cut. It is also very useful in any medico legal situations if they arise in case the tubal ligation fails and the cut end of the tubes are diathermied to prevent recanalisation. We make sure there is no bleeding. This is done on both sides. The tubes are put back in the abdominal cavity. When the suture material is absorbed, the cut ends of the tube separate.

This method of tubal ligation is called Pomeroy’s method. It is very simple and can be taught easily. The failure rate is 1 per 1000 at the end of one year, 7.5 per 1000 at the end of10 years. There can be deaths due to bleeding or infection although it is rare. I have seen one death after a postpartum tubal ligation probably due to deep venous thrombosis.

The Aldrige method is more temporary, where the  Fimbrial  end of the tube is tucked in . It is good for a successful reversal.

A number of surgeons remove the whole tube. This can interfere with ovarian blood supply however the recent research has shown it to be protective against ovarian cancer.

 In another method called the Madleners methods, the tube are crushed at two points and tied. No tube is removed. I have seen two cases of hydrosalpinex (swollen tubes full of fluid) following Madleners tubal ligation.

Tubal ligation can also be performed via the vagina. The vaginal tubal ligation is hardly used anywhere in the world. It also has a high risk of infection. The tubal ligation even by laparatomy can sometimes be difficult if, a woman had many pelvic surgeries or infections, as this can make difficult to identify and lift up the tubes. If following a tubal ligation, you feel you may be pregnant see your doctor urgently. If it is an early pregnancy it can be aborted if you so desire otherwise   doctors can look after your pregnancy.  Tubal ligation as such does not do any harm to your pregnancy.  Always call your doctor if you have unusual pain, fever, abnormal bleeding, pain in the calf and any other problem that is worrying you. Complications of tubal ligation are generally minor and easily managed; your surgeon always discusses these with you.

KEYHOLE SURGERY OR LAPARASCOPY

Keyhole surgery is the method used in most countries. It is often not used if the woman is obese, or is likely to have pelvic problems which can make the identification and picking up of the tubes difficult. It is usually done under a general anaesthesia in a well equipped hospital by a properly trained surgeon. The surgeon explains the procedure to you. The complications, failure rate and reversibility is also explained to you depending upon the method he uses. After general anaesthesia, he then makes two cuts one near the belly button and other at the bikini line in the middle or to one side. The belly is filled with gas, he identifies the pelvic organs, once the surgeon has access to fallopian tubes, and he usually seals them off by using, Filshie clips or rings. Sometimes they burn them and then may or may not cut them. It is harder to reverse the tube once they have been burnt.  Filshie clips are expensive and require an extra gadget, so it is not often used.

Some surgeons often prefer either to do the removal of either the tubes, or do a removal of Fimbrial ends of the tubes only. Recent research has shown that it is protective against ovarian cancer, as most of the ovarian cancers seem to arise from the Fimbrial end of the tube. One ovarian cancer is prevented after 100 such operations have been performed.

A new surgical method of achieving tubal occlusion has been added to help women. This is called hysteroscopic sterilization.It is only available in limited countries. It can be done under light sedation even in the surgeon’s office.

The surgeon inserts a small titanium coil, going through the vagina into the uterine cavity and than going through the tubal opening deposits the coil in the tube this coil is called ESSURE. At present this is the only hysteroscopic method available. After this operation you have to wait three months so that your body has created scar tissue around it totally blocking your tubes. At the end of three months a special test is performed to make sure that in fact your tubes are blocked. During this time you have to continue using your normal contraception before they confirmed that they are blocked. This was considered to be a negative factor regarding Essure. The failure rate is higher than laparoscopic sterilization. Reversibility has been tried with some success.
In recent times there has been some controversy about Essure because many women have required repeat operations. Some of these women who had this done in many situations were already compromised because of obesity, previous surgery, and co-morbidities. The repeat procedure had to be performed under a general anesthetic, which was not completely satisfactory. In view of these recent objections, please be sure that you are happy to have this procedure performed upon yourself.