[Surgical procedures for sterilization of the women: certainty--complications (author's transl)]

Abstract

The time (interval, postpartum, postabortum), location (uterus, mucus membrane of the oviducts, tubes), access (transcervical, transvaginal, trans-abdominal) and the actual method of sterilization for the women (surgical, electric, thermic, mechanical) can be differentiated and combined with each other in various ways. Today the usual procedure is sterilization by partial resection of the oviducts performed laparoscopically in the interval via electrocoagulation and surgically after delivery via periumbilical minilaparotomy. Laparoscopic sterilization via electrocoagulation has a rate of failure of about 1:1,000 and the mortality rate is less than 1:10,000. The most frequent complications are: hemorrhages due to injury of the larger vessels and burns in the intestine caused by the electric current. For this reason, conventional (:unipolar") electrocoagulation should be replaced by the so-called bipolar coagulation or other newer methods which avoid these complications. On the basis of the current literature, no definitive statements can be made regarding the reliability of the newer methods (silastic ring, plastic clips, thermocoagulation). An additional, although up until now purely hypothetic, advantage of the newer methods is the possibility of reversibility. With conventional electrocoagulation, the rate of reversilbility is very low. Additional alternatives are also culdotomy and minilaparotomy in the interval with the assistance of a uterus elevator. Both ways of access may be combined with various methods of sterilization. The pros and cons of the hysterectomy as a method of sterilization are still being discussed. Occasional late sequelae of sterilization such as menstrual disorders, pain and, particularly, problems related to sexual intercourse have only recently come to light. They have not yet been adequately investigated.

PIP: Female sterilization may be distinguished according to timing (e.g., pospartum, in the interval), site of operation, access point, and method. Transcervical procedures are still in the development phase. Tubal sterilization is performed by electrocoagulation, tubal resection, or mechanical closure of the tubes with clips or rings. The most reliable method is hysterectomy (although 15 cases of ectoptic pregnancies in hysterectomized women have been reported). The pregnancy rate of 1-2/1000 with laproscopic electrocoagulation is apparently not affected by specific technique used, e.g., by whether or not tubes are completely severed. Incomplete coagulation is an important cause of failures, and when using the new bipolar instruments that create only a narrow coagulation zone, it is advisable to repeat the procedure to ensure complete closure. With metal clips, the failure rate is high (1-10%); experience with bands and plastics is inconclusive. An advantage cited for the newer methods is reversibility, but practical experience is still limited and at present, sterilization should be regarded as irreversible. Data show that mortality and complication rates are much higher for hysterectomies than for other methods. Delayed complications of sterilization are primarily pain and menstrual disorders - perhaps attributable to the abnormal mobility of the ovaries and severed tubes - with coital and psychic disturbances also reported. Postpartum tubal sterilization has lost ground to laparoscopic sterilization. Hysteroscopic sterilization, still being developed, offers the prospect of an outpatient method with few complications, but the failure rate is still too high. Sterilization by laparoscope and culdotomy are comparable in ease of performance, mortality rate, and length of hospital stay. In electrocoagulation, high-frequency current, with its risk of intestinal burns, is obsolete and should be replaced by the safer bipolar or thermal methods. Minilaparotomy, increasingly used in Asia, offers an alternative to culdotomy. Because of high mortality and morbidity rates, hysterectomy is hardly suitable as a sterilization method only, but may be the preferred method in case of a pathological condition or an imminent induced abortion.