Permanent contraception (sterilization): Clinical sciences

Permanent contraception, or sterilization, refers to surgery that closes off or removes the fallopian tubes to prevent fertilization of an egg by sperm, thereby preventing pregnancy. Female sterilization can be achieved by occluding the fallopian tubes, removing a portion of the fallopian tubes, or removing the tubes entirely. It is a good option for patients who have contraindications or barriers to using other forms of contraception as well as those who do not wish to use other forms of contraception.

When a patient presents for permanent contraception, your first step is to obtain a focused history. Assess the patient’s age, gravidity, and parity. Keep in mind that there is no minimum necessary age, number of pregnancies, or number of children required for a patient to undergo sterilization.

Next, assess their medical and surgical history. Specifically ask about conditions such as endometriosis or a history of extensive surgery resulting in adhesions, which may distort the normal anatomy making a procedure technically more difficult. Finally, assess the patient’s preference for contraception. There are many reversible contraceptive options available, including long-acting reversible contraceptives or LARCs. Patients should never feel pressured or coerced into a permanent procedure such as sterilization.

If the patient no longer desires permanent contraception, or remains unsure, do not proceed with permanent sterilization and instead counsel them on all available contraceptive options. On the flip side, if the patient continues to desire permanent contraception, your next step is comprehensive counseling.

You can begin by counseling on all contraceptive options available. Many patients are not aware of options beyond condoms and birth control pills. LARCs are just as effective as sterilization and provide patients with a good alternative to surgery. Some patients may also choose for their partner to undergo sterilization, which can be achieved via vasectomy.

Here’s a clinical pearl! Vasectomy blocks the ability of the sperm to fertilize an egg by occluding the vas deferens and making ejaculate sterile. This is completed during an outpatient procedure with local anesthesia. In fact, vasectomy is more effective, less expensive, and safer when compared to female sterilization. Keep in mind that vasectomy is not immediately effective and that the patient must follow up in 3-6 months to confirm azoospermia with a semen analysis. Be sure to counsel the couple on backup contraception until the confirmatory test is completed!

Okay, let’s get back to counseling our patient. As with any patient undergoing surgery, discuss the safety of surgery and possible complications including bleeding, infection, and injury to surrounding structures. In general, laparoscopy is considered very safe with low rates of complications and rare procedure-related morbidity.

Take into consideration the patient’s medical and surgical history and address any comorbidities as not all patients are optimal candidates for surgery. These include patients with a history of severe cardiac or pulmonary disease and those with morbid obesity, which can make it more difficult to ventilate patients during general anesthesia. Also optimize those with uncontrolled diabetes or patients who use tobacco, which can result in poor wound healing. In these cases, it is often reasonable to offer contraceptive alternatives or postpone surgery to enhance health status. However, it is always important to weigh the individual risks of an unintended pregnancy versus the risks of elective surgery as there are no absolute contraindications to permanent sterilization.

A unique consideration in regards to sterilization is the risk of regret, specifically in patients who are less than 30 years old and those with low parity. Make sure they understand that if they change their mind regarding future pregnancy, a reversal procedure is expensive, often not covered by insurance, and may not be possible or successful. Additionally, they may require the use of in vitro fertilization, which also may not be covered by insurance. This is by no means a contraindication to proceeding with surgery but should always be reviewed so the patient is well informed.