In the United States, one third of couples attempting to prevent pregnancy, particularly if the woman is > 30 years old, choose permanent contraception with vasectomy or tubal sterilization.
Sterilization procedures are very effective; pregnancy rates at 1 year are
Vasectomy: 0.15%
Fallopian tube permanent contraception procedures: 0.6%
Sterilization is intended to be and should be assumed to be permanent. If pregnancy is desired, a reversal procedure may be considered, but live birth rates after such procedures are
After vasectomy reversal: About 26% (1)
After tubal sterilization: A small percentage when the tubes are closed and 0% when the tubes are removed (in vitro fertilization may be used successfully)
In women, successful reversal depends on patient age, type of tubal procedure, percentage of tube that remains, amount of scarring in the pelvic area, and fertility test results in the woman and her partner.
Vasectomy
For this procedure, the vasa deferentia are cut, and the cut ends are ligated or fulgurated. Vasectomy can be done in about 20 minutes; a local anesthetic is used. Sterility requires about 20 ejaculations after the operation and should be documented by 2 sperm-free ejaculates, usually obtained 3 months after the operation. A back-up contraceptive method should be used until that time.
Mild discomfort for 2 to 3 days after the procedure is common. Taking nonsteroidal anti-inflammatory drugs (NSAIDs) and not attempting ejaculation are recommended during this period.
Complications of vasectomy include
Hematoma (≤ 5%)
Sperm granulomas (inflammatory responses to sperm leakage)
Spontaneous reanastomosis, which usually occurs shortly after the procedure
The cumulative pregnancy rate is 1.1% at 5 years after vasectomy.
Tubal Sterilization
For tubal sterilization, the fallopian tubes may be
Cut and a segment excised
Closed by ligation, fulguration, or various mechanical devices (plastic bands or rings, spring-loaded clips)
Completely removed
Pregnancy rates are higher with spring-loaded clips than plastic bands. Procedures that use mechanical devices cause less tissue damage and thus may be more reversible than closure by ligation or fulguration. Complete removal of the fallopian tubes is associated with a 40 to 50% reduction in the risk of ovarian cancer (2). Postpartum permanent contraception has lower failure rates than interval procedures.
The following surgical approaches may be used:
Laparoscopy, usually used for internal procedures (after postpartum period)
Minilaparotomy, usually used for postpartum procedures
Tubal ligation can be done during cesarean delivery or 1 to 2 days after vaginal delivery via a small periumbilical incision (minilaparotomy) (3).
Permanent contraception by laparoscopy
Laparoscopic procedures used to provide permanent contraception for women are done as an interval procedure (unrelated to pregnancy), usually at least 6 weeks after delivery and in the operating room; a general anesthetic is used.
The cumulative failure rate of these procedures is about 1.8% at 10 years; however, certain procedures have higher failure rates than others.
Permanent contraception by minilaparotomy
Minilaparotomy is sometimes used instead of laparoscopic procedures, usually when women want permanent contraception soon after delivery of a baby.
Minilaparotomy requires a general, regional, or local anesthetic. It involves a small abdominal incision (about 2.5 to 7.6 cm) and removal of a section of each fallopian tube. Compared with laparoscopy, minilaparotomy causes more pain, and recovery takes slightly longer.
Permanent contraception by hysteroscopy
In the early 2000s, hysteroscopy with placement of coiled microinserts into the fallopian tube was used to provide permanent contraception. As of December 31, 2018, the devices used in this method were removed from the market. Thus, this method is no longer being used.
The coils used for hysteroscopic sterilization consist of an outer layer of a nickel/titanium alloy and an inner layer of stainless steel and polyethylene terephthalate (PET). The PET fibers stimulate an ingrowth reaction that occludes the tubes.
Unintended pregnancy rates are similar with hysteroscopic and laparoscopic permanent contraception. If patients have ongoing pelvic pain or vaginal bleeding, the microinserts may have to be removed, Typically, the microinserts are removed by hysteroscopy, but laparoscopy may be required if part of the microinsert is outside the fallopian tube.
Complications
Complications of tubal sterilization are uncommon. They include
Death: 1 to 2/100,000 women
Hemorrhage or intestinal injuries: About 0.5% of women
Other complications (eg, failure of tubal occlusion): Up to about 5% of women
Ectopic pregnancy: About 30% of pregnancies that occur after tubal occlusion
Complications of permanent contraception by hysteroscopy may also include pelvic pain, abnormal uterine bleeding, and inflammatory disorders.
References
1. Lee R, Li PS, Schlegel PN, Goldstein M: Reassessing reconstruction in the management of obstructive azoospermia: reconstruction or sperm acquisition? Urol Clin North Am 35 (2):289-301, 2008. doi: 10.1016/j.ucl.2008.01.005
2. Hanley GE, Pearce CL, Talhouk A, et al: Outcomes From Opportunistic Salpingectomy for Ovarian Cancer Prevention. JAMA Netw Open 5(2):e2147343, 2022. Published 2022 Feb 1. doi:10.1001/jamanetworkopen.2021.47343
3. Yoon SH, Kim SN, Shim SH, et al: Bilateral salpingectomy can reduce the risk of ovarian cancer in the general population: A meta-analysis. Eur J Cancer 55:38-46, 2016. doi:10.1016/j.ejca.2015.12.003
Key Points
Tell patients that vasectomy or tubal ligation should be considered permanent, although a reversal procedure can sometimes restore fertility.
For men, the vasa deferentia are cut, then ligated or fulgurated; sterility is confirmed after 2 ejaculations are sperm-free, usually after 3 months.
For women, the fallopian tubes are cut or removed; when cut, then part of the tubes is excised, or the tubes are closed by ligation, fulguration, or mechanical devices such as plastic bands or rings; procedures used include laparoscopy and minilaparotomy.
