Special Feature
Tubal Sterilization Techniques
By Kenneth Noller, MD
Several months ago, one of our readers wrote the editorial staff and asked a question that I can paraphrase: "Which technique of tubal sterilization should we use in our practices?" Obviously, this physician is aware of the recent information that has been published from the Centers for Disease Control and Prevention (CDC). That information has changed the way many of us have approached our patients when discussing tubal sterilization.
The history of tubal sterilization is quite interesting. The first widely accepted method of tubal occlusion was the Pomeroy technique, devised by Ralph Pomeroy, but not reported during his lifetime. This simple procedure should be counted as one of the most important techniques ever developed in the field of gynecologic surgery. Although many other techniques of open sterilization have been developed, this simple, safe occlusion of the fallopian tubes using absorbable suture may be our best overall choice.
For many years, for many societal reasons (including religious, ethical, sexist, and racist) sterilization was frowned upon by the medical community. I well remember the years when a physician might not be allowed to perform a sterilization procedure without consultation from another physician, agreement in writing by the patient’s husband, and classification of the patient according to some mixture of her age and parity. Fortunately, those days are behind us. Sterilization is currently the most widely practiced method of contraception in the United States.
Although laparoscopy was first introduced as a diagnostic procedure, it rapidly became the method of choice for the performance of tubal sterilization. Several different techniques were developed, unipolar cautery being the first. When significant problems with unipolar cautery were identified, bipolar cautery, silastic bands, and interlocking clips were (and are) widely used. Nonetheless, Pomeroy tubal sterilization remains a common procedure in the immediate postpartum.
As a resident in obstetrics and gynecology, I was taught that postpartum tubal sterilization was the method most likely to fail. Reviewing published data from that era, it is clear that: 1) there were no good data; and 2) postpartum tubal sterilization was no better or worse than other techniques.
However, by the 1980s information was beginning to emerge that suggested that postpartum tubal sterilization was as good as laparoscopy, and all were extremely successful.1,2 But the data from these early reports of the "sterilization era" were flawed. Most represented short follow-up, inconsistent reporting, and poor study design.
Fortunately, the CDC accepted a proposal by Peterson and associates to perform a prospective study of women undergoing tubal sterilization at several medical centers. As would be expected from this preeminent epidemiologic study group, the methodology and study execution are impeccable. Their publication,which came out in April 1996, provides us with information we can use directly when discussing tubal sterilization with our patients.3
The study identified several important outcomes. First, while tubal sterilization is effective overall (approximately 2 failures per 100 procedures after 10 years), it is less effective than most of us had expected, and there are considerable differences among the techniques. Based on the information from the early 1980s, most women have been quoted a risk of pregnancy following any type of tubal sterilization of approximately 3-4 per 1000 procedures. The CDC report clearly shows that the failure rate is substantially higher. The main reason for the high rate of failure was the discovery that pregnancies continue to occur for many years after the sterilization procedure. Previous studies usually only counted pregnancies within the first 12 months. When followed for 10 years the overall failure rate is nearly 2%. Likewise, the CDC was able to show that there were significant differences in success rates among the various procedures. In contrast to widely held beliefs, postpartum tubal sterilization (usually using the Pomeroy technique) and unipolar coagulation resulted in the lowest rate of pregnancy, with less than 1% of procedures resulting in pregnancy. Silicone rubber band application was the next best technique, but resulted in more than twice the number of failures. Bipolar cautery and spring clips were the least effective methods.
Peterson et al also identified the fact that women who were sterilized at an earlier age (younger than 28 years) were more likely to have a subsequent pregnancy than those women who were sterilized at age 34 or older.3 Finally, when pregnancies did occur nearly one-third were ectopic.
Further examination of the data suggests that bipolar coagulation is probably as good as the silicone band technique when the operator is thoroughly familiar with the technology. The CDC study was performed at a time when bipolar cautery was just being introduced into some of the medical centers in the project, and thus, it is possible that the poor performance of bipolar cauterization might be due to relatively inexperienced operators.
A second publication from the same study group focused on ectopic pregnancy and reported that the overall 10-year cumulative probability of the ectopic pregnancy was 7.3 per 1000 procedures for all techniques combined.3 However, those women having bipolar tubal coagulation at younger than 30 years of age had an ectopic pregnancy rate 27 times higher than those women who underwent postpartum partial salpingectomy.
How should we answer the question posed by our reader? Unfortunately, like so many things in medicine there is no single answer. While postpartum sterilization using the Pomeroy technique results in the lowest rates of pregnancy and ectopic pregnancy, many women do not make the decision to have sterilization performed at the end of pregnancy (and indeed some information suggests that more women regret postpartum sterilization than interval sterilization). Unipolar coagulation has the lowest failure rate among laparoscopic techniques but is also associated with the highest risk of serious morbidity. While the rubber band and clip techniques fail more often than unipolar cautery, they are more successfully reversed than other techniques.
In summary, there is no one best method of tubal sterilization. However, knowledge of the success rates of the various techniques allows the physician to discuss realistic failure rates with each patient. In addition, the patient can be informed that late failures do occur as long as a decade after the procedure.
I do need to add one other thought. Nowhere in the papers discussed above nor in this piece have I mentioned hysterectomy as a sterilization method. Although some morbidity may occur following tubal sterilization in rare cases, the rate of morbidity and mortality from hysterectomy far exceeds that of the simpler techniques. Thus, there is no place for hysterectomy as a method of sterilization.
References
1. Romney SL, et al. Gynecology and Obstetrics, The Health Care of Women. New York, NY: McGraw-Hill Book Company; 1981:846-849.
2. Jones HW, et al. Novak’s Textbook of Gynecology, Eleventh ed. Baltimore, Md: Williams & Wilkins; 1988:26-28.
3. Peterson HB, et al. Am J Obstet Gynecol 1996;174: 1161-1170.
Which of the following methods of tubal sterilization has the lowest, 10-year cumulative failure rate?
a. Postpartum partial salpingectomy
b. Laparoscopic bipolar coagulation
c. Laparoscopic silicone rubber band application
d. Laparoscopic clip application
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