Mortality risk associated with tubal sterilization in United States hospitals

The efficacy and safety of different techniques for trocar insertion in laparoscopic surgery

A review of the available published data reveals no discernable difference in the safety of the three commonly-used methods of trocar insertion (Veress needle, direct and open) for laparoscopic surgery. Each method has individual advantages and disadvantages, with similar morbidity and mortality, when performed by experienced operators with appropriate indications. The individual surgeon should assess which technique best suits his or her operating style in light of the particular circumstance of each patient. Preference should be given to the method with which the surgeon is most comfortable, or with which he or she has the most experience. All patients should be warned prior to undergoing abdominal surgery that, regardless of the method employed for laparoscopy, penetrating injury to internal structures occurs in approximately 1 in 1000 cases.

Essure®: a new device for hysteroscopic tubal sterilization in an outpatient setting

OBJECTIVE

To evaluate the results of hysteroscopic placement of an intratubal device for permanent birth control in 85 women in an outpatient setting.

DESIGN

Prospective, observational study.

SETTING

Private university hospital.

PATIENT(S)

Eighty-five premenopausal women who asked for tubal sterilization by hysteroscopy between July 2002 and July 2003.

INTERVENTION(S)

Hysteroscopic placement of titanium-dacron intratubal devices in an outpatient setting.

MAIN OUTCOME MEASURE(S)

Procedure feasibility without anesthesia, success rate of device implantation, patient satisfaction, and confirmation of correct placement.

RESULT(S)

Successful placement was achieved in 81 patients (95%). Mean time elapsed between the start of hysteroscopy, placement of devices, and removal of optics was 9 minutes (range, 1-35 minutes). No intraoperative or postoperative complications were detected. Of 81 patients, 75 (93%) had abdominal x-ray performed at the third month; bilateral correct placement was confirmed in all of them.

CONCLUSION(S)

Essure is a safe, effective, and minimally aggressive procedure with satisfactory patient acceptance that does not require anesthesia or hospitalization. It seems to be a good alternative to laparoscopic tubal sterilization.

Tubal sterilization: focus on the U.S. experience

OBJECTIVE

To review the frequency, effectiveness, and clinical sequelae of tubal sterilization with a focus on the U.S. experience.

DESIGN

A review of U.S. health care statistics and English-language literature using a MEDLINE search, bibliographies of key references, and U.S. government publications.

PATIENT(S)

Women seeking tubal sterilization.

INTERVENTION

Tubal sterilization.

MAIN OUTCOME MEASURE(S)

Effectiveness and long-term risks and benefits.

RESULT(S)

Half of the 700,000 annual bilateral tubal sterilizations (TS) are performed postpartum and half as ambulatory interval procedures. Eleven million U.S. women 15-44 years of age rely on TS for contraception. Failure rates vary by method with one third or more resulting in ectopic pregnancy. Reversal is most successful after use of methods that destroy the least tube. Evidence of menstrual or hormonal disturbance after TS is weak, although some studies find higher rates of hysterectomy among previously sterilized women. Decreased risk of subsequent ovarian cancer has been observed among sterilized women.

CONCLUSION(S)

Tubal sterilization is highly effective and safe. Failures, although uncommon, occur at higher rates than previously appreciated. Evidence for hormonal or menstrual changes due to TS is weak. Tubal sterilization is associated with decreased risk of ovarian cancer.

The safety of laparoscopy performed by direct trocar insertion and carbon dioxide insufflation under vision

The records of 6,173 laparoscopies performed by specialist gynaecologists in the course of routine gynaecological care using the technique of direct insertion of the umbilical trocar and insufflation of carbon dioxide under vision were reviewed to ascertain the incidence of serious complications. A review of the published literature on laparoscopy methodology was also undertaken to complement the data obtained from this study. The nature of the records precluded accurate assessment of both indications and minor complications. There were 4 perforating bowel injuries (0.06%) requiring laparotomy (s small intestine, 2 large intestine). There were no cases of major vascular injury or gas embolus necessitating surgical or resuscitative measures. On 3 of the 4 occasions where bowel injury occurred the patients had undergone prior abdominal surgery and had midline vertical subumbilical incisions. Review of the published literature demonstrated bowel or vessel perforation rates (requiring laparotomy or resuscitation) of 1 in 1,000 regardless of whether the method of gaining peritoneal access was open (Hasson) technique, Verres needle insufflation, or direct trocar. Direct trocar insertion may reduce the risk of gas embolism by insufflating only after intraperitoneal replacement has been confirmed, moreover it allows immediate recognition and rapid treatment of major blood vessel laceration, both of which have been identified as being crucial in reducing laparoscopy associated mortality. When compared to other available methods of gaining peritoneal access for laparoscopy, direct trocar insertion followed by insufflation of carbon dioxide under vision can be performed with the same degree of safety for the patient. It is simply wrong to deduce from the available data that one particular technique of gaining peritoneal access is superior to another. Each have their individual advantages and disadvantages and similar morbidity when performed by experienced operators with appropriate indications. In light of this observation, each alternative should be considered by the individual surgeon to assess which would best suit his or her operating technique and the particular circumstance of each patient. Indeed preference should be given to the method with which the surgeon is most comfortable or with which he or she has the most experience.

A fifteen-year review of female sterilization by minilaparotomy under local anesthesia in Kenya

This paper is a comprehensive review of literature concerning the Kenyan experience with female sterilization through minilaparotomy under local anesthesia (ML/LA). A composite picture from analysis of several studies that include some 12,000 clients since 1979 reveals an average Kenyan user to be 31-34 years old (SD 4.9) with 5.9-6.8 children (SD 1.7-1.8). In up to 96% of cases, the indication for choosing sterilization is personal socio-economic considerations. The majority of clients (97%-99%) report satisfaction with their choice of sterilization at the first follow-up visit, and 96-99% state that they would recommend the method to others. The operation takes an average of 14 min (SD 4.5-5.3) "skin-to-skin" through a 2.5.2.8 cm incision (SD 0.5). A mean of 18 cm3 of 1% lignocaine is used (SD 2.7). Most clients (76.4%) have no post-operative complaints; those who do have any complaints report minor transitory problems. Similarly, most clients (96%) have moderate, little, or no peri-operative pain, but 1.9%-5% report much pain. The intra-operative and early complication rate is 0.9%. Some 3.3% of clients suffer at least one complication, some multiple, and the complication rate at 6 weeks is 4.1%, with major complications occurring in 0.7% of cases, and minor complications in 3.4%. The crude failure rate is 0.4% in the first year and 0.1% in the second year, when corrected for luteal phase pregnancies, which account for 50% of all "failures," the actual failure rate is 0.2% in the first year and 0.1% in the second year both for interval and postpartum procedures. This literature review finds outpatient ML/LA to be a relatively safe, simple, effective, and well-accepted option for most Kenyan couples seeking contraception that is intended to be permanent. Counseling, adequate client assessment, and voluntarism have been shown to be essential elements, not only for client satisfaction and avoidance of possible future regret, but also for technical ease of the operative procedure. Recommendations that derive from the Kenya experience are made.

Epidemiologic research in an integrated regional medical care system: the Marshfield Epidemiologic Study Area

To capitalize on Marshfield Clinic's advantages for population-based health research, we developed the Marshfield Epidemiologic Study Area (MESA). Marshfield Clinic is an integrated system consisting of a large multispecialty clinic and 23 affiliated clinics. Clinic physicians provide virtually all of the medical care, both inpatient and outpatient, for residents of the area. MESA consists of 14 ZIP codes in which over 95% of the 50,000 residents and most significant health events are captured in Marshfield Clinic databases, including all deaths, 94% of hospital discharges, and 92% of medical outpatient visits. MESA exemplifies the research potential of integrated medical care systems and the efforts required to realize that potential. Because it is representative of a defined population and provides an unselected sample of patients, MESA is well suited for epidemiologic research and research elucidating the clinical spectrum and natural history of diseases and the effectiveness of treatment.

Mortality after gynaecologic operations in Finland, 1986-1991

OBJECTIVE

To study the current in-hospital, 30-day and 42-day mortality after conventional gynaecologic procedures in Finland, with special reference to hysterectomy.

DESIGN

Nationwide six-year annual study.

SETTING

Data were from the Finnish Population Register Centre, the Finnish Cause-of-Death and Hospital Discharge Register, and the Register for Legal Abortions and Sterilisations.

SUBJECTS

Gynaecologic operations (n = 299,257) performed between January 1986 and December 1991.

MAIN OUTCOME MEASURES

The overall and age-adjusted mortality rates during the initial hospitalisation, as well as 30 and 42 days after the operations. Age-adjusted probability of dying within 42 days after hysterectomy compared with the overall probability of age-matched Finnish female control population.

RESULTS

Overall mortality rates per 10,000 hysterectomies increased gradually from 6.0 during initial hospitalisation to 9.1 and 12.9 when calculated 30 and 42 days post-operatively. The overall 42-day mortality rates of radical hysterectomy, curettage and laparoscopy (other than sterilisation) exceeded the post-hysterectomy mortality rate, while the rates after caesarean section, legal abortion and laparoscopic sterilisation did not. No deaths occurred after laparoscopic sterilisation (n = 40,346). The patients who died after radical hysterectomy, curettage and for other laparoscopy than sterilisation were old, and the great majority of them died of cancer.

CONCLUSIONS

The mortality rates after gynaecologic procedures in Finland are currently very low and have clearly decreased in recent decades. Patients may be reassured that conventional gynaecologic operations are safe.

Low-cost office laparoscopic sterilization

Between September 1986 and February 1992 we performed 210 laparoscopic tubal ligations in our office under local anesthesia using the Hulka clip. During the last 2 years we used a microchip video camera and endocoagulated the fallopian tubes adjacent to the clip in 84 women. The length of time for each procedure ranged from 15 to 30 minutes (average 20 min). There were no intraoperative complications. Failure to tolerate abdominal lifting (the "belly" test) was the only contraindication in this series. Previous abdominal surgery was not a contraindication. The three known failures in our first 69 cases were thought to be inaccurate clip applications. Subsequently, we added endocoagulation to the technique. Our procedure is cost efficient and time saving for both patients and physicians.

Tubal cyst following tubal sterilization: a delayed complication

Clinical pictures and histopathological findings in 15 patients of tubal cyst following tubal sterilization were analyzed. The interval between tubal sterilization and occurrence of tubal cyst was 10 years (ranged from 4 to 21 years). Clinically 8 cases (53%) suffered from lower abdominal pain, 5 cases (33%) from hypermenorrhea coexistent with uterine myoma and 2 cases (13%) from irregular menstruation. Five out of 9 patients with ultrasound examination were suspected to have tubal cyst before operation. The size of tubal cyst ranged from 1.5 to 9.0 cm in diameter with mean 3.4 cm. Eleven were unilateral and 4 were bilateral. Histologically they showed flattened mucosal epithelial cells with absence of epithelial plica, compression atrophy of muscular layer, suture stitch or granuloma and intact fimbria with clear serous fluid. Thus, the differential diagnosis of adnexal cyst in patients with a past history of tubal sterilization should include tubal cyst.

Case-fatality rates for tubal sterilization in U.S. hospitals, 1979 to 1980

To update a 1977 to 1978 case-fatality estimate for tubal sterilization in U.S. hospitals, we reviewed the medical records of women reported by the Commission on Professional and Hospital Activities to have died after tubal sterilization procedures in 1979 or 1980. We project that the most reasonable case-fatality rate estimate is slightly greater than 9 per 100,000 sterilizations if all deaths associated with the procedure are considered. Rate estimates that assume minimum and maximum numbers of all associated deaths in our sample are approximately 6 per 100,000 and 10 per 100,000 sterilizations, respectively. However, when only deaths that can be attributed to sterilization per se are considered, the most reasonable case-fatality rate is estimated at between 1 and 2 per 100,000 procedures, a lower rate than previously reported. Rate estimates that assume minimum and maximum numbers of attributable deaths in our sample are approximately 1 per 100,000 and 5 per 100,000 sterilizations, respectively. These results further indicate that death attributable to tubal sterilization is rare.

Mortality associated with sterilization: preliminary results of an international collaborative observational study

Sterilization is the contraceptive method most widely used worldwide, yet the case-fatality rate of deaths attributable to sterilization is not known. We used data collected from 1971-1979 from 28 countries by Family Health International to estimate case-fatality rates. We adjusted these rates for individuals lost to follow-up. Of 41,834 sterilizations, 23 resulted in deaths temporally associated with the procedure used. The adjusted attributable case-fatality rates were 13.4 per 100,000 for interval procedures, 53.3 per 100,000 for postabortion procedures, and 43.4 per 100,000 sterilizations after vaginal delivery. Multiple factors contributed to the deaths, including pre-existing health problems, infection and anesthesia. Prevention of deaths resulting from sterilization depends on complete ascertainment of deaths associated with sterilization and careful investigation to determine preventable risk factors. We conclude that, overall, sterilization in these programs was conducted with very low attributable mortality.

The mortality risk associated with hysterectomy

To study the risks of mortality associated with hysterectomy that are specific to age, race, surgical approach, and associated conditions, we used data collected by the Commission on Professional and Hospital Activities during 1979 and 1980. Four hundred seventy-seven deaths were recorded among 317,389 women having abdominal hysterectomies and 46 deaths among 119,972 women having vaginal hysterectomies. The mortality rates for hysterectomy, standardized for age and race, were higher for procedures associated with pregnancy or cancer than for procedures not associated with these conditions (29.2, 37.8, and 6.0 per 10,000 procedures, respectively). Hysterectomies associated with pregnancy or cancer constituted 8% of all hysterectomies performed. However, 61% of all deaths occurred in women with pregnancy- or cancer-related conditions. The mortality rate associated with hysterectomy increased with age and was twice as high among black women.

Comparative risks and costs of male and female sterilization

Couples who are considering elective sterilization should compare the risks and costs of male and female sterilization procedures as part of the decision process. Morbidity, mortality, failure rates, and short-term costs associated with male and female sterilization procedures were estimated from data available in previous case series. Male sterilization procedures were found to have zero attributable deaths and significantly less major complications when compared to female sterilization procedures. No less than 14 deaths a year can be attributed to female sterilization procedures in the US. Male and female sterilization procedures have efficacy rates that are not significantly different from each other. The short-term costs of female sterilization are 3.0 to 4.1 times that of vasectomy.

Capnography in the early diagnosis of carbon dioxide embolism during laparoscopy

Venous embolism of carbon dioxide occurred during elective diagnostic laparoscopy in a healthy adult female. The diagnosis of gas embolism was made on the basis of the sudden abrupt onset of systolic and diastolic murmurs. The continuously recorded end-tidal carbon dioxide concentration (FETCO2) increased abruptly from 3.8 to 4.2 per cent and then slowly decreased to 4.0 per cent over the subsequent 30 seconds. CO2 insufflation was terminated immediately following the establishment of the diagnosis. The patient recovered uneventfully. A transient but rapid rise in FETCO2 is suggested as a useful early sign of venous CO2 embolism during laparoscopy.

Sterilization-associated deaths: a global survey

Except for data from several geographically limited studies, little is known globally about the number and causes of death associated with surgical sterilization. To identify clinical characteristics and problems leading to deaths related to the procedures, the International Planned Parenthood Federation ( IPPF ) and the Centers for Disease Control (CDC) in the United States collaborated in a global mail survey of 4642 physicians. Usable responses were received from 1298 physicians (28%) in 80 countries. Fifty-five sterilization-associated deaths which occurred from January 1, 1980 to June 30, 1982 were reported. The most frequently reported causes of death were infection, anesthetic complications, and hemorrhage. There were some regional differences in the relative frequencies of these causes. Most cases did not involve surgical accident. The characteristics most frequently associated with the reported fatal procedures were: interval sterilizations, minilaparotomy incision, tubal ligation and general anesthesia. Most deaths were attributable to the surgical sterilization procedure.

Pharmacokinetics and pharmacodynamics of local analgesia for laparoscopic tubal ligations

The pharmacokinetics and pharmacodynamics of lidocaine and bupivacaine, when used for laparoscopic sterilization under local anesthesia, are described in 21 patients. Under direct vision with the use of a laparoscope, local anesthetic solution was sprayed onto the fallopian tubes. Nine patients were administered 12 ml of lidocaine 2% (240 mg), and 12 patients received 20 ml of bupivacaine 0.5% (100 mg). Samples of venous blood were drawn at 0, 5, 10, 15, 20, 30, 60, and 120 minutes after the intraperitoneal placement of local anesthetic. Drug assays were performed by means of gas chromatography. The peak concentration of lidocaine was detected within 30 minutes. The mean concentration was 1.70 +/- 0.34 micrograms/mg (range, 1.19 to 2.07 micrograms/ml; convulsive level, 18 to 26 micrograms/ml). The peak concentration of bupivacaine was not evident until 60 minutes after injection. The mean concentration was 0.44 +/- 0.15 micrograms/ml (range, 0.20 to 0.77 micrograms/ml; convulsive level, 4.5 to 5.5 micrograms/ml). These findings may justify the use of larger volumes of these local anesthetics for more painful diagnostic laparoscopies whenever adhesions and/or extensive manipulation is anticipated.

Deaths attributable to tubal sterilization in the United States, 1977 to 1981

In 1979, the Centers for Disease Control began surveillance of deaths attributable to tubal sterilization in order to determine why they occur and what may be done to prevent them. Since that time, 29 such deaths have been identified as occurring in the United States from 1977 through 1981. Of these 29 deaths, 11 followed complications of general anesthesia, seven were due to sepsis, four were due to hemorrhage, three were due to myocardial infarction, and four deaths were related to other causes. Some of these deaths might have been prevented by use of endotracheal intubation for general anesthesia, particularly for laparoscopic sterilization, safer use of unipolar coagulation or use of alternative techniques, careful insertion of the needle and trocar for laparoscopy, and discontinuation of oral contraceptives before sterilization. Further surveillance may help to make tubal sterilization even safer.

The safety and efficacy of tubal sterilization: an international overview

This article presents a synthesis of some of the major published studies on the efficacy and safety of tubal sterilization. The conclusions of this overview are that tubal sterilization is a safe operation, long-term sequelae of tubal sterilization have not been well documented, and the risk of pregnancy following tubal sterilization is less than 1 in 100. Continued study is needed to determine how to make a safe and effective procedure even safer and more effective.