Sterilization failure, sterilization reversal, and pregnancy after sterilization reversal in Quebec

Declining rates of sterilisation reversal procedures in western Australian women from 1990 to 2008: the relationship with age, hospital type and government policy changes

BACKGROUND

Female sterilisation is usually performed on an elective basis at perceived family completion, however, around 1-3% of women who have undergone sterilisation elect to undergo sterilisation reversal (SR) at a later stage. The trends in SR rates in Western Australia (WA), proportions of SR procedures between hospital types (public and private), and the effects of Federal Government policies on these trends are unknown.

METHODS

Using records from statutory state-wide data collections of hospital separations and births, we conducted a retrospective descriptive study of all women aged 15-49 years who underwent a SR procedure during the period 1st January 1990 to 31st December 2008 (n = 1868 procedures).

RESULTS

From 1991 to 2007 the annual incidence rate of SR procedures per 10,000 women declined from 47.0 to 3.6. Logistic regression modelling showed that from 1997 to 2001 the odds of women undergoing SR in a private hospital as opposed to all other hospitals were 1.39 times higher (95% CI 1.07-1.81) and 7.51 times higher (95% CI 5.46-10.31) from 2002 to 2008. There were significant decreases in SR rates overall and among different age groups after the Federal Government interventions.

CONCLUSION

Rates of SR procedures in WA have declined from 1990 to 2008, particularly following policy changes such as the introduction of private health insurance (PHI) policies. This suggests decisions to undergo SR may be influenced by Federal Government interventions.

Effectiveness of bilateral tubotubal anastomosis in a large outpatient population

STUDY QUESTION

Is bilateral tubotubal anastomosis a successful treatment in an outpatient patient population?

SUMMARY ANSWER

For women wanting children after tubal sterilization, bilateral tubotubal anastomosis is an effective outpatient treatment.

WHAT IS KNOWN ALREADY

With the current emphasis in reproductive medicine on high technology procedures, the effectiveness of female surgical sterilization reversal is often overlooked. Previous clinical studies of tubal sterilization reversal have been mostly retrospective analyses of small patient populations.

STUDY DESIGN, SIZE, DURATION

A cohort of women who underwent outpatient bilateral tubotubal anastomosis from January 2000 to June 2013 was followed prospectively until December 2014 to determine the proportions of women undergoing the procedure who became pregnant and who had live births. Data were collected at the time of pregnancy. Differences in pregnancy rates and live birth rates associated with age, race and sterilization method were evaluated.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 6692 women, aged 20-51 years, underwent outpatient bilateral tubotubal anastomosis.

MAIN RESULTS AND THE ROLE OF CHANCE

The crude overall pregnancy rate was 69%. The crude overall birth rate was 35%. Results varied according to age at sterilization reversal and the method of sterilization. Women under 30 years of age at reversal of ring/clip sterilizations had an 88% pregnancy rate and 62% birth rate. Pregnancy and birth rates declined as age increased at sterilization reversal. Coagulation sterilization reversals resulted in the lowest rates of pregnancies and births. Ligation/resection reversals had intermediate success rates.

LIMITATIONS, REASONS FOR CAUTION

Limitations of our study include probable underreporting of pregnancies based on patient-initiated reports; possible errors in the reporting of pregnancies or early miscarriages that may have been based solely on home pregnancy tests; and probable over-reporting of the diagnosis of ectopic pregnancies. We identified age and sterilization method as being associated with subsequent pregnancy, however, in order to be considered predictive, the associations would need to be validated in an independent second prospectively studied group of representative patients. Finally, we also included patients in the study population who had additional surgical procedures performed at the time of tubotubal anastomosis (e.g. uterine myomectomy, fimbrioplasty, ovarian cystectomy and adhesiolysis), factors that could result in differences in pregnancy statistics in our study versus other patient populations.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this study can help inform patients and clinicians about this low technology alternative to IVF.

STUDY FUNDING/COMPETING INTERESTS

None.

TRIAL REGISTRATION NUMBER

N/A.

Female sterilization failure: Review over a decade and its clinicopathological correlation

Objectives:

The primary objective of the following study is to determine the demographic patterns of women presenting as sterilization-failure and secondary is to evaluate possible etiological factors for failure and lay standard guidelines to reduce failure rate.

Materials and Methods:

The present study is retrospective study conducted in Department of Obstetrics and Gynecology, Government Medical College and Hospital-based on the case records maintained in our institution over a decade (April 2002-March 2012).

Results:

Over a decade, 140 cases of sterilization-failure with longest interval of 20 years have been documented out of 80 (57.14%) cases were of minilaparotomy (minilap), 53 (37.86%) laparoscopic tubal ligation and 5 (3.57%) were lower segment cesarean section. In 84 cases (60%) sterilization were performed in Primary Health Centre (PHC). Only 58 (41.43%) patients reported failure in 1^st trimester (<12 weeks). 14 cases (10%) were of ectopic pregnancy. There were 25 cases (17.86%) of spontaneous recanalization. In 27 cases (19.29%) failure was due to improper surgical procedure and rest 54 (38.57%) have conceived due to tuboperitoneal fistula.

Conclusion:

Female sterilization even though considered as permanent method of contraception, recanalization is possible even 20 years after procedure. Maximum cases of failure were with minilap and those were performed at PHC. The most common cause of failure was tuboperitoneal fistula. Ectopic pregnancies were seen in 10% of cases. Proper counseling of patient is must. There is a need to stick to standards of sterilization procedure to prevent future failure.

A study on the reversal of sterilisation in women over two decades

OBJECTIVES

The present study was undertaken to check the relevance of reversal of sterilization in women in the present era of test tube babies, to evaluate the Standard guidelines for sterilization, (The site of the occlusion of the fallopian tube must be always be within 2-3 cm from the uterine cornu in the isthmal portion, excision of 1 cm of the tube should be done. Use of cautery and crushing of the tube should be avoided.) are being followed universally in the institution and outside, to study the demographic patterns of women coming for reversal of sterilization and to evaluate the causes for either the inability to perform reversal of sterilization or the adversaries like ectopic pregnancy that occur after the procedure.

METHODS

The present study is a retrospective study carried out in the Department of Microsurgery, Obstetrics and Gynecology, Government Kilpauk Medical College and Hospital Chennai based on the case records maintained in the institution. Three groups of women have been chosen at various periods and the various factors related have been compared. This includes the women who have come to the institution for reversal of sterilization during the years 1991-1995, 2000-2004 and 2006-2008 respectively.

RESULT

The demand for reversal has increased almost 81 % after 2005 whereas the standards of sterilization are actually being followed in <17 % of women. The incidence of Ectopic pregnancies has increased and the incidence of take home pregnancies has come down.

CONCLUSION

There is a need to stick to the standards of sterilization. Proper selection of candidates for sterilization and reversal of sterilization is important.

Laparoscopic laser sterilisation: An alternative option

The aim of this prospective study was to evaluate the safety and efficacy of female laparoscopic laser tubal sterilisation. A total of 265 women underwent laparoscopic laser sterilisation as a day-case procedure at Princess Royal University Hospital in Kent between 1996 and 2001. The fallopian tube was divided at the isthmic portion using a neodymium-yttrium aluminium garnet (Nd:YAG) laser probe. All procedures were completed laparoscopically and patients were discharged within 6 h of surgery. No perioperative complications were encountered. The mean follow-up duration was 36 months (range 2 - 7 years) and no intra- or extrauterine pregnancies were reported throughout the entire follow-up period. We conclude that laparoscopic Nd:YAG laser sterilisation appears to be a safe and effective day-case method of female sterilisation. Larger studies with longer follow-up are needed to further define its role as a reliable long-term contraceptive method.

Training of residents in laparoscopic tubal sterilization: long-term failure rates

OBJECTIVES

Laparoscopic tubal sterilization with bipolar coagulation is a common and effective method of contraception, and a procedure much used to teach laparoscopic surgical skills to Obstetrics and Gynaecology residents (trainees); but it has an inherent risk of failure. This study investigated the long-term failure rate of this procedure when performed by Obstetrics and Gynaecology residents on women treated in their teaching clinics.

METHODS

From 1991 to 1994, Obstetrics and Gynaecology residents carried out 386 laparoscopic tubal sterilizations with bipolar coagulation at Yale-New Haven Hospital. Six to nine years after the procedure, the women concerned were contacted by telephone and data were collected about sterilization failure.

RESULTS

Two failures of laparoscopic tubal sterilization with bipolar coagulation were identified: an ectopic pregnancy and a spontaneous abortion. For this time period, the long-term sterilization failure rate was 1.9% (0-4.4%).

CONCLUSIONS

The long-term sterilization failure rate for laparoscopic tubal sterilization with bipolar coagulation performed by residents is comparable to the results of prior studies. These findings can be used to properly counsel women at a teaching clinic about the risks of sterilization failure with this procedure, and attest to the adequacy of residents' training and supervision.

Regret following female sterilization at a young age: a systematic review

Women who undergo sterilization may later regret this decision. This systematic review examines whether age at sterilization is associated with poststerilization regret. Using MEDLINE and EMBASE, we identified 19 articles that examined associations between women's age at sterilization and later regret, requests for sterilization reversal and undergoing sterilization reversal or requesting in vitro fertilization (IVF) procedures. Study results showed that the younger women were at the time of sterilization, the more likely they were to report regretting that decision. Women undergoing sterilization at the age 30 years or younger were about twice as likely as those over 30 to express regret. They were also from 3.5 to 18 times as likely to request information about reversing the procedure and about 8 times as likely to actually undergo reversal or an evaluation for IVF. Results of studies that examined risk by continuous age showed a consistent inverse relationship between women's age at sterilization and their likelihood of regretting having had the procedure.

Laparoscopic surgery

The generic advantages of avoiding a large laparotomy incision are now well established. For the patient, a laparoscopic procedure is invariably less painful, and recovery and return to full normal activities is more rapid. There are also significant gains in short-term quality of life measures associated with the laparoscopic approach. For the surgeon, improved visualisation offers the opportunity of more precise and accurate surgery. These advantages are usually offset by longer operating times, the use of complex and expensive equipment, and the possibility of new types of complications and increased risk of standard operative morbidity. The aim of this chapter is to identify areas of general technique in which the risks associated with laparoscopic surgery can be minimised while retaining all the advantages of the approach. This is being achieved partly by improved and simplified instrumentation, partly by refinement in techniques, and partly by an increasing awareness of the potential pitfalls of the approach and by adopting strategies to avoid these problems. The majority of gynaecological procedures are already performed endoscopically and all gynaecologists who operate will need to become proficient in these techniques. This chapter outlines techniques for safe laparoscopic entry and safe bipolar diathermy techniques, and describes how to undertake some of the simpler laparoscopic procedures; the evidence supporting these approaches is also presented. Surgical proficiency in safe laparoscopic entry and laparoscopic tubal surgery should lead to the confidence to then undertake more complex procedures.

The role of fallopian tube anastomosis in training fellows: A survey of current reproductive endocrinology fellows and practitioners

This survey of fellows and reproductive endocrinologists in practice suggests that decreasing numbers of tubal reanastomosis procedures are being performed. This change has occurred both in fellow training and in the clinical practice of reproductive endocrinologists.