Female sterilization. Evidence

Contraception for the Cardiac Patient: a Cardiologist’s Primer

Purpose of review

Cardiovascular disease (CVD) is the number one cause of maternal mortality in the USA. There are many cardiac conditions which pose significant risk to maternal health, and these women should be offered options to avoid unwanted pregnancies. Individualized contraceptive counseling focusing on woman’s desire for future pregnancy, comorbid conditions, and desire for hormone or non-hormonal (contraceptive) options is paramount to avoid adverse or unwanted side effects. The purpose of this review is to give general guidance on prescribing both hormonal and non-hormonal contraceptives for providers caring for women with heart disease.

Recent findings

Specific recommendation for the use of either non-hormonal or hormonal contraception requires knowledge of the types of contraceptive options available, cost, failure rates, and contraindications to use. Newer progestin-only options have become available and should be considered first-line therapy for women with cardiovascular disease.

Summary

The physiologic burden of pregnancy on the cardiovascular system can cause significant maternal morbidity and mortality for women with underlying CVD. These women should be offered safe and effective options for birth control, and both cardiology and obstetrical providers alike should possess fundamental knowledge of appropriate options.

Knowledge, attitudes, and perceptions of antenatal women to postpartum bilateral tubal ligation at Greys Hospital, KwaZulu-Natal, South Africa

OBJECTIVES

To evaluate the associations between socio-demographic factors and the general knowledge, the attitudes and perceptions of women attending antenatal clinic at Greys Hospital regarding postpartum tubal ligation (BTL).

METHODS

A prospective cross-sectional study describing the perceptions about BTL in 241 pregnant women was conducted.

RESULTS

One hundred and sixty six (68.9%) participants needed to involve their partners before tubal ligation. Thirty five percent of 102 participants who would not have BTL against partner's wish were unemployed. Eighty three (34.4%) participants, mostly with secondary and tertiary education believed that successful reversal of BTL is guaranteed. Fifty two percent of participants, predominantly with no formal schooling and primary education levels were unaware of the risk of falling pregnant after BTL. Sixty seven (27.8%) participants, predominantly with primary education or no formal schooling believed that BTL protects against STIs and HIV. Seventy eight (32.4%) of participants would not have BTL due to religious beliefs, however, participants from the same religion gave different answers to the question.

CONCLUSION

The study showed a significant lack of knowledge on key points of BTL. Socio-demographic factors still influence this subject and should not be underestimated during counselling of the patients to reduce potential morbidity and litigation.

Multilevel Perspectives on Female Sterilization in Low-Income Communities in Mumbai, India

Surgical sterilization is the primary method of contraception among low-income women in India. This article, using qualitative analysis of key informant, in-depth interviews, and quantitative analyses, examines the antecedents, process, and outcomes of sterilization for women in a low-income area in Mumbai, India. Family planning policies, socioeconomic factors, and gender roles constrain women's reproductive choices. Procedures for sterilization rarely follow protocol, particularly during pre-procedure counseling and consent. Women who choose sterilization often marry early, begin conceiving soon after marriage, and reach or exceed ideal family size early due to problems in accessing reversible contraceptives. Despite these constraints, this study indicates that from the perspective of women, the decision to undergo sterilization is empowering, as they have fulfilled their reproductive duties and can effectively exercise control over their fertility and sexuality. This empowerment results in little post-sterilization regret, improved emotional health, and improved sexual relationships following sterilization.

Blockade of tubal patency following transcervical administration of polidocanol foam: initial studies in rhesus macaques

OBJECTIVE

To demonstrate the feasibility of polidocanol foam (PF) as a nonsurgical method of female permanent contraception using a nonhuman primate model.

STUDY DESIGN

Four groups of adult female rhesus macaques underwent either transcervical treatment with 5% PF directly into the uterine cavity, treatment with inert (methylcellulose, MF) foam or no treatment followed by removal of the reproductive tract for histologic evaluation. Untreated animals were included in Group 1 (n=3). Group 2 animals (n=4) were treated once with MF. Group 3 (n=7) received a single, and Group 4 (n=5) received multiple monthly treatments with PF; in these 2 groups, baseline tubal patency was assessed either laparoscopically by chromopertubation (CP) or by hysterosalpingography.

RESULTS

Group 1 (untreated) and Group 2 (MF) animals had normal tubal histology. In contrast, Group 3 and 4 females treated with PF showed evidence of tubal damage. In Group 4, bilateral tubal blockade was noted on CP after two (n=2) or three (n=3) treatments. Histologic analysis confirmed complete tubal occlusion (loss of epithelium, fibrosis) in three of these animals, and one showed significant tubal damage localized to the intramural segment. Nontarget (cervix, vagina, endometrium, ovary) reproductive tissues were unaffected. While similar tubal changes were observed after a single treatment (Group 3), endometrial hemorrhage was also noted as an acute change.

CONCLUSION

PF is a promising candidate agent for nonsurgical permanent female contraception. The histologic features of PF occlusion are confined to the intramural portion of the tube.

IMPLICATIONS

This study in rhesus macaques supports further development of transcervical administration of PF as a nonsurgical approach to permanent contraception. A nonsurgical method could reduce risks and costs associated with surgical female sterilization and increase access to permanent contraception.

Currently available devices for female sterilization

Sterilization is now the method of family planning most commonly used in the world. Over the last 150 years, research has evolved in the search for the ideal method of female sterilization. The procedure should ideally have high efficacy, be readily accessible and be personally and culturally acceptable. The method should be simple, quick, easily learned and be able to be performed in an outpatient setting without general anesthesia. The most common and effective method for sterilization has, thus far, been via the laparoscopic route. Hysteroscopic sterilization, however, potentially fulfills many of these ideal criteria, but until recently has remained more of a concept than a reality.

Minilaparotomy female sterilisation in a rural setup: a comparison of two antibiotic regimens

Female sterilisation is the world's most popular contraceptive method. With present advances in contraceptive technology, surgical contraception seems to be the most popular and safest method of fertility control all over the world. The advent of laparoscopy has made the procedure easier in developed countries but not so widely in a developing country like India. Current study was carried out to compare two antibiotic regimens on patients undergoing minilaparotomy tubal ligation and also to see whether local anaesthesia and intravenous sedation/analgesia can be safely practised in a rural setup, where the infrastructure of a tertiary level institution was unavailable. Out of 729 patients, none were referred to a higher centre due to any surgical or anaesthetic problem and a lower rate of infection in the group receiving postoperative combination antibiotic supports the fact that female sterilisation can be performed safely with common antibiotic coverage available in the rural hospitals of developing countries with limited operative facilities.

Informing abortion counseling: an examination of evidence-based practices used in emotional care for other stigmatized and sensitive health issues

OBJECTIVE

Emotional care is an important component of abortion services. Evidence-based counseling for other stigmatized and sensitive health issues may be informative for the improvement of abortion counseling.

METHODS

We searched the literature for practices used in emotional care for stigmatized and sensitive health issues. We made analytic choices for the selection of articles using the "constant comparative method," a grounded theory technique. We selected practices that were effective in supporting coping and improving psychosocial adjustment. Findings were synthesized and analyzed to draw evidence-based implications for abortion counseling.

RESULTS

We uncovered nine practices used in emotional care for stigmatized and sensitive health issues that have been shown to support coping or improve psychological adjustment. The techniques and interventions identified were: self-awareness assessments, peer counseling, decision aids, encouraging active client participation, supporting decision satisfaction, support groups, Internet-based support, ongoing telephone counseling, and public artistic expression.

CONCLUSION

A variety of patient-centered, evidence-based interventions used for other health issues are applicable in emotional care for abortion. Evaluation of these practices in the abortion counseling setting can determine their appropriateness and effectiveness.

PRACTICE IMPLICATIONS

Abortion care providers may be able to integrate additional patient-centered practices to support coping or improve psychological adjustment after abortion.

Association of single nucleotide polymorphisms in glycosylation genes with risk of epithelial ovarian cancer

Studies suggest that underglycosylation of the cell membrane mucin MUC1 may be associated with epithelial ovarian cancer. We identified 26 genes involved in glycosylation and examined 93 single nucleotide polymorphisms (SNP) with a minor allele frequency of > or =0.05 in relation to incident ovarian cancer. Cases were ascertained at the Mayo Clinic, Rochester, MN (n = 396) or a 48-county region in North Carolina (Duke University; n = 534). Ovarian cancer-free controls (n = 1,037) were frequency matched to the cases on age, race, and residence. Subjects were interviewed to obtain data on risk factors and a sample of blood for DNA and genotyped using the Illumina GoldenGate assay. We excluded subjects and individual SNPs with genotype call rates of <90%. Data were analyzed using logistic regression, with adjustment for age and residence. We fitted dominant, log additive, and recessive genetic models. Among Caucasians, nine SNPs in eight genes were associated with risk at P < 0.05 under at least one genetic model before adjusting for multiple testing. A SNP in GALNT1 (rs17647532) was the only one that remained statistically significant after Bonferroni adjustment for multiple testing but was not statistically significant in Hardy-Weinberg equilibrium among controls. Haplotype analyses revealed a global association of GALNT1 with risk (P = 0.038, under a recessive genetic model), which largely reflected a decreased risk of one haplotype (0.10 frequency; odds ratio, 0.07; P = 0.01) compared with the most common haplotype (0.39 frequency). These results suggest that genetic polymorphisms in the glycoslyation process may be novel risk factors for ovarian cancer.

Tubal sterilization: Complications of laparoscopy and minilaparotomy

OBJECTIVE

To evaluate whether intra- and post-operative morbidity varies according to the method used for female sterilization.

STUDY DESIGN

The database of the Swiss obstetric study group was analyzed for a period of 9 years. After the exclusion of cases with extraneous factors that may have influenced the operative outcome, three groups of patients were identified: (1) interval laparoscopic sterilization unrelated to pregnancy (n=20,325); (2) postpartum laparoscopic sterilization (n=2233); (3) postpartum sterilization by minilaparotomy (n=5095). Intra-operative and post-operative complications were compared according to the surgical approach.

RESULTS

A total of 27,653 patients were included in the study. The proportion of major complications was higher in group 3 than in group 1 (0.39% versus 0.10%, odds ratio 4.0, 95% CI 2.15-7.44, p<0.001) but not statistically different between groups 1 (0.10%) and 2 (0.18%). Minor complications were statistically significantly more frequent in group 3 (0.82%) than in group 1 (0.26%) or group 2 (0.27%). There was no case of intra-operative or post-operative death in the study population.

CONCLUSION

When available, a laparoscopic approach should be chosen for female sterilization. After uneventful pregnancy course and delivery, it does not seem justified to delay the endoscopic sterilization to a later time.

Contraceptive options during perimenopause

During the transition years leading to menopause, the possibility of conception persists, although at a lower rate. Contraceptive choices available to perimenopausal women are as varied as those for their younger counterparts, albeit with some limitations related predominantly to coexisting medical conditions rather than the advancing age itself. In this review, different contraceptive choices pertaining to this age group will be discussed, with a focus on evidence-based data.

The effect of tubal ligation scoring and sterilization counseling on the request for tubal reanastomosis

OBJECTIVE

The aim of this study is to emphasize the role of counseling methods that are meant to decrease the request for tubal ligation reversal, such as tubal ligation scoring.

METHOD

This study covers 389 patients who were admitted for tubal sterilization to Cukurova University, Faculty of Medicine, Obstetrics and Gynecology Department, between 1 January 1990 and 31 December 1999. We have used the 'Tubal ligation score' on these 389 patients. Four hundred and seventeen patients who underwent bilateral Pomeroy type tubal ligation during cesarean section without having undergone tubal ligation scoring in the same time interval, were accepted as the control group.

RESULTS

Laparoscopic tubal ligation (with a Yoon ring) was performed on 368 patients who had a score of 6 or higher. Twenty-one patients who got a score of 6 or lower were recounseled and another family planning method was prescribed to them. None of the 368 patients to whom tubal ligation scoring was done previous to laparoscopic tubal ligation returned to our clinic for tubal reanastomosis. Fifteen of the 417 patients (3.6%) in the control group returned to our clinic for tubal reanastomosis.

CONCLUSION

Tubal ligation scoring may decrease the ratio of patients who request a tubal ligation reversal.

SURGICAL TECHNIQUE FOR TUBAL LIGATION IN WHITE‐TAILED DEER (ODOCOILEUS VIRGINIANUS)

Surgical tubal ligation was used to sterilize urban free-ranging white-tailed deer (Odocoileus virginianus) as a methodology of a larger study investigating the influences of intact, sterile females on population dynamics and behavior. Deer were either trapped in clover traps (n = 55) and induced with an i.m. injection of xylazine and tiletamine/zolazepam or induced by a similar protocol by dart (n = 12), then intubated and maintained on isoflurane in oxygen. Over 3 yr, individual female deer (n = 103) were captured in Highland Park, Illinois, with a subset of females sterilized using tubal ligation by ventral laparotomy (n = 63). Other sterilization procedures included tubal transection by ventral (n = 1) or right lateral (n = 2) laparoscopy and ovariohysterectomy by ventral laparotomy (n = 1). One mortality (1/ 67, 1.5%) of a doe with an advanced pregnancy was attributed to a lengthy right lateral laparoscopic surgery that was converted to a right lateral laparotomy. The initial surgical modality of laparoscopy was altered in favor of a ventral laparotomy for simplification of the project and improved surgical access in late-term gravid does. Laparotomy techniques included oviductal ligation and transection (n = 14), application of an oviductal mechanical clip (n = 9), ligation and partial salpingectomy (n = 40), and ovariohysterectomy (n = 1). As of 2 yr poststerilization, no surgical does were observed with fawns, indicating that these procedures provide sterilization with low mortality in urban white-tailed deer.

Transcervical polidocanol as a nonsurgical method of female sterilization: A pilot study

We have studied the effects of transcervically administered polidocanol on uterine and fallopian tube morphology in Wistar rats and Rhesus monkeys. Polidocanol is a synthetic, long-chain fatty acid that is widely used as a sclerosing agent in Europe. The goal of the study was to determine whether polidocanol would safely cause tubal occlusion in an animal model. Twenty female Wistar rats and three female Rhesus monkeys underwent transcervical injection of polidocanol or physiological saline. The animals were followed for 30 days and then a lower laparotomy was performed, with excision of the entire upper reproductive tract. Specimens were subsequently examined for macroscopic and microscopic changes. Only cyclic changes were observed in the control animals of both species. Fifteen macroscopic and 37 microscopic changes were observed in the uterine horns of the 10 rats treated with polidocanol. There was no observed effect in the monkey fallopian tube. These results suggest that species differences that exist between rodents and primates may influence the effects of transcervical polidocanol. Experiments using a primate model are needed as proof of concept prior to human studies of candidate agents for transcervical tubal sterilization.

Canadian Contraception Consensus

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

Management of menstrual problems and contraception in adolescents with mental retardation: a medical, legal, and ethical review with new suggested guidelines

The controversial history of the reproductive rights of the mentally retarded has led to the formulation of laws in the past century designed to protect women from forced sterilization. Significantly, however, in their official ethical guidelines, The American College of Obstetricians and Gynecologists states that "sterilization should not be denied to individuals simply because they also may be vulnerable to coercion" (Int J Gynaecol Obstet 1999; 65:317). Recent advances in medical and surgical methods of contraception and control of menstrual abnormalities have led to a re-evaluation of the management of adolescents with special needs. Physicians, the courts, parents, and caretakers need to be aware of the latest medical and surgical options available, the current applicable laws in each state if such exist, and the ethical guidelines to determine what treatment option is in the best interests of the patient. This review examines the history of the sterilization of the mentally retarded, the latest surgical and pharmacologic treatments available, and the current legal environment and proposes an algorithm to facilitate the management of menstrual hygiene and contraception.

Female sterilization: an update

Female sterilization is the most popular form of birth control in the world. It is performed laparoscopically or through a minilap, depending on the timing (postpartum) and where the patient lives. It is a safe and efficacious procedure with few complications that can be performed under local or general anaesthesia. The techniques presently in use are all adequate and the choice should evolve from a discussion between the doctor and the patient.