A total of 250,136 laparoscopic sterilizations by a single operator

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.

Diagnosis, treatment and follow up of women undergoing conscious pain mapping for chronic pelvic pain: a prospective cohort study

OBJECTIVE

To assess the efficacy of conscious pain mapping in diagnosing and treating chronic pelvic pain (CPP).

DESIGN

Prospective cohort study. Setting Gynaecology Department, UK District General Hospital.

POPULATION

Forty-three women diagnosed with CPP.

METHODS

The cohort was followed up for 18-24 months after diagnosis and treatment based on conscious pain mapping.

MAIN OUTCOME MEASURES

Improvement of pain assessed by using visual analogue scale (VAS) pain scores at 6-month follow up.

RESULTS

Thirty-nine women had successful conscious pain mapping. Pelvic pathology was identified in 18, pelvic congestion in 13 and 8 women had normal pelvic organs. In 35 women (90%), conscious pain mapping identified the cause of pain. Five out of eight women (63%) who were judged to have a normal pelvis had positive findings at pain mapping. VAS scores fell significantly from pre-treatment to post-treatment values at 6-month follow up (P < 0.01). Overall, 26 women (74%) felt that their symptoms had improved after treatment based on findings at pain mapping. However, we concluded that pain mapping only contributed to the diagnosis and treatment in seven women (27%), who may not have received appropriate diagnosis and treatment if they had a laparoscopy under general anaesthetic. Conclusions CONSCIOUS: pain mapping is a useful additional investigation in the management of women with CPP. It can be employed in women with a negative laparoscopy or with visible pathology where the conventional treatment has failed.

Reproductive health and obstetricians and gynecologists

The art of medicine provides a rare opportunity to understand human values and to contribute toward the well-being of one's fellow humans--women in the case of ob-gyn--a contribution that fits in with the mission of the International Federation of Gynaecology Obstetrics (FIGO). Obstetricians and gynecologists should indeed take it upon themselves to improve conditions for women, since the bond and respect between the two is a significant one. It is obstetricians-gynecologists who can provide the much needed technical information to throw light on justifying services that deal with devastating, debilitating, degenerating, and devaluating situations, such as neglected pregnancy, disregard toward cancer detection, and humiliating genital mutilation. Indeed, this can be termed as "terrorism in ob-gyn," neglected by those who should deal with it. Those in ob-gyn and other medical professions clearly witness gender inequality and its ugly aftermath, a degradation of women's reproductive rights. Ob-gyn must look a little beyond just the lucrative practice of the plain science of obstetrics and gynecology and undertake the responsibility to help and protect the health and life of women around the world. A conscientious doctor cannot practice medicine on women's bodies alone, but must also "practice" against several social evils, the prevention of which is crucial to women's health. Obstetricians and gynecologists can utilize their access to policymakers and health "builders" to carry this brief for women's health, and can urge governments to take a second look at women's rights to ensure that they are on par with the accepted norms of human rights, to be protected and propagated.

Laparoscopic tubal sterilization after two or more cesarean sections

STUDY OBJECTIVE

To determine the safety of laparoscopic tubal sterilization in women who have had two or more cesarean sections.

DESIGN

Retrospective study (Canadian Task Force classification III).

SETTING

Private clinic and hospitals.

PATIENTS

Two hundred ten consecutive women.

INTERVENTION

Laparoscopic tubal sterilization.

MEASUREMENTS AND MAIN RESULTS

The procedures were done with no difficulty in all but two women. In addition to the two failures, one woman experienced bladder trauma.

CONCLUSION

Laparoscopic sterilization after several cesarean sections is possible and is associated with low morbidity. Scarring from cesarean sections should not be a contraindication if extra care is taken.

Female sterilization. Evidence

The literature review herein reveals substantial information regarding the safety, efficacy, short-term complications, long-term complications, and noncontraceptive benefits of sterilization. This information should be helpful for providers and potential sterilization candidates. The review also reveals areas where the data are unclear. Points to keep in mind during counseling include the following: The vast majority of women are satisfied with the decision to undergo sterilization. The fact that regret occurs underscores the importance of counseling and adequate individual deliberation before the procedure. In addition to the difficulty and expense associated with sterilization reversal, the woman should thoroughly understand the permanence of the procedure. Although failure is a rare event, it can occur many years after the procedure. Although evidence suggests that hysterectomy rates are higher in sterilized women aged less than 30 to 35 years, it is unlikely that there is a plausible biologic effect of sterilization on hysterectomy risk. An association between tubal sterilization and menstrual cycle changes does not seem valid for changes noted up to 2 years after the procedure. Data are unclear and inconsistent among studies observing women more than 2 years after the procedure. Evidence consistently shows that sterilization is associated with a reduced incidence of ovarian cancer and pelvic inflammatory diseases. Most studies show no effect or improvement of sexual satisfaction after sterilization. Complications during and postprocedure are rare. Sterilization provides no protection against the acquisition of sexually transmitted disease. Patients and their physicians should recognize that sterilized women may need more targeted preventive efforts for health screening and to reduce high-risk behavior than women who use other contraceptive methods. The surgeon's experience and the woman's preferences should govern the ultimate decision regarding the approach and occlusion method. Level II-2 evidence indicates comparable safety between interval laparoscopy and minilaparotomy. Data consistently show that in experienced trained hands, tubal sterilization is safe and highly effective regardless of the approach or occlusive method. Attention to the subtleties of technique seems to be most important in ensuring procedure safety and efficacy. Reanalysis of the CREST data shows that the cumulative failure rate of bipolar coagulation is comparable with the failure rate of unipolar coagulation if a substantial length of tube is adequately coagulated. The data discussed herein can be used to guide management decisions that may increase accessibility and reduce cost of the procedure. Low-resource settings and office settings have maintained an excellent safety record for this procedure through performance of sterilization under local anesthesia. The use of local anesthesia enables a change in procedure location from an inpatient operating room to a free-standing surgical clinic or adequately equipped office. Local anesthesia, with or without preoperative medication, is an excellent option associated with a lower complication risk, reduced cost, and shorter, easier recovery. The surgeon should have specific training in the effective use of local anesthetics, preoperative medications, and management of rare complications in low-resource settings. Little additional research is needed regarding the safety and efficacy of standard sterilization approaches and occlusion methods. There is a need for continued development of nonsurgical methods of sterilization, microlaparoscopic approaches performed in the office setting, and the feasibility and acceptance of service provision by nonspecialist health care providers. The evidence indicates that female sterilization can be performed safely in a variety of resource settings ranging from rural sterilization camps in developing countries to high-tech, resource-rich operating rooms in developed c

Quality of care within the Indian family welfare programme: a review of recent evidence

India's family planning program represents one of the earliest and most ambitious efforts in a developing country to address the issue of high fertility. Despite its more than four decades of existence, little is known concerning how the program is implemented at the field level, especially in relation to the quality of services provided. In this article, empirical evidence on the accessibility and quality of services provided through the Indian family planning program is reviewed and synthesized. The review highlights the serious and systemic shortcomings in quality of care that characterize the Indian program in such areas as restricted method choice, limited information provided to clients, poor technical standards, and low levels of follow-up and continuity of care. The factors constraining higher service quality are subsequently reviewed, and the prospects for improving quality of care within the Indian program are assessed.

Sterilization and its consequences

The purpose of this review is to analyze critically the two techniques of sterilization (bilateral tubal ligation [BTL] and vasectomy) so that a physician may provide informed consent about methods of sterilization. A MEDLINE search and extensive review of published literature dating back to 1966 was undertaken to compare preoperative counseling, operative procedures, postoperative complications, procedure-related costs, psychosocial consequences, and feasibility of reversal between BTL and a vasectomy. Compared with a vasectomy, BTL is 20 times more likely to have major complications, 10 to 37 times more likely to fail, and cost three times as much. Moreover, the procedure-related mortality, although rare, is 12 times higher with sterilization of the woman than of the man. Despite these advantages, 300,000 more BTLs were done in 1987 than vasectomies. In 1987, there were 976,000 sterilizations (65 percent BTLs and 35 percent vasectomies) with an overall cost of $1.8 billion. Over $260 million could have been saved if equal numbers of vasectomies and BTLs had been performed, or more than $800 million if 80 percent had been vasectomies, as was the case in 1971. The safest, most efficacious, and least expensive method of sterilization is vasectomy. For these reasons, physicians should recommend vasectomy when providing counseling on sterilization, despite the popularity of BTL.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader will be able to predict the failure rates and likelihood of successful reversal of tubal ligation and vasectomy; to recall the difference in cost between the two sterilization procedures, and to describe the short-term and long-term complications associated with each of the two methods of sterilization.

Microlaparoscopy under local anesthesia and conscious pain mapping for the diagnosis and management of pelvic pain

Chronic pelvic pain is a complex disorder with multiple etiologies. Recently, the technique of microlaparoscopy under local anesthesia has been applied to chronic pelvic pain. The specialized technique of conscious pain mapping has been developed to aid in the diagnosis of these patients. This paper will review the history and usage of office and microlaparoscopy in general. It will then discuss specific applications for patients with acute or chronic pelvic pain.

Anesthesia for gynecologic laparoscopy

Despite developments in instruments and improvements in surgical and anesthesia techniques, laparoscopy is still associated with complications that may be lethal, including those related to anesthesia. Both anesthesiologist and surgeon must thoroughly understand potential complications of the procedure, including physiologic alterations, principles of anesthetic management and postoperative pain control, and problems related to anesthesia. (J Am Assoc Gynecol Laparosc 6(3):245-258, 1999)

Office microlaparoscopy under local anesthesia

Office laparoscopy under local anesthesia is especially suited to meet the current pressures of quality versus cost in an era of managed care. It is likely that this technique will soon become a major part of the practicing gynecologist's diagnostic operative armamentarium. Advantages of office microlaparoscopy under local anesthesia are realized by the practitioner, the patient, and the managed care provider. Office microlaparoscopy under local anesthesia is a safe, effective, and less costly tool for the evaluation of patients with many different indications. To date, the procedure has been primarily used for patients with infertility, chronic pelvic pain, and tubal ligation. The ease of scheduling, reduced costs, and rapid recovery suggest that it may be the preferred initial procedure for these patients.

Risk factors for laparoscopically confirmed pelvic inflammatory disease: findings from Mumbai (Bombay), India

OBJECTIVES

Sexually transmitted diseases (STDs) are an important cause of pelvic inflammatory disease (PID) but have often not been detected in microbiological studies of Indian women admitted to hospital gynaecology wards or private clinics. In this cross sectional study, women living in the inner city of Mumbai (Bombay) were investigated for socioeconomic, clinical, and microbiological risk factors for PID.

METHODS

Microbiological tests and laparoscopic examination were carried out on 2736 women aged < or = 35 years who came to a health facility with suspected acute salpingitis or infertility or for laparoscopic sterilisation. 86 women with a clinical diagnosis of PID were not referred for laparoscopy although their characteristics are described. Associations between various risk factors and PID status were investigated and logistic regression performed on all factors that remained significant.

RESULTS

Of women with a laparoscopically confirmed evaluation, 26 women had acute and 48 chronic pelvic infection. Independent risk factors for PID were later age at menarche (> or = 14 years), a history of stillbirth and no previous pregnancy, history of tuberculosis, STD, dilatation and curettage or previous laparoscopy, and presence of Gardnerella vaginalis.

CONCLUSIONS

It is concluded that STD related risk factors applied to only a small proportion of PID cases and that other determinants of PID are important, including obstetric complications, invasive surgical procedures such as laparoscopy, and tuberculosis.

Microlaparoscopic tubal ligation under local anesthesia

Local anesthesia to perform laparoscopic tubal ligation is of increased interest due to potential safety and cost benefits. We performed tubal ligation using microlaparoscopic techniques with local anesthesia and continuous intravenous sedation in 16 women desiring sterilization. Operating and recovery times and patient satisfaction were recorded and compared with values for 30 similar women undergoing microlaparoscopic tubal ligation under general anesthesia. Mean +/- SD operating and recovery times for local and general anesthesia were 29.3+/- 8.1 versus 33.6 +/- 11.1 minutes, and 83.9 +/- 59.4 versus 114.5 +/- 69.8 minutes, respectively. Patient satisfaction was high. The potential for cost savings when performed in an outpatient or clinic setting is significant.

Minilaparoscopy in gynecology

During the past several years technological advances have led to the development of small diameter endoscopes (minilaparoscopes) which facilitate the performance of laparoscopy under local anesthesia. Minilaparoscopy promises many advantages and less complications. Today, indications of minilaparoscopy are mainly diagnostic and minimal interventions but technological development and clinical studies might reveal it as a substitute for conventional laparoscopy.

Laparoscopic tubal ligation in a minimally invasive surgical unit under local anesthesia compared to a conventional operating room approach under general anesthesia

OBJECTIVE

This study was done to compare costs, operating and recovery times, safety, and patient acceptance between (a) minimally invasive laparoscopic tubal ligation under sedation and local anesthesia and (b) conventional laparoscopic operating-room-based tubal ligations under general anesthesia.

METHODS

Fourteen women desiring sterilization were randomized between tubal ligation under sedation/local analgesia versus general anesthesia. Procedures were performed by supervised residents previously unfamiliar with the minimally invasive technique. Hospital charges were used as a surrogate for cost. Operating or procedure room times, surgical complications, and recovery times were recorded. Patient acceptance was assessed using satisfaction surveys administered in the recovery room and again 1 week postoperatively.

RESULTS

The cost of minimally invasive tubal ligation was significantly lower than for the conventional technique ($1,615+/-$134 vs $2,820+/-$110, p < 0.001). Surgical times were not different between the two procedures: 40.4+/-15 min for the conventional technique versus 32.9+/-10 min for minimally invasive surgery. However, the total in-room time required in the operating room significantly exceeded that for the procedure room technique (84+/-10 min vs 60+/-2 min, p < 0.05). Likewise, recovery time for the general anesthesia technique was longer (48+/-6 min vs 14+/-7 min, p < 0.03). No complications were encountered with either surgical method. Patient satisfaction for pain, fatigue, and days of missed work was similar between the two groups.

CONCLUSIONS

The use of minimally invasive surgery to perform tubal ligation is advantageous over conventional laparoscopic tubal ligation under general anesthesia with regard to cost and time utilization. The minimally invasive technique appears to be easy to learn, safe, and well tolerated.

Office laparoscopy under local anesthesia for gamete intrafallopian transfer: technique and tolerance

OBJECTIVE

To describe our technique for laparoscopic GIFT under local anesthesia and to evaluate patient tolerance and surgeon satisfaction in 175 consecutive procedures.

DESIGN

Prospective cohort study.

SETTING

University infertility practice.

PATIENT(S)

All GIFT candidates from 1992 to 1996 were offered the procedure. Of 119 patients, 119 chose local anesthesia for 175 procedures and 1 patient elected to have general anesthesia.

INTERVENTION(S)

Transvaginal ultrasound-guided egg retrieval followed by GIFT in the clinic procedure room with a 5-mm laparoscope and two accessory 3-mm trocars with local anesthesia and i.v. sedation.

MAIN OUTCOME MEASURE(S)

Patient tolerance and acceptance, duration of the procedure, amount of analgesics, surgeon satisfaction, and pregnancy rate (PR).

RESULT(S)

The laparoscopic portion lasted an average of 27 minutes, with a mean dose of 1.41 mg of midazolam and 68 micrograms of fentanyl used. Sixty-nine percent of the patients scored "very good," 20% "good," 9% "acceptable," and 2% "poor." All 38 patients undergoing 97 repeat procedures selected local anesthesia again. For women < 40 years of age, clinical PR and delivery rate were 43% and 38%, respectively.

CONCLUSION(S)

Routine office GIFT under local anesthesia is effective and well accepted by the surgeon and is preferred by patients. It offers a significant cost containment and scheduling flexibility in addition to high success rates.

Office microlaparoscopy under local anesthesia for chronic pelvic pain

STUDY OBJECTIVE

To investigate the utility, tolerance, and costs associated with a program of office laparoscopy under local anesthesia using fiberoptic microlaparoscopes (<2 mm) and accessory instrumentation (<2 mm) for the evaluation of patients with chronic pelvic pain (CPP).

DESIGN

Prospective, nonselected cohort study.

SETTING

Office-based free-standing faculty practice at a tertiary care referral center.

PATIENTS

All women with a history of CPP from February to June 1995 who required diagnostic laparoscopy were compared with a cohort of patients undergoing in office diagnostic laparoscopy for the evaluation of infertility during the same period.

INTERVENTIONS

All patients underwent diagnostic office microlaparoscopy under local anesthesia (OLULA) with supplemental intravenous sedation, as well as conscious pain mapping.

MEASUREMENTS AND MAIN RESULTS

A specific questionnaire was developed to follow all aspects of patient acceptance and tolerance of the procedures, and all patients were queried preoperatively, and 30 minutes and 1 week postoperatively. Pain was evaluated with a modification of the McGill pain inventory. A subset of questions evaluated the length of time until usual activities were resumed, anxiety level, and general acceptance of the procedure including set-up, operative time, and recovery time until discharge. Overall, there was a high degree of patient acceptance and satisfaction with OLULA; however, women with CPP experienced greater intraoperative and postoperative pain than those with infertility. Some patients with CPP had a generalized visceral hypersensitivity to pain; all areas of the pelvis and bowel were sensitive, and pain was not completely blocked with local anesthesia. Average procedure length was similar for the two groups. Patients with CPP required greater postoperative analgesia and took longer to return to work. Conscious pain mapping identified a focal source of pain in three patients and generalized visceral hypersensitivity in a majority of patients with CPP. Neither of these were found in patients with infertility. Compared with traditional laparoscopy there was almost an 80% reduction in costs.

CONCLUSION

Office laparoscopy under local anesthesia is safe and effective for the evaluation of patients with CPP and is less expensive than traditional laparoscopy. Although the procedure is better tolerated by women undergoing infertility evaluation, it was well tolerated by both groups. Conscious pain mapping helps identify potential areas of pelvic pain and helps further characterize patients with CPP.

Laparoscopic silastic band sterilization failures

Silastic band laparoscopic sterilization was introduced in the early 1970s as an alternative to unipolar cautery laparoscopy. Banding eliminates burn injury and reduces tubal destruction. However, in comparison with other methods, the success of Silastic banding may depend more on tubal morphology. This case-control study of 70 banding failures and 140 controls matched for age, gravidity, and date of procedure reveals that morphologic abnormalities of pelvic organs (adhesions or tubal thickening) or a history of a disease known to cause such abnormalities (pelvic inflammatory disease) increases the risk of sterilization failure. The risk of failure is further increased if the procedure is performed immediately postpartum or postabortion rather than as an interval procedure.

A comparison of the cost of local versus general anesthesia for laparoscopic sterilization in an operating room setting

OBJECTIVE

To compare the charges between laparoscopic sterilization performed under either local or general anesthesia in a traditional operating room setting with anesthesia personnel in attendance.

DESIGN

A retrospective review of charges.

SETTING

The Regional Medical Center, Memphis, Tennessee.

PATIENTS

Sixty-five women undergoing laparoscopic sterilization, 33 under local and 32 under general anesthesia. Interventions. Laparoscopic sterilization.

MEASUREMENTS AND MAIN RESULTS

Patient demographics, history of pelvic inflammatory disease, and history of previous surgery were similar for both groups. Operating room and recovery room times were shorter for patients whose procedures were performed under local anesthesia. Flat-rate fee schedules reduced the cost savings for cases performed under local anesthesia to $529 dollars per case, with 76% ($402) of the savings related to anesthetic drugs or equipment.

CONCLUSION

Although these savings appear minimal on a per case basis, if 50% of the approximately 210,000 laparoscopic sterilizations performed in the United States each year were performed under local anesthesia, a savings of over $55 million could be achieved (105,000 cases X $529 = $55,545,000). This would result in substantial overall monetary savings to the health care system.

The potential for improved abdominal procedures and approaches for tubal occlusion

Methods of sterilization by the abdominal route are reviewed. There are wide variations in practice which reflect experience, training and resources in different countries. Clip sterilization comes nearest to fulfilling the criteria of a satisfactory method, whether performed by laparoscopy or minilaparotomy. The development of the Cambridge clip seems to offer the prospect of a significant improvement in reliability and safe application while microlaparoscopy and a smaller clip would facilitate the use of local anesthesia and decrease morbidity.

Pelvic inflammatory disease: a clinical syndrome with social causes

Prevalence of pelvic inflammatory disease (PID) reflects community and individual risk factors. Cultural and behavioural factors influence community prevalence of sexually transmitted disease (STD), illegal abortion, puerperal sepsis and contraceptive usage--all of which influence risk of PID. The relative importance of these factors will vary by region. Individual risk factors for the ascent of a lower genital tract infection are still poorly understood but are thought to be behavioural and immunological. Prevention of PID must be undertaken at several levels. At primary level, it requires a reduction in community risk. At secondary level, individual risk can be modified by ensuring diagnosis and treatment of STD before damage of the upper genital tract occurs. More attention to cultural factors should increase the potential for prevention at both levels.

Camp laparoscopic sterilization deaths in Gujarat State, India, 1978-1980

An early experience of camp laparoscopic sterilization in Gujarat State, India, resulted in 22 deaths among 106,500 women undergoing the operation during 1979 and 1980. Increased risk of death was seen when larger numbers of procedures were performed by year or month of year. The least experienced surgeons had the highest case-fatality rate. Improvised settings (i.e., school buildings) exacerbated the risk of death, as did advanced age, and, to a lesser extent, high parity. Errors in clinical judgment were identified in some fatal procedures. A system of health audit of large sterilization programs is needed.