Sterilization
ST1 GP Northern Deanery, UK
E-mail: daniellepeet{at}doctors.org.uk
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Abstract |
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 TOP Abstract The GP curriculum and...The consultationMethodsComplicationsFailure ratesEctopic pregnancy in female...HysterectomyRegretThe alternativesConsentEthical dilemmasReferences |
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Sterilization can be an empowering decision for the right person at the right time in their life. There are good alternatives, such as the intrauterine device, which provide better prevention of pregnancy without the risks associated with surgery. This article discusses the pros and cons of female and male sterilization and provides advice on how best to facilitate informed, patient-centred family planning.
The curriculum statements 10.1: women's health, 10.2: men's health and 11: sexual health require a GP trainee to have skills and knowledge about sterilization
The article also covers competences and essential attitudes for patient-centred care and a holistic approach. It touches on the curriculum for ethics and values based medicine.
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In 2001, 10% of women and 15% of men between the ages of 16 and 49 had undergone surgical procedures to permanently prevent pregnancy. Since the 1960s, getting ‘your tubes tied’ (tubal occlusion) or ‘The Snip’ (vasectomy) were popular procedures for couples who felt their family was complete. The General Practice Research Database in 1999 reported 47 268 tubal occlusions performed alongside 64 422 vasectomies. Ethically it is a unique situation as the doctor is being asked to operate on a healthy human being to modify a natural phenomenon. Given its potential risks, it is a decision not to be taken lightly, especially when several non-surgical, reversible and highly effective alternative contraceptive methods are now routinely available. This article aims to enable you to fully empower patients seeking family planning advice.
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The consultation |
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TOPAbstractThe GP curriculum and...The consultationMethodsComplicationsFailure ratesEctopic pregnancy in female...HysterectomyRegretThe alternativesConsentEthical dilemmasReferences |
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Prior to coming into the consultation room the majority of patients will have thought carefully about their decision. Despite this, a full sexual health, gynaecological and obstetric history alongside relevant focused examination is required with both the patient and their partner present where possible (see Box 1). This allows both the patient and their partner to express any concerns, enables the GP to ascertain their expectations and identifies any factors that would put them at risk of complications. After information sharing the couple may need time to discuss the issues and it is common practice to schedule further consultations prior to formulating a joint management plan which may involve referral to secondary care.
Box 1. Details to be covered in the first consultation
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There are no absolute contraindications to either female or male sterilization provided the patient requests the procedure themselves during time of sound mind and as long as they are not acting under external duress. Details about their decision should be documented prior to referral and counselling about the specific procedures initiated. The counselling and advice should be given in the context of local service provision and resources and be supported by accurate leaflets for the patient to take away.
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Methods |
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TOPAbstractThe GP curriculum and...The consultationMethodsComplicationsFailure ratesEctopic pregnancy in female...HysterectomyRegretThe alternativesConsentEthical dilemmasReferences |
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Complications |
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TOPAbstractThe GP curriculum and...The consultationMethodsComplicationsFailure ratesEctopic pregnancy in female...HysterectomyRegretThe alternativesConsentEthical dilemmasReferences |
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The green top guidelines from Royal College of Obstetricians and Gynaecologists (RCOG) are up-to-date evidence-based recommendations which guide health care professionals with decision making. They are an excellent resource, providing statistics to put complications into perspective when counselling patients about their sterilization procedure. Although taking legal consent is left in the realms of the operating surgeon, beginning the process in primary care promotes informed decision making and rapport.
In female, sterilization serious injuries to bowel, bladder or blood vessel are rare (1 in 2000) but should be communicated to the patient. The green top guidelines specifically recommend the use of Filshie clips which have been shown to provide the lowest rate of conception and less ectopic pregnancies. Sterilization can be done at the time of elective Caesarean Section (CS) if the woman has been counselled thoroughly but due to the increase rate of regret in this group of patients consent should be obtained as far in advance as possible and not any later than 1 week prior to the procedure. Commonly, women can experience shoulder-tip pain and pelvic pain in the perioperative period. To minimize this, surgeons are recommended to use lignocaine subdiaphragmatically and in the mesosalphinx.
Sperm granuloma, a leakage of sperm from the vas, develops in 15–40% of patients undergoing vasectomy and may cause pain in up to 3% of patients in whom it develops. Fortunately, it usually settles in time with pain killers. After vasectomy, two sperm analyses to confirm azoospermia must be undertaken 2–4 weeks apart. These two samples are key in ensuring adequate contraception and many areas will strictly monitor whether patients produce these samples. Research has shown that there is absolutely no increased risk of prostate cancer, testicular cancer or heart disease in men who have had a vasectomy compared to the general population. Equally men should be reassured that vasectomy will not affect their sexual function which is an extremely common concern.
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Failure rates |
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TOPAbstractThe GP curriculum and...The consultationMethodsComplicationsFailure ratesEctopic pregnancy in female...HysterectomyRegretThe alternativesConsentEthical dilemmasReferences |
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The RCOG guidelines quote the conception rate of women post-tubal occlusion is 1 in 200 and for men 1 in 2000 following vasectomy. With female sterilization, conception can happen several years after the procedure and this should be made clear in the counselling. Specifically, women who are sterilized during CS or immediately post-partum or during surgical termination of pregnancy have increased failure rates compared to women who have this done electively. Women sterilized under the age 30 also have more failure rates. Clinical governance activities including regular audit cycles and better training locally have been shown to improve failure rates.
Only trained professionals registered with the fellowship of family planning and reproductive health care can undertake a vasectomy. In doctors with no experience, the training must involve 10 sessions under supervision of 40 procedures before they can operate independently. Similarly, trainees who are performing laparoscopic female sterilization must be adequately supervised as most conceptions after sterilization are due to improper application of the occlusive devices to the wrong structure by inexperienced operators.
Sterilization should be considered a permanent method of contraception and the slim chance of conception at reversal, as well as the financial implications should be stressed during counselling. Success of reversal procedures for tubal occlusion is around 50% and is dependent on the method used and the woman’s age. The majority of patients will require in-vitro fertilisation, which is not provided by the NHS, to facilitate fertilization.
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Ectopic pregnancy in female sterilization |
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TOPAbstractThe GP curriculum and...The consultationMethodsComplicationsFailure ratesEctopic pregnancy in female...HysterectomyRegretThe alternativesConsentEthical dilemmasReferences |
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In all, 75% of pregnancies in women after tubal occlusion are ectopic pregnancies. These women often present atypically making diagnosis difficult meaning that any GP should have a low threshold to initiate investigations in women who have a past history of surgical sterilization. It is imperative to educate women to present early if any abnormal bleeding or pain occurs to be promptly investigated.
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Hysterectomy |
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TOPAbstractThe GP curriculum and...The consultationMethodsComplicationsFailure ratesEctopic pregnancy in female...HysterectomyRegretThe alternativesConsentEthical dilemmasReferences |
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There is no evidence that female sterilization makes any difference to existing menstrual cycles or sexual function. In all, 20% of women will eventually go on to have a hysterectomy after tubal occlusion. No biological reason has been found for this increase rate. Those more likely to undergo hysterectomy after sterilization have pre-existing gynaecological disorders such as fibroids or endometriosis.
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Regret |
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TOPAbstractThe GP curriculum and...The consultationMethodsComplicationsFailure ratesEctopic pregnancy in female...HysterectomyRegretThe alternativesConsentEthical dilemmasReferences |
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Box 2 illustrates those patients at higher risk of regret. Regret is two to four times more likely in women under 30 compared with over 30. There has been a consistent inverse relationship between the woman's age at sterilization and the likelihood of regret in the literature ranging from 20% in women aged 30 and 5.9% in women over 30. In all, 40% of women aged 18–24 years at time of sterilization requested reversal information in the next 14 years, illustrating how caution should be used in this age group. For women under 30, regret decreases with time from the last live birth and is low among women who had no previous births.
| Box 2. Patients who should have extra support during decision making Extra counselling as increased risk of regret
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The alternatives |
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TOPAbstractThe GP curriculum and...The consultationMethodsComplicationsFailure ratesEctopic pregnancy in female...HysterectomyRegretThe alternativesConsentEthical dilemmasReferences |
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There are many alternative contraceptives that have the advantage of being reversible and avoid the need to have an operation and undergo a general anaesthetic. The mirena intra-uterine device is a particularly good alternative since it has a failure rate similar to vasectomy and has the added benefit of making menstruation lighter and more manageable. All alternatives should be discussed and leaflets given (see Table 1).
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Consent |
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TOPAbstractThe GP curriculum and...The consultationMethodsComplicationsFailure ratesEctopic pregnancy in female...HysterectomyRegretThe alternativesConsentEthical dilemmasReferences |
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It should be remembered that the legal responsibility of the procedure lies with the person performing or supervising a trainee even if consent has been taken by another person. All verbal information should be reinforced by use of leaflets—Figs. 1 and 2 show diagrams available from the RCOG.
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Ethical dilemmas |
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TOPAbstractThe GP curriculum and...The consultationMethodsComplicationsFailure ratesEctopic pregnancy in female...HysterectomyRegretThe alternativesConsentEthical dilemmasReferences |
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In any patient interaction, the GMC duties of a doctor should be at the forefront of our mind. In discussion of sterilization, the care of the patient should be our first concern facilitated by listening to the patient and respecting their views. Our personal beliefs should not prejudice patient care. Often patients will make decision that may be the opposite of what we think is ‘best for them’ but treating patients as rational adults sometimes means letting them do things that they may later bitterly regret.
As discussed by Benn et al in the BMJ, cases that hit the media are often young, childless single women who request sterilization. It argues in this article that provided she is well informed of the risks and the increased risk of regret, it is ethical to sterlize young childless adults for non-medical reasons. If it is felt that the patient lacks capacity or is being coerced, guidance from a specialist and possibly a soliciter should be sought.
Key points
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References |
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TOPAbstractThe GP curriculum and...The consultationMethodsComplicationsFailure ratesEctopic pregnancy in female...HysterectomyRegretThe alternativesConsentEthical dilemmasReferences |
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Benn P, et al. Sterilisation of young, competent, and childless adults. BMJ (2005) 350:1323–5.
Curriculum document—Women's Health. RCGP. (2007) Available via www.rcgp-curriculum.org.uk/PDF/curr_10_1_Womens_Health.pdf [date last accessed 30.04.08].
Curtis KM, et al. Regret following female sterilization at a young age: a systematic review. Contraception (2006) 73(2):205–10.[CrossRef][Web of Science][Medline]
FPA—putting sexual health on the agenda. www.fpa.org.uk.
Hillis SD. Higher hysterectomy risk for sterilised than non sterilised women. Obstetrics and Gynaecology (1998) 89:241–6.
Hillis SD. Post sterilisation regret. Obstetrics Gynecology (1999) 93:889–95.[CrossRef][Web of Science][Medline]
Information to patients about male and female sterilisation. RCOG website. Available via www.rcog.org.uk/resources/public/pdf/PI_sterilisation_women_men.pdf [date last accessed 30.04.08].
Jamieson D, et al. The risk of pregnancy after vasectomy. Obstetrics Gynecology (2004) 103:848–50.[Web of Science][Medline]
Male and female sterilisation—evidence based guidelines no 4. RCOG. (2004) Available via www.rcog.org.uk/resources/Public/pdf/sterilisation_full060607.pdf [date last accessed 30.04.08].
Nardin JM, et al. Techniques for the interruption of tubal patency for female sterilisation. Cochrane Database of Systematic Reviews (2002) (Issue 4).
Peterson HB. Sterilisation. Obstetrics Gynecology (2008) 11(1):189–203.
Peterson HB, et al. The risk of ectopic pregnancy after tubal sterilisation. New England Journal of Medicine (1997) 336:762–7.
Roberts H. Good practice in sterilisation. BMJ (2000) 320:662–3.
Royal College of Obstetricians and Gynaecologists. www.rcog.org.uk.
Schmidt JE, et al. Requesting information about and obtaining reversal after tubal sterilisation. Fertility and Sterility (2000) 74:892–8.[CrossRef][Web of Science][Medline]
Women's Health Information. www.womens-health.co.uk.
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