Sterilising a woman

Pregnancy occurs if an egg is fertilised by a sperm. This occurs when both partners produce eggs and sperms optimally, the fallopian tubes are patent, and sexual intercourse occurs about the time an egg is released by the ovary. It takes only one sperm to fertilise an egg. When the egg is prevented from meeting the sperm by cutting, blocking or sealing the fallopian tubes, fertilisation cannot occur. The types of female sterilisation are tubal occlusion by abdominal surgery and hysteroscopic sterilisation. Considerations Female sterilisation should always be viewed as permanent. Reversal is sometimes possible with microsurgery to re-join the blocked or severed fallopian tubes. However, a successful operation does not mean that it is possible to have a pregnancy. A discussion with the doctor about the family circumstances and wishes is vital in making the correct decision. The doctor will provide the relevant information and counselling before carrying out the procedure. As a vasectomy is simpler and has fewer risks, it should always be considered first before female sterilisation. Sterilisation should only be considered if there is an absolute certainty that any, or any more, children are not wanted. If there is any doubt, another contraceptive method should be used until one is absolutely sure. If either partner has any doubts or concerns, it is advisable to use some other reversible contraceptive method, which is almost or just as effective as sterilisation. Decisions about sterilisation should never be made during or after a major event in one's life, eg after childbirth or miscarriage. A discussion with one's spouse or partner is helpful prior to a decision on sterilisation. It would be preferable if the couple both agree to the procedure, although it is not a legal requirement to have the spouse's or partner's consent. Female sterilisation can be performed at any age. However, doctors are generally reluctant to carry out sterilisation in individuals below 30 years of age, especially if they do not have children, because there is an increased likelihood of regret. Advantages Female sterilisation is effective, with more than 99 per cent chance of preventing pregnancy. Abdominal surgical methods - blockage of (tubal occlusion) or removal of the fallopian tubes (salpingectomy) - is effective immediately. Hysteroscopic sterilisation is effective after about three months, with 96 per cent of sterilised women reported to have blocked tubes by then. The reproductive organs will continue to function just like before the procedure. The ovaries will continue to produce eggs, which will be absorbed by the body. Female hormone production is unaffected as the hormones are released directly into the blood. Sterilisation does not affect sex drive or the enjoyment of sex. In fact, many women report improved sexual enjoyment, as there is no longer the fear of an unplanned pregnancy. Intercourse can take place any time it is comfortable to do so, but doctors usually advise use of contraceptives until the first period after the procedure. Disadvantages Female sterilisation methods require procedures that are more complex than male sterilisation. Like all other procedures, there is a very small risk of bleeding, infection or damage to internal organs. The abdominal surgical sterilisation methods can fail, ie the fallopian tubes may re-join on their own. This occurs rarely, with only about one in 200 women getting pregnant in their lifetime after a female sterilisation procedure. Should pregnancy occur after female sterilisation, there is an increased likelihood that it will be sited outside the uterus (ectopic pregnancy), usually the fallopian tubes. An ectopic pregnancy is a potentially life threatening condition. As such, a pregnancy test should be done if a period is missed after such a procedure. If it is positive, an ultrasound scan is needed to check whether the pregnancy is sited inside or outside the uterus. Immediate medical attention must be sought if the period is delayed or light or there is sudden or unusual lower abdominal pain. There is a small likelihood of pregnancy after hysteroscopic sterilisation. Other possible problems include post-operative pain (about eight in 10 women), bleeding after the procedure, and incorrect insertion of the implants (about two in 100 women). Female sterilisation does not provide protection against sexually transmitted infections (STIs). If one is at increased risk of STIs - one has multiple sexual partners or one is unsure about one's sexual partner - then it is advisable to use condoms even after sterilisation. Tubal occlusion Here, the fallopian tubes are cut, sealed or blocked in an operation, thereby preventing the egg and sperm from meeting. The tubes can be approached by a laparoscopy or a mini-laparotomy. The former is a common approach. It involves a small incision under the umbilicus and the insertion of a flexible tube with a lens (laparoscope) that is connected to a light source. This enables the gynaecologist to see the fallopian tubes. Another incision is made in the abdominal wall between the umbilicus and pubic bone to insert an instrument to carry out the procedure. The latter involves making a small incision in the lower abdomen between the navel and pubic bone. This permits access to the fallopian tubes by the gynaecologist. The choice of approach is influenced by factors such as obesity, previous abdominal or pelvic surgery, and previous infections of the uterus and fallopian tubes (pelvic inflammatory disease). There are different ways of tubal occlusion: application of plastic or titanium clamps or silicone rings to the fallopian tubes, tying (ligation) or cutting off a segment of the tubes (excision) or sealing (cauterisation or diathermy). A laparoscopy or mini-laparotomy is usually carried out under general anaesthesia, although it is sometimes done under local anaesthesia. If tubal occlusion has been unsuccessful or the fallopian tubes are diseased, the tubes may be partially or totally removed (salpingectomy). Both laparoscopy and mini-laparotomy require hospitalisation for a day or two. Hysteroscopic sterilisation This method is not widely available. It involves insertion of a hysteroscope - a narrow tube with a telescope at one end - into the uterus through the vagina and cervix. After identifying the opening of each fallopian tube into the uterus, a metallic piece is then inserted into each tube with a guide wire. The scar tissue that forms around the implant eventually blocks off the tubes. There is no need to make any surgical incisions with hysteroscopic sterilisation (which is carried out under local anaesthesia), and sometimes, a sedative is given as well. Other contraceptive methods have to be used until there is confirmation by imaging that both fallopian tubes are blocked. The imaging techniques are hysterosalpingram, which is an x-ray done after a dye is injected through the cervix to confirm that the tubes are blocked, or hysterosalpingo-contrast-sonography, which is an ultrasound carried out after dye is injected into the tubes. Recovery There should be information provided about what to expect and what to do after discharge, including a telephone contact if there are any problems or questions. It is not uncommon to feel some discomfort for a few days post-operatively. Returning to work is possible after a few days, depending on one's general health. Most doctors advise avoiding heavy lifting for about a week. There may be slight vaginal bleeding and some abdominal discomfort after the procedure. The discomfort should be relieved with the painkillers prescribed. If the pain or bleeding worsens, medical attention should be sought. Stitches for the abdominal incisions may or may not need to be removed. Dissolvable sutures would disappear by itself. An appointment will be given if the stitches need to be removed. The wound dressing can usually be removed a day after the procedure. Doctors usually advise usage of another contraceptive method until the first period after tubal occlusion; and for about three months after hysteroscopic sterilisation following imaging confirmation that the tubes have been blocked off. Condoms should be used if there is need for protection against STIs. Sex can be resumed as soon as it is comfortable to do so. Reversal Female sterilisation can be reversed, but it is a very difficult process involving removal of the blocked part of the tubes and re-joining the ends. There is no guarantee of pregnancy after a sterilisation reversal. The success rates of reversal depend on factors like age and the method used in the original operation. For example, if the tubes were clamped rather than tied, successful reversal is more likely. The current success rate of reversal is between 50 to 60 per cent, ie 50 to 60 of 100 women who have a reversal will have patency of their tubes restored. This should not be equated to pregnancy rates. There are no long-term effects from male and female sterilisation. A vasectomy should be considered first as it is simpler and there are fewer risks. Although both operations are minor procedures, the decision to have either operation has far reaching implications and it should be made only after the couple is sure that they do not want any more children or never want any children. Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with. For further information, e-mail starhealth@thestar.com.my

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