Sterilization: Female Fe ale and Male Paula Bednarek, MD Assistant Professor Dept of Obstetrics and Gynecology Oregon Health & Science University

U.S. Contraceptive Use METHOD

WOMEN ((ages g 1515-44))

TUBAL LIGATION

28%

Oral contraceptives

27%

Male condom

21%

VASECTOMY

11%

Injectable

3%

Diapragm

2%

IUD

1% Piccino et al. Fam Plann Perspect. 1998

Contraceptive Efficacy Method

Pregnancies per 1000 women (5--year)) (5

IUD - Mirena® Mirena®

5

VASECTOMY

10

TUBAL LIGATION

13

IUD - ParaGard ParaGard® ®

14

Injectable

32

Oral contraceptives

70

Male condom

90

Periodic abstinence

198 Trussell et al. Fam Plann Perspect. 1999

Tubal Ligation „

Timing „ „ „

„

Post-partum PostPost--abortion Post Interval (unrelated to pregnancy)

Approaches „ „ „ „ „

Mini-laparotomy MiniLaparoscopic Hysteroscopic Transvaginal (colpotomy) Ch i l sclerosing Chemical l i agentt - Quinacrine Q i i

Tubal Ligation „

Anesthesia „ „

General Regional g

„

Voluntary „ „

„

Contraindications „ „ „

Anesthesia Severe adhesions Severe dysmenorrhea

„

Mental disabilities Teenagers Medicaid

Informed consent „ „

Explanation p of p procedure,, includingg anesthesia Benefits „ „

„

Alternatives „ „

„

Highly effective Reduction R d i iin risk i k off ovarian i cancer (OR 0.30.3 0 3-0.9) 0 9) andd PID Other forms of contraception p Vasectomy

Potential risks „ „ „ „

Operative Failure Ectopic p p pregnancy g y No change in menstruation, sexual desire or pleasure

Post--sterilization regret Post „ „

Overall 33-10% Associated with: „ „

„

Not associated with: „ „ „ „ „

„

Young age at time of sterilization Change in marital status R li i Religious b background k d Socioeconomic status Educational level Low parity Postpartum or post post--abortion sterilization

1-2% seek reversal

Mini--laparotomy Mini „

Advantages g „ „ „

Postpartum Local anesthesia Partial salpingectomy „ „

„

Lower failure rate Tissue to pathology

Disadvantages „ „ „

More postpost-op pain Longer recovery Wound healing

„

Methods „ „ „ „ „ „ „ „

Pomeroy Parkland Irving Uchida Madlener Oxford Kroener Aldridge

Pomeroy method

Pomeroy method

L Laparoscopic i T Techniques h i „

Advantages „

„

„

Opportunity to inspect abdomen B l visible Barely i ibl incision i ii scar(s) Rapid p recoveryy

„

Disadvantages „ „ „

Operative risks Anesthesia risks Cost „ „

Equipment Trainingg

Filschie® Filschie ® Clip

Falope® Falope ® Ring

Bipolar cautery

CREST Study „ „ „ „ „

C ll b ti R Collaborative Review i off Sterilization St ili ti Study St d 10,685 women Prospectively P i l enrolled ll d cohort h Followed 88--14 years Outcomes (cumulative over 10 years) „ „

18.5 pregnancies per 1000 procedures 7 3 ectopic 7.3 i pregnancies i per 1000 procedures d

Peterson, et al. Am J Obstet Gynecol. 1996

CREST: Failure by Method Method PP partial salpingectomy

Pregnancies per 1000 procedures 7.5

Unipolar coagulation

7.5

Falope ring

17.7

Interval partial salpingectomy

20.1

Bipolar coagulation

24.8 4.8

Hulka® Hulka ® clips

36.5

All methods

18 5 18.5 Peterson, et al. Am J Obstet Gynecol. 1996

Reasons for Failure „

Surgeon failure Misidentification of structures „ Technical failure „

„

Method failure Recanalization „ Fistula formation „

„

Postpartum vs. Interval Method „ Loss to follow follow--up „

Essure® Essure ® Procedure „

„ „

„

Non--incisional, Non incisional transcervical permanent tubal occlusion Micro--inserts are placed in the fallopian tubes Micro Introduced with standard hysteroscopic approach h with i h tubal b l cannulation l i Can be performed in outpatient setting without general anesthesia

Essure® Essure ® Delivery System

Essure® Essure ® Procedure

3-month Hysterosalpingogram

Vasectomy „

Worldwide „ „ „ „ „

„

5% of married couples N Zealand New Z l d – 23% Netherlands – 11% China – 8% India – 7%

U.S. „

11% (500,000 per year)

Vasectomy „

Performed by Urologists (71.1%) „ Family y practitioners p (15.4%) ( %) „ General surgeons (12.9%) „

„

Safer than tubal ligation Less invasive „ Local anesthesia „

„ „

Cost-effective CostFailure rate