Medical brain notes 42

  Sterilization All available surgical methods of sterilization prevent the union of sperm and egg, either by preventing the passage of sperm into the ejaculate (vasectomy) or by permanently occluding the fallopian tube (tubal ligation and hystero-scopic sterilization).   Although it is possible to reverse some forms of sterilization, the difficulty of doing so, combined with the generally poor rate of success and the financial expense, demands that patients con-sider the procedure permanent.   The physician should counsel couples who are considering surgical sterilization and assist them in determining the best method.   Changes in operative techniques; anesthesia methods; and attitudes of the public, insurance providers, and physi-cians have contributed to the rapid increase in the number of sterilization procedures performed each year. Modern methods of surgical sterilization are less invasive, less ex-pensive, safer, and as effective—if not more effective—than th...

  STERILIZATION OF MEN   About one-third of all surgical sterilization procedures are performed on men. The technique for  vasectomy  varies and includes excision and ligation, electrocautery, and me-chanical or chemical occlusion of the vas deferens. Because vasectomy is performed outside the abdominal cavity, the procedure is safer, more easily performed in most cases, less expensive, and generally more effective than procedures done on women. Vasectomy is also more easily reversed than most female sterilization procedures (Fig. 25.1). The main benefit of tubal ligation over vasectomy is immediate sterility. Minor postoperative complications occur in 5% to 10% of cases, and include bleeding, hematomas, acute and chronic pain, and local skin infections.  Some authors report a greater inci-dence of depression and change in body image after vasec-tomy than after female sterilization. This risk may be minimized with preoperative counseling and education. Concern h...

  STERILIZATION OF WOMEN   Surgical sterilization techniques for women can be per-formed by laparoscopy, hysteroscopy, minilaparotomy, or transvaginally.  Sterilization can be performed as an intervalprocedure, after a spontaneous or elective abortion, or as a post partum procedure at the time of caesarean delivery or following vaginal delivery.     Some nonsurgical methods based on prin-ciples of immunization as well as sclerosing agents are under investigation, but remain experimental although promising. Regardless of the method chosen, patients should be counseled about the various components of the procedure, effectiveness rates, and possible complications. Failure rates of tubal sterilization are roughly comparable with those of the intrauterine contraceptive (IUC). Pregnancy should also be ruled out prior to performing any steriliza-tion procedure.   Laparoscopy   Performed as an outpatient interval procedure, laparo-scopic techniques may be carr...

  REVERSAL OF TUBAL LIGATION   Reversal of tubal ligation by microsurgical techniques is most successful when minimal damage is done to the smallest length of the fallopian tube (e.g., Hulka clip, Filshie clip, or Falope ring)—in some series approaching 50% to 75%. In most cases, however, rates of 25% to 50% are more reasonable expectations, so that many specialists in infertility recommend the use of assisted reproductive technology (e.g., in vitro fertilization) rather than attempts at tubal ligation reversal with the attendant low success rates and increased risk of tubal ectopic pregnancy.   A patient who has undergone tubal reversal and becomes pregnant is presumed to have an ectopic pregnancy until intrauterine pregnancy is established.

  THE DECISION FOR STERILIZATION   The decision for sterilization is an important one and the patient should be fully informed about the procedure and its risks, effectiveness, and long-term implications (Box 25.1). Components of presterilization counseling should include:   ·    Permanent nature of the procedure   ·    Alternative methods available, including male sterilization   ·    Reasons for choosing sterilization   ·    Screening for risk indicators for regret   ·    Details of the procedure, including risks and benefits   ·    The possibility of failure, including ectopic pregnancy   ·    The need to use condoms for protection against sexu-ally transmitted diseases, including HIV   ·    Completion of informed consent process   ·    Local regulations regarding interval from time of con-sent to procedure     Despite careful coun...