Surgical sterilization in women has changed dramatically over the past 20 years. The development of laparoscopy and minilaparotomy have made the procedure readily available even in developing countries. In the United States, changing social values and changes in hospital regulations have done as much as technology to account for the tremendous increases in the number of women undergoing sterilization. Improved sterilization procedures have resulted in lower costs for sterilization and lowered morbidity and mortality rates. Hysterectomy for sterilization alone carries unacceptable morbidity and mortality rates. Originally, laparoscopic techniques utilized unipolar cautery. However, bowel burns, a rare but serious complication, were reported, and this led to newer techniques. These techniques, using bands, clips, and bipolar cautery, have gained increasing popularity and have eliminated many of the serious complications of female sterilization. Historically, there has been concern that tubal sterilization by any method produces, in significant numbers of patients, the subsequent gynecologic and psychologic problems called "post-tubal ligation syndrome." A review of earlier literature indicates that many of these studies have serious methodologic problems, including recall bias, inappropriate control groups, failure to elicit prior history of gynecologic or psychologic problems, and failure to account for the use of oral contraceptives or IUDs. More recent large prospective epidemiologic studies that have controlled for prior gynecologic problems and contraceptive usage have failed to show increased incidence of gynecologic sequelae in large numbers of women. However, there are some data to support the concept that in certain individuals, sterilization may result in disruption of ovarian blood or nerve supply, producing gynecologic sequelae. Additional data from these ongoing large-scale studies and others should help to elucidate this problem in the future. Pregnancy after sterilization (even excluding pregnancies present at the time of the procedure) is more common the first year after the procedure with the risk decreasing in subsequent years.(ABSTRACT TRUNCATED AT 400 WORDS)
PIP: Surgical sterilization has changed dramatically over the past 20 years; the development of laparoscopy and minilaparotomy have made the procedure readily available even in developing countries. Improved sterilization procedures have resulted in lower costs for sterilization and lowered morbidity and mortality rates. Historically there has been concern that tubal sterilization by any method produces, in significant numbers of patients, the post-tubal ligation syndrome. More recent studies that have controlled for prior gynecologic problems and contraceptive usage have failed to show increased incidence of gynecologic sequelae in large numbers of women, but there are data to support the concept that in certain individuals, sterilization may result in disruption of ovarian blood or nerve supply, producing gynecologic sequelae. Data from the Collaborative Review of Sterilization (CREST) conducted by the Centers for Disease Control from 1978-81 are analyzed. Overall complication rates were 42.8% for abdominal hysterectomy and 24.5% for the vaginal procedure. Postoperative febrile morbidity was the most common complication but 0.8% of the abdominal hysterectomies and 1.6% of the vaginal hysterectomies required repeat exploratory operations. In another series of 5018 women 0.45% had bleeding complications during unipolar cautery, 0.29% required laparotomy. In a series of 846 silastic ring sterilizations, 3.1% had bleeding complications but only 2 of these required laparotomy and 1.6% had complications related to the ring technique. It was also shown by the CREST data that: 1) the use of an IUD 1 month prior to sterilization did not alter the risk of complications, 2) sterilization and removal of an IUD should not be performed at the same time, and 3) the risk of requiring laparotomy to complete the sterilization procedure is greater if the woman has a history of previous abdominal or pelvic surgery or obesity greater than 12% of ideal body weight. Pregnancy after sterilization is more common the 1st year after the procedure with the risk decreasing in subsequent years. 1st-year failures are about 0.18-0.37/100 women years and then fall off to 0.1--0.12/100 woman years in subsequent years. The ratio of ectopic pregnancy among these pregnancies is higher after laparoscopic cautery techniques. Band and clips may be slightly less effective than the use of electrocoagulation or the Pomeroy technique. Resection is associated with a slightly higer risk of mesosalpingeal bleeding.