Female sterilization has the advantage of being a single decision which is best thought of as a “permanent decision.” The most common procedures are tubal ligation and Essure® tubal occlusion. In terms of the tubal ligation method, anesthesia, sepsis and hemorrhage can cause mortality, but at a very low rate of 1 to 2 per 70,000. The Essure® tubal occlusion procedure was approved in 2002 and involves placing titanium-dacron coils (micro inserts) into the Fallopian tubes during hysteroscopy. This method involves no surgery and no general anesthesia. Over the course of 3 months, the micro inserts cause tissue to form and block the Fallopian tubes (http://www.essuremd. com/). As many as 6 to 22% of women report subsequent “regret” about their sterilization decision, although only 1% elect to reverse the procedure.52,53 The likelihood of regret is increased in women who have been provided with inadequate counseling, women younger than age 30 years, women who have had postpartum procedures, and women who have experienced a change in their marital status or relationships. Sterilization should be considered a permanent non-reversible option. Although it may be technically possible to reverse some sterilization methods, it is expensive, requires major surgery, and medical insurance does not typically reimburse this expense; success is not guaranteed. The success rate for a subsequent pregnancy is 43 to 86% and assisted reproductive technologies are frequently required. Women seeking this method should be counseled about the availability of other methods, such as OCPs, injectables and IUDs that are effective if used consistently, and more easily reversible. The failure rate for tubal ligation though low, is greater than was once appreciated.54 An average of 18.5 out of 700 women will become pregnant within the seven-year period following sterilization. Onethird of the pregnancies that occur are ectopic. The highest risk of pregnancy is among young women sterilized with bipolar coagulation (54.3/700) or by clip occlusion (52.1/700). Postpartum tubal ligations are less effective than ligations performed at other “interval” periods. The clinician should have a low index of suspicion in ordering a pregnancy test in the evaluation of an individual with relevant symptoms or signs. A pregnant patient with a previous tubal ligation should be assumed to have an ectopic pregnancy unless proven otherwise. Complications Mortality: 1 to 2 deaths/70,000 women compared to a maternal mortality rate of 12.1/70,000 live births. Morbidity Excessive bleeding or hemorrhage, infection, anesthesia-related complications, trauma to abdominal organs, future risk of ectopic pregnancy complications. Sterilization does not cause of lack of libido, loss of femininity, or weight gain. Three primary methods are used: tubal ligation, mechanical occlusion of the Fallopian tubes, and electrocoagulation (the most common and simplest to perform). Mechanical occlusion techniques include clips, rings, or microinserts. Microinserts are relatively new, approved by the FDA in 2002 and inserted transcervically by hysteroscopic visualization. Patients must undergo a hysterosalpingogram three months after surgery and use back-up contraception until occlusion has been confirmed.55 Partner/spousal permission is not required but discussing the decision with the partner may improve the quality of the decision making. Federally funded sterilizations may not be performed on anyone under 21 years of age or incapable of informed consent. There is a 30-day waiting period which extends from the signing of the consent form to the time the procedure is performed.
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