4

(_Surgical_Metho
d_)

Sterilization
What Is Sterilization?
Sterilization is a permanent form of birth control that either
prevents a woman from getting pregnant or prevents a man from
releasing sperm. A health care provider must perform the
sterilization procedure, w hich usually involves surgery. These
procedures usually are not reversible.
A sterilization implant is a nonsurgical method for
permanently blocking the fallopian (pronounced fuh-LOH-pee-uhn)
tubes. A health care provider threads a thin tube through the vagina
and into the uterus to place a soft, flexible insert into each fallopian
tube. No incisions are necessary. During the next 3 months, scar
tissue forms around the inserts and blocks the fallopian tubes so that sperm cannot reach an egg. After 3
months, a health care provider conducts tests to ensure that scar tissue has fully blocked the fallopian
tubes. A backup method of contraception is used until the tests show that the tubes are fully blocked.

For Males

Vasectomy
A vasectomy is a form of sterilization of a man. A vasectomy
ensures that no sperm will exit from his penis when he ejaculates
during sexual intercourse.
A vasectomy is usually performed by either a urologist or a gen
eral surgeon. Under local anesthesia, the vas deferens (tubes that carry
sperm from the testicles into the urethra, also known as ductus deferens) from each testicle is severed.
The open ends are then closed off. A vasectomy can be performed in
the clinic and involves making two small openings in the scrotum.
After a vasectomy, the man may feel tenderness or bruising around
the incision site.
A vasectomy does not interfere with the ability of a man to
have an erection or the quantity of his ejaculation fluid. After a man
has a vasectomy, another second form of birth control should be
used until his ejaculatefluid is found to be free from sperm. This
usually takes 10 to 20 ejaculations.
Vasectomy reversals are possible, but they tend to be
expensive and are not guaranteed to be effective. A vasectomy should be considered a permanent form of
birth control.

A vasectomy does not protect a man or his partner from sexually transmitted infections

What happen during a vasectomy?

Your testicles and scrotum are cleaned with an antiseptic and possibly shaved.
You may be given an oral or intravenous (IV) medicine to reduce anxiety and make you sleepy. If you do
take this medicine, you may not remember much about the procedure.
Each vas deferens is located by touch.
A local anesthetic is injected into the area.
Your doctor makes one or two small openings in your scrotum. Through an opening, the two vas
deferens tubes are cut. The two ends of the vas deferens are tied, stitched, or sealed. Electrocautery
may be used to seal the ends with heat. Scar tissue from the surgery helps block the tubes.

The vas deferens is then replaced inside the scrotum and the skin is closed with stitches that dissolve and
do not have to be removed.
The procedure takes about 20 to 30 minutes and can be done in an office or clinic. It may be done by
a family medicine doctor, a urologist, or a general surgeon.
No-scalpel vasectomy is a technique that uses a small clamp with pointed ends. Instead of using a
scalpel to cut the skin, the clamp is poked through the skin of the scrotum and then opened. The
benefits of this procedure include less bleeding, a smaller hole in the skin, and fewer complications. Noscalpel vasectomy is as effective as traditional vasectomy.
In the Vasclip implant procedure, the vas deferens is locked closed with a device called a Vasclip. The
vas deferens is not cut, sutured, or cauterized (sealed by burning), which possibly reduces the potential
for pain and complications. Some studies show that clipping is not as effective as other methods of
sealing off the vas deferens.

Advantages

 Vasectomy is a permanent method of birth control. Once your semen does not contain sperm, you do
not need to worry about using other birth control methods.
Vasectomy is a safer, cheaper procedure that causes fewer complications than tubal ligation in
women.1
Although vasectomy is expensive, it is a one-time cost and is often covered by medical insurance. The
cost of other methods, such as birth control pills or condoms and spermicide, is likely to be greater over
time.

Disadvantages
A vasectomy does not protect against sexually transmitted infections (STIs), including infection with
the human immunodeficiency virus (HIV). Condoms are the most effective method for preventing STIs. To
protect yourself and your partner from STIs, use a condom every time you have sex.

Other considerations
If you are considering a vasectomy, be absolutely certain that you will never want to father a child.

 A vasectomy is not usually recommended for men who are

considering banking sperm in case they decide later to have
children. Discuss other options with your partner and your
health professional.
Surgery to reconnect the vas deferens (vasectomy reversal) is
available. But the reversal procedure is difficult. Sometimes a
doctor can remove sperm from the testicle in men who have
had a vasectomy or a reversal that didn't work. The sperm
can then be used for in vitro fertilization. Both vasectomy
reversal and sperm retrieval can be expensive, may not be
covered by insurance, and may not always work.
Studies looking at whether having a vasectomy increases the
risk of prostate cancer have had mixed results, but there may
be a very small risk. This is something to think about as you
think about the possible risks and benefits of having a
vasectomy.
Some doctors or health insurance plans may require a waiting
period from the time you request a vasectomy and the time the procedure is done. This time allows you
to be certain about your decision.
Researchers are studying other male birth control methods, such as reversible vasectomy or hormonal
methods. Reversible vasectomy involves plugging the vas deferens and then removing the plug when
birth control is no longer wanted. Hormonal methods include pills or injections that the man would use
to prevent sperm production. So far, no new method has been shown to be effective enough, with low
side effects, to be marketed for men.

Side effects of vasectomy

The risk of complications after a vasectomy is very low. Complications may include:
Bleeding under the skin, which may cause swelling or bruising.

 Infection at the site of the incision. In rare instances, an infection develops inside the scrotum.
Sperm leaking from a vas deferens into the tissue around it and forming a small lump (sperm
granuloma). This condition is usually not painful, and it can be treated with rest and pain medicine.
Surgery may be needed to remove the granuloma.
Inflammation of the tubes that move sperm from the testicles (congestive epididymitis).
In rare cases, the vas deferens growing back together (recanalization) so the man becomes fertile
again.

For FeMales

Tubal ligation (tubes tied)

Tubal ligation is also known as "having one's tubes
tied," or having a "tubal." Tubal ligation is for women, and like
a vasectomy, should be considered a permanent form of birth
control.
A tubal ligation is performed under general, regional, or
local anesthesia and can be performed as an outpatient
procedure. The surgeon or OB/GYN uses one of several
procedures in order to a ccess a woman's Fallopian tubes
(which run from the top part of her uterus to each
ovary). A laparoscopy is a procedure in which a small
incision is made just below the navel. A viewing tube
(scope) can then be inserted through this incision to
view and reach the Fallopian tubes. A minilaparotomy
is a small incision in the lower abdomen that is
sometimes used for tubal ligation most commonly in
the postpartum period (after childbirth).
Once the doctor has access to a woman's
Fallopian tubes, they are closed off by using a clip,
cutting and tying, or cauterizing (burning) the tubes.

The procedure takes anywhere from 10 to

45

minutes.
Side effects of a tubal ligation may
infection, bleeding (hemorrhage), and any

include
effects or

complications associated with being under

general anesthesia.
A tubal ligation blocks a woman's Fallopian tubes. As a result
of the procedure, about 1 inch of each tube is blocked
off. An egg can no longer travel down the tube to the
uterus, and sperm cannot make contact with the
egg. Tubal ligation should have no effect on a
woman's menstrual cycle or hormone production.
A woman's tubal ligation can be surgically reversed, usually with more success than in men who
have had a vasectomy. About 1% to 2% of women in the US seek a reversal of tubal ligation.
A tubal ligation does not protect a woman or her partner from sexually transmitted infections
(sexually transmitted diseases, or STDs). It is also not an absolute method of birth control because a small
percentage of women become pregnant after a tubal ligation. Pregnancy after tubal ligation is uncommon
(occurring in less than 2% of women), and the risk of pregnancy appears to be related to age (younger
women have more post-tubal ligation pregnancies) as well as the type of procedure used for the
sterilization.

 Tubal ligation method

There are several different ways of closing the fallopian tubes,
banding them shut or cutting and stitching or
will probably prefer one of these tubal
ligation methods.
A tubal ligation can be done using a:

including clipping or
burning them closed. Your surgeon

A laparoscopy or mini-lap

A laparoscopy or mini-lap. These are done by

inserting a viewing instrument and surgical tools
through two small incisions (laparoscopy) or one
small incision (mini-lap) in the abdomen.
Postpartum tubal ligation This is usually done as
a mini-laparotomy after childbirth. The fallopian
tubes are higher in the abdomen right after pregnancy,
so the
incision is made below the belly button (navel). The
procedure is often done within 24 to 36 hours after
the baby is delivered.
An open tubal ligation (laparotomy) is done
through a larger incision in the abdomen. It may be
recommended if you need abdominal surgery for
other reasons (such as a cesarean section) or have
had pelvic inflammatory disease
(PID), endometriosis, or previous abdominal or
pelvic surgery. These conditions often cause
scarring or sticking together (adhesion) of tissue and organs in the abdomen. Scarring or adhesions can
make one of the other types o f tubal ligation more difficult and risky.

Postpartum tubal ligation

 Laparoscopy is usually done with a general

anesthetic. Laparotomy or mini-laparotomy can be
done using general anesthesia or a regional
anesthetic, also known as an epidural.
Reversing a tubal ligation is possible, but it isn't
highly successful. This is why tubal ligation is
considered a permanent method of birth control.

Usage

Tubal ligation and tubal implants are not 100%

effective at preventing pregnancy.
There is a slight risk of becoming pregnant after
tubal ligation. This happens to about 5 out of
1,000 women after 1 year. After a total of 5 years
following tubal ligation, about 13 out of 1,000
women will have become pregnant.

Pregnancy may occur if:

Reversing a tubal ligation

The tubes grow back together or a new passage

forms (recanalization) that allows an egg to be fertilized by sperm. Your doctor can discuss which
method of ligation is more effective for preventing tubes from growing back together.
The surgery was not done correctly.
You were pregnant at the time of surgery.
Tubal implants
Studies show that over 2 years, fewer than 1 out of 100 women with implants got pregnant.
A tubal implant can be difficult to insert. Some women have to have a repeat procedure before both
tubal implants are properly placed.
Tubal ligation and tubal implants do not change your monthlymenstrual cycle. You will still release an
egg each month (ovulate) and have menstrual periods. You will go through menopause at the same time
that you would have if you hadn't had the surgery. Your sexual desires won't change, although you may

feel more relaxed about having sex because you don't have to worry about becoming
pregnant.

Advantages
Tubal ligation and tubal implants are permanent methods of birth control and allow
you to be sexually active without worrying about becoming pregnant.
Although tubal ligation and tubal implants are expensive, it is a one-time cost.
These procedures are usually covered by medical insurance, and there are no costs
after the surgery is done. The cost of other birth control methods, such as pills or
condoms and spermicide, may be greater over time.

Disadvantages
Tubal ligation and tubal implants do not protect against sexually transmitted
infections (STIs), including infection with the human immunodeficiency virus (HIV). To
help protect yourself and your partner from possible STIs, use a condom every time
you have sex. You must use another form of birth control for 3 months after

Side Effects of Tubal Ligation

Even minimally invasive medical procedures involve risks that patients should
understand before determining treatment. Side effects of tubal ligation are usually mild, but
risks can involve unwanted pregnancies and reaction to surgery.

Review these potential side effects of tubal ligation with your doctor when determining
the best treatment plan for your goals:
Bleed, infection or damage to surrounding tissue during/after surgery
Reactions to anesthesia

Difficulty breaking/pneumonia or heart problems caused by anesthesia

Procedure failure or incomplete tubal closure (risk for becoming pregnant)
If pregnancy occurs, patients have an increased risk of ectopic pregnancy
Injury to surrounding organs or tissues caused by surgical procedure.

While not a direct result of surgical risks, many women experience regret as a side effect of tubal
ligation. While there has been some success in reversing the procedure, tubal ligation is a permanent
treatment to stop pregnancy. If a woman later decides she would like to be pregnant, it may be difficult to
reverse the procedure.

Hysteroscopic sterilization
Hysteroscopic sterilization is a nonsurgical
form of permanent birth control in which a
physician inserts a 4-centimeter (1.6 inch) lon g
metal coil into each one of a woman's two Fallopian
tubes via a scope passed through the cervix into
the uterus (hysteroscope), and from there into the
openings of the Fallopian tubes. Over the next few
months, tissue grows over the coil to form a plug
that prevents fertilized eggs from traveling from
the ovaries to the uterus.
The procedure takes about 30 minutes, can
be done in a doctor's office, and usually requires
only a local anesthetic. During a 3-month period after the coils are inserted, women must use other forms
of birth control until their physician verifies by an imaging test known as a hysterosalpingogram (HSG) that
the Fallopian tubes are completely blocked.
Like tubal ligation, this form of sterilization is permanent (not reversible) and is designed as an
alternative to surgical sterilization which requires general anesthesia and an incision. About 6% of women
who have the procedure develop side effects, mainly due to improper placement of the coils.

This form of sterilization, like other methods of surgical sterilization, does not protect a woman or her
partner from sexually transmitted diseases (STDs).

Safety and Effectiveness:

There are few long-term follow-up data regarding hysteroscopic sterilization. The longest follow-up
study is a case series in which 163 women completed five years follow-up; no adverse device-related
events were reported and 99% were tolerating the device well. Tubal and uterine perforation have been
reported and may be asymptomatic or present as pelvic pain; some perforations are noted when a patient
has post-procedure pregnancy. A review of the FDA's Manufacturer and User Facility Device Experience
database from the introduction of Essure in 2002 to July 2008 did not reveal any major adverse events
(death, bowel injury, or major vascular injury), but there were 2 reports of devices embedding into
abdominal structures and requiring removal after procedures complicated by uterine perforations. For
women with significant medical problems (such as severe cardiac disease) who require permanent
contraception but might otherwise carry considerable surgical risks, Essure has been shown to be a safe
alternative to tubal ligation. Expulsion of one or both micro-inserts has been reported. As an example, in
one large series (n=1630), at up to 42 months of follow-up, the rate of expulsion of one micro-insert was
less than 1%. Reports of persistent pelvic pain and infection are rare. Cornual abscess have been described
in a woman who underwent hysteroscopic sterilization combined with endometrial ablation, although this
is likely a very rare complication. No device related obstetric complications have been reported in women
who have given birth after hysteroscopic sterilization.
Patient satisfaction is high after hysteroscopic sterilization. Outcome measures for this method include
correct placement of device and contraceptive effectiveness. According to the phase II multicenter trial of
effectiveness, no pregnancies were reported in 6015 woman-months of exposure to intercourse following
documented bilateral tubal occlusion. In the two largest Essure case series 10 pregnancies were reported
after approximately 6,000 procedures and 64 pregnancies were reported after approximately 50,000
procedures. Of note, in both series, the number of procedures was estimated by the device distributor and
the pregnancy rate was based on voluntary reporting to the distributor or study author. The most common

reasons for contraceptive failure of hysteroscopic sterilization are: pregnant at the time of placement,
incorrect placement -- unilateral or tubal or uterine perforation; non-compliance with postoperative
instruction -- failure to use contraception until confirmation of occlusion or failure to have follow-up
imaging; misreading of imaging study used to confirm bilateral occlusion.
The rate of successful placement of the Essure permanent birth control device in a large study at the
university medical centers is 92.1%, with a post-Essure pregnancy rate of 0.95%. The majority of
placement failures may be attributed to difficulty visualizing the tubal ostia. Essure hysteroscopic
sterilization appears to provide a minimally invasive, practical and effective method of permanent
sterilization.

Advantages of hysteroscopic sterilization over sterilization via laparoscopy or

laparotomy are:

No incision;
Can be performed in an office setting so it is more cost- and time-effective;
Minimal to no anesthetic requirements;
Less post-operative pain;
Can be performed in women with extensive pelvic adhesions;
Can be performed in women with co-morbidities that preclude laparoscopy or laparotomy.

Disadvantages are:

Need for contraception for 12 weeks post-procedure (until tubal occlusion is confirmed);
Expense of device and imaging study to confirm tubal occlusion;
Higher risk of unilateral tubal occlusion;
Electrical conductivity of micro-insert limits the use of electrocautery during subsequent pelvic
procedures (eg, endometrial ablation);
Need for adequate vaginal surgical training to minimize potential complications.

Hysterectomy

A hysterectomy is the surgical removal

of a woman's uterus and, depending on her
overall health status and the reason for the
operation, perhaps her ovaries as well. No
woman who has had a hysterectomy can
become pregnant; it is an irreversible method
of birth control and absolute sterilization. A
laparoscopic hysterectomy (removal of the
uterus through tiny incisions in the abdomen
through which instruments are placed) is
possible when there are no complications and
no suspicion of cancer. A partial hysterectomy,
which spares the cervix and removes the
upper part of the uterus, is also a common
surgical technique.
If a woman has other chronic medical problems that may be helped by a hysterectomy (such as abnormally excessive
menstrual bleeding, uterine fibroids, uterine growths), than this may be an appropriate procedure for her to consider.
Otherwise, contraception should be considered a secondary benefit and not a sole reason to have the procedure.

Types Of Hysterectomy:
Hysterectomy, in the literal
sense of the word, means
merely removal of the
uterus. However other
organs such as ovaries,
fallopian tubes and the
cervix are very frequently
removed as part of the
surgery.

 Radical hysterectomy: complete removal of the uterus, cervix, upper vagina, and parametrium.
Indicated for cancer. Lymph nodes, ovaries and fallopian tubes are also usually removed in this
situation, such as in Wertheim's
hysterectomy.
Total hysterectomy: complete
removal of the uterus and
cervix, with or without oophorectomy.
Subtotal hysterectomy: removal of the uterus, leaving the cervix in situ.

Comparison Of Hysterectomy Procedures

Risks and Benefits:

Hysterectomy is a major surgical procedure that has risks and benefits, and affects a
woman's hormonal balance and overall health for the rest of her life. Because of this,
hysterectomy is normally recommended as a last resort to remedy certain intractable
uterine/reproductive system conditions. Such conditions include, but are not limited to:
Certain types of reproductive system cancers (uterine, cervical, ovarian, endometrium) or tumors,
including uterine fibroids that do not respond to more conservative treatment options.
Severe and intractable endometriosis (growth of the uterine lining outside the uterine cavity)
and/or adenomyosis (a form of endometriosis, where the uterine lining has grown into and
sometimes through the uterine wall musculature), after pharmaceutical or other surgical options
have been exhausted.
Chronic pelvic pain, after pharmaceutical or other surgical options have been exhausted.
Postpartum to remove either a severe case of placenta praevia (a placenta that has either formed
over or inside the birth canal) or placenta percreta (a placenta that has grown into and through the
wall of the uterus to attach itself to other organs), as well as a last resort in case of
excessive obstetrical haemorrhage.
Several forms of vaginal prolapse.

What are the side effects of a hysterectomy?

Some studies have shown that 10 to 40 percent of women experience a decrease in sexual response or
libido following the operation. This may be related to a testosterone deficiency that can develop if the
ovaries are removed, which in turn reduces the production of androgens. This imbalance can be treated
through hormone therapy, including the use of natural testosterone creams applied vaginally. (Most
hysterectomies spare the ovaries, however, thus sparing ovarian hormonal function.) Since contractions of
the uterus can contribute to orgasm, some women report that they have more difficulty reaching a
satisfying orgasm.
A recent study, however, found no real difference in women's sexual response before and after a
hysterectomy. Some women even reported an improvement! Of course it's not terribly surprising that
women who've long endured excessive bleeding and pain during intercourse as a result of fibroids would
indeed have a better sex life after the operation.

Since the nerves to the bladder pass near the uterus and may be damaged during a hysterectomy,
women who've had the surgery are at higher risk for developing stress incontinence (some urine is
released when exercise, sexual activity, sneezing, or coughing puts pressure on the abdomen). This can
usually be resolved through regular practice of Kegel exercises, simple pelvic muscle exercises that can be
done at home or even driving a car.