Sterilizations is the most often used method of contraception worldwide. Female sterilization is used as a contraceptive method by a fifth of married women, totaling 225 million users. In comparison, vasectomy is less common and underutilized in most countries, with around 33 million users globally in 2007. In the UK, female sterilization has become less common in the last decade. Increased use of long-acting reversible contraception (LARC) methods is thought to be the cause of this trend. The number of vasectomies performed in the UK has decreased from 2000 to 2010.
Counselling for male and female sterilization
Ideally, sterilization therapy should include a discussion of alternative contraception techniques. Counselling should be sufficient to secure valid consent for the procedure. Before proceeding with the treatment and anaesthesia, a medical history should be obtained to ensure suitability. Women should provide a menstrual and gynaecological history. Eligibility for the surgery should be determined by a medical history and examination.
Vasectomy
What is it?
Vasectomy, often known as male sterilization, is a permanent technique of contraception that divides or occludes the vas deferens, preventing sperm from passing through the epididymis.
Procedure techniques
Vasectomy is typically performed under local anaesthesia as an outpatient procedure. There are two options for opening the scrotum: a single midline incision or bilateral incisions. The fascial sheath is opened longitudinally to split the vas. The procedure involves removing a segment of the vas and occluding its distal and proximal ends using various ways.
Sutures are typically used to ligate the vas, however other procedures such as cautery or unipolar diathermy can also be utilized.
The fascial sheath can be inserted between the severed ends of the vas. This is the fascial sheath can be inserted between the severed ends of the vas. This is known as fascial interposition (FI). This procedure seems to lessen vasectomy failure. Although there is limited randomized trial evidence, a Cochrane study found that occluding the lumen with cautery and FI is the most effective approach.
Irrigation of the vas lumen does not lower failure rates and using clips to occlude the vas is no longer suggested because to their high failure rate. Histological investigation of removed vas is not always necessary.
The no-scalpel vasectomy (NSV), a minimally invasive method developed in China in the 1970s, has been linked to lower rates of haematoma and infection. A tiny clamp is used to hold the vas through the scrotal skin, followed by a sharp-tipped dissecting forceps to pierce (rather than incise) the scrotum. Although MIV procedures are preferred for isolating the vas deferens, traditional scalpel approaches are still widely used by surgeons worldwide.
Advantages
Vasectomy is a safe and effective method of permanent contraception that typically does not require general anaesthesia.
Disdvantages
Vasectomy, unlike other methods of contraception, involves a surgical operation with potential hazards. It takes time to take effect and can be difficult to reverse.
Complications
Men may feel soreness, bruising, and swelling in the first several days after surgery. The following are examples of recognized complications:
- Scrotal haematoma affects 1-2% of men but can be treated with scrotal support and analgesics.
- Up to 1% of men experience wound infections, which may require hospitalization for drainage.
- Epididymitis is a blockage of the epididymis that causes pressure and pain in under 6% of men.
- Sperm granuloma are small lumps induced by a local inflammatory response. They can occur due to sperm leakage from the severed ends of the vas (risk 2 in 100). This generally resolves but may necessitate surgical excision.
- Chronic testicular or scrotal pain (after vasectomy syndrome): The reported incidence ranges from 12-52%, but these statistics are primarily based on questionnaires and may be an overestimate. Pain may be caused by scar tissue around nerve fibres or granuloma formation in the epididymis and vas deferens. The pain is normally not severe but might linger for a long time.
Stopping contraception: PVSA
Before using vasectomy for contraception, males should undergo post-vasectomy semen analysis (PVSA). This confirms the procedure’s success or identifies early failure. There is no consensus on the appropriate quantity and timing of PVSA samples, which are often determined locally. Traditionally, men provided two sperm samples, one month apart. If both indicated no sperm, ‘clearing’ was provided, and the vasectomy may be used for contraception. Recent guidance suggests using a single azoospermia specimen to confirm clearance. In a tiny percentage of males (1.4-2.5%), non-motile sperm remains following vasectomy. ‘Special clearance’ may be granted in certain instances. In nations without PVSA, it is advisable to remove sperm through ejaculation before discontinuing other forms of contraception.
Efficacy
Following clearance, the lifetime failure rate of vasectomy is one in 2000. Early or operational failure can be caused by technical failure (e.g., wrong structure occluded) or early recanalization of the vein. PVSA specimens do not produce azoospermia, indicating the presence of this condition. The early failure rate should be below 1%. Late failures are caused by recanalization of the vas deferens and can occur years after the surgery. Late failures refer to the existence of sperm in ejaculates after confirming sterility (azoospermia or special clearance at PVSA).
Reversal of vasectomy
During preoperative counselling, men should understand that vasectomy is a permanent procedure. Reversal requests are often made when starting a new relationship. Vasectomy reversal success rates range from 50-80%. Successful reversal and subsequent pregnancy rates fall over time following vasectomy, with significantly lower rates after 10 years. The drop in success over time may be due to antisperm antibodies, but their importance is unknown. In the UK, reversing a vasectomy is not typically covered by the NHS, resulting in additional costs for the patient.
Vasectomy and disease
There is no indication that vasectomy raises the risk of heart disease or prostate cancer. Some reports indicate an increased risk of testicular cancer. While some findings suggest an increased incidence of prostate cancer, this is thought to be a non-causative link.
Female sterilization
What is it?
Occluding the fallopian tubes can prevent sperm from reaching the ampulla and fertilizing the ovum.
Techniques
Abdominal approach
This is the most common way to access and occlude the fallopian tubes globally. In the UK and USA, laparoscopic female sterilization is routinely performed. However, in poor countries, due to limited equipment, facilities, and competence in laparoscopic surgery, mini-laparotomies are sometimes used for sterilization. Occlusion can be achieved through:
Mechanical Methods: Each tube is secured with a clip or ring. The Filshie clip, a titanium clip, is commonly used in the UK. It is put at right angles to the isthmic part of the tube, 1-2 cm from the cornu, completely encasing the tube.
Surgical procedures: include tying the tube with absorbable sutures and removing a section. Tying and ligating tubes may have a lower failure rate than mechanical procedures for postpartum sterilization, despite not being employed as a first-line method in most developed nations. The evidence, however, is mixed.
Bipolar diathermy: is not recommended as the primary approach of tubal occlusion due to its difficulty in reversing and increased risk of ectopic pregnancy.
Transcervical approach
Hysteroscopic sterilization: Since 2009, NICE in the UK has supported the mechanical occlusion of tubes using tubal cannulation and intrafallopian implants. Essure®, the only licenced product, is approved by both the EU and US FDA.
Essure® is a flexible micro-insert that causes scar development, occluding the fallopian tubes. The inflammatory reaction in the tubes peaks at 3 weeks; therefore, women should use supplemental contraception for 3 months after the treatment. Tubal occlusion is confirmed with a transvaginal ultrasound scan, X-ray, or hysterosalpingogram.
Chemical occlusion: involves blindly inserting quinacrine hydrochloride pellets into the uterine cavity, which has been practiced in impoverished nations for years. Quinacrine can cause endothelial fibrosis in the proximal Fallopian tubes. This procedure is not licenced in the United Kingdom.
Quinacrine sterilization was banned in India in 1998 due to concerns about teratogenicity and carcinogenicity. However, research from Vietnam and Chile, where the method has been used for many years, has shown an acceptable safety profile.
Anaesthesia and analgesia
In the UK, most laparoscopic female sterilizations are performed on a single day under general anaesthesia. To alleviate post-procedure pain caused by tubal ischaemia, apply local anaesthetic to the tubes before or after occlusion. Local anaesthesia (with or without sedation) is a viable alternative to general anaesthesia. Hysteroscopic sterilization can be performed with local anaesthesia, intravenous sedation, or without anaesthesia altogether.
Advantages
- Method independent of sexual intercourse.
- High effectiveness
- Permanent
- Non-hormonal approach.
Disadvantages
- Surgical technique is required, with attendant hazards.
- Frequently requires a general anaesthetic.
- Permanent
- Provides no STI protection.
- Increased chance of ectopic pregnancy if fails.
Complications of laparoscopy
Efficacy
The lifetime failure rate of tubal occlusion is estimated at one in 200. The Filshie clip experiences 2-3 failures per 1000 procedures during a 10-year period. At a two-year follow-up, Essure® is predicted to be 99.8% effective at preventing pregnancy.
Contraception
A pregnancy test should be performed on the day of surgery, but it does not detect luteal-phase pregnancy. Women should utilize a reliable method of contraception for the month leading up to the sterilization and until their next menstrual period.
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