Current Status of Elective Sterilization in the United States

Abstract

The desire for smaller families has brought about a change in obstetrics and gynecology with more and more women asking for contraception and elective sterilization. Surveys conducted in 1970 and 1973 found couples choosing sterilization increased from 16.3% to 23.5%. In 1973, 33.7% of couples with wives over age 30 had chosen sterilization. In 1975, 174 sterilizations were performed for every 1000 births, 105 of these postpartum and 69 laparoscopic. The average physician performing laparoscopic sterilization does 62 per year or a little more than 1 per week. Attempts to perform them in clinics or doctors' offices have not proved satisfactory because of the potential major complications. However, they are commonly performed in the hospital on an outpatient basis. Major complication rate in the U.S. (complication requiring laparotomy) is 3.7/1000 cases and the death rate is 2.5/100,000. Compared with the recurrent annual risks of pills and IUDs, which are in the same range as this 1-time only procedure, it is easy to understand why more than 200,000 chose laparoscopic sterilization in 1975. Increasingly younger women are asking for sterilization but the physician is warned to use his common sense and make sure informed consent is obtained. Both the Association for Voluntary Sterilization and the Planned Parenthood Federation of America have patient instruction materials available. Reversibility is still questionable. Reversal of the most popular U.S. procedure, some form of Pomeroy postpartum sterilization, requires laparotomy with isthmic-ampullary anastomosis and has a 20-40% pregnancy rate and an increased risk of ectopic pregnancy. Electrocoagulation as performed in the U.S. destroys the entire isthmic portion of the tube and may require ampullary implantation for reversal. Relatively few have been performed. Microsurgery holds promise although to date fewer than 50 cases have been reported in the literature. Use of clips and bands may improve reversibility. Comparative techniques are briefly summarized. The most popular in the U.S. is postpartum Pomeroy, the 2nd laparoscopic sterilization with a 2-hole technique. Hysterectomy is popular, especially when other gynecological conditions are present; its use is falling with increase in availability of laparoscopy. Colpotomy, culdoscopy, and fimbriectomy are not greatly popular. Studies have given conflicting results for subsequent gynecologic symptoms after sterilization, 1 in Britian suggesting a higher incidence and 1 showing less. The effect on incidence of ectopic pregnancy has not been shown either, although with increased use of sterilization, figures should begin to be available. The Food and Drug Administration is regulating introduction of new devices in this rapidly growing field.