In the United States, one third of couples attempting to prevent pregnancy, particularly if the woman is > 30 years old, choose permanent contraception with vasectomy or tubal sterilization.
Sterilization procedures are very effective; pregnancy rates at 1 year are
Vasectomy: 0.15%
Fallopian tube permanent contraception procedures: 0.6%
Sterilization is intended to be and should be assumed to be permanent. If pregnancy is desired, a reversal procedure may be considered, but live birth rates after such procedures are
After vasectomy reversal: About 26% (1)
After tubal sterilization: A small percentage when the tubes are closed and 0% when the tubes are removed (in vitro fertilization may be used successfully)
In women, successful reversal depends on patient age, type of tubal procedure, percentage of tube that remains, amount of scarring in the pelvic area, and fertility test results in the woman and her partner.
Vasectomy
For this procedure, the vasa deferentia are cut, and the cut ends are ligated or fulgurated. Vasectomy can be done in about 20 minutes; a local anesthetic is used. Sterility requires about 20 ejaculations after the operation and should be documented by 2 sperm-free ejaculates, usually obtained 3 months after the operation. A back-up contraceptive method should be used until that time.
Mild discomfort for 2 to 3 days after the procedure is common. Taking nonsteroidal anti-inflammatory drugs (NSAIDs) and not attempting ejaculation are recommended during this period.
Complications of vasectomy include
Hematoma (≤ 5%)
Sperm granulomas (inflammatory responses to sperm leakage)
Spontaneous reanastomosis, which usually occurs shortly after the procedure
The cumulative pregnancy rate is 1.1% at 5 years after vasectomy.
Tubal Sterilization
For tubal sterilization, the fallopian tubes may be
Cut and a segment excised
Closed by ligation, fulguration, or various mechanical devices (plastic bands or rings, spring-loaded clips)
Completely removed
Pregnancy rates are higher with spring-loaded clips than plastic bands. Procedures that use mechanical devices cause less tissue damage and thus may be more reversible than closure by ligation or fulguration. Complete removal of the fallopian tubes is associated with a 40 to 50% reduction in the risk of ovarian cancer (2). Postpartum permanent contraception has lower failure rates than interval procedures.
The following surgical approaches may be used:
Laparoscopy, usually used for internal procedures (after postpartum period)
Minilaparotomy, usually used for postpartum procedures
Tubal ligation can be done during cesarean delivery or 1 to 2 days after vaginal delivery via a small periumbilical incision (minilaparotomy) (3).
Key Points
Tell patients that vasectomy or tubal ligation should be considered permanent, although a reversal procedure can sometimes restore fertility.
For men, the vasa deferentia are cut, then ligated or fulgurated; sterility is confirmed after 2 ejaculations are sperm-free, usually after 3 months.
For women, the fallopian tubes are cut or removed; when cut, then part of the tubes is excised, or the tubes are closed by ligation, fulguration, or mechanical devices such as plastic bands or rings; procedures used include laparoscopy and minilaparotomy.
