Patients should be informed completely about both male and female sterilization options, as well as the risks and benefits of alternative, long-acting, reversible contraceptives. Although some sterilization techniques have greater potential for reversibility than others, any sterilization operation should be viewed as a final contraceptive method by an individual, concluding his or her reproductive potential. Counseling should include factors that lead to sterilization regret, for example marital instability, death of children, etc. The decision to undergo sterilization must be based solely on the desire to have no more children. Utilizing any other factors, for example, to improve a relationship or an economic situation, increases the risk of poststerilization regret. Young age at time of sterilization (age 20–24) is the strongest predictor of sterilization regret. Overall, the incidence of postoperative regret is 6% and 0.2% request a reversal procedure.

Preoperative counseling should also include an explanation of the factors and risks of sterilization failure, including the higher probability of ectopic pregnancy if a gestation occurs, compared to the lower ectopic risk of women who conceive without prior tubal sterilization surgery. According to the US Collaborative Review on Sterilization (CREST) study, the risk of sterilization failure is 1.9%, or 18.5 per 1000 sterilizations. Patients should be reminded that sterilization operations offer no protection against sexually transmitted diseases (STDs), including HIV infection. Potential operative and postoperative complications and the need for their correction should be addressed, such as anesthesia risks, damage to major organs or blood vessels, and infection.

The counseling process should begin in a relaxed environment, well in advance of the operation, so that the patients have ample time to make a well-informed decision. Obtaining consent concurrent with labor or an abortion procedure should be avoided. The stress associated with these events could lead to a higher incidence of poststerilization regret. Physicians should be familiar with federal/state laws and/or insurance requirements that dictate a specific interval between obtaining consent and performing the surgery. Additionally, federal/state regulations may require the use of special consent forms.

Postpartum tubal ligation

According to the CREST study, postpartum partial salpingectomy, performed in the first 48 hours after delivery prior to uterine involution, has the lowest rate of tubal sterilization failure. The Pomeroy, modified Irving, and Uchida tubal ligations performed through small infraumbilical incisions remain the procedures of choice in the immediate postpartum period. The surgery can be performed on the delivery table, often utilizing the same anesthesia. They are simple and rapid with an “acceptable” failure rate well below 1:1000 for the Irving and Uchida methods. Additionally, they do not prolong the postpartum hospital stay. The Pomeroy method, midsegment tubal excision after placement of plain catgut sutures, is the most commonly used technique with a failure rate reported to be about 0.6% at 1 year and a cumulative 10-year pregnancy risk of 7.5%. Although the modified Irving method, where the proximal stump is buried in the myometrium and the distal stump is tied off but not buried in the broad ligament, requires more time than the Pomeroy and has less chance of reversibility, it may be more successful. Only one pregnancy has been documented in the literature. Tubal clips, such as the Filshie, may offer higher chances of reversibility but tubal clips have demonstrated the highest rates of sterilization failure.

Interval sterilization

Interval sterilization refers to any sterilization procedure performed in the nonpuerperal state 6 weeks after delivery or later. The surgical route selected, either a minilaparotomy approach or laparoscopic tubal sterilization, is based on individual patient characteristics, such as patient weight, previous abdominal surgeries or any co-morbid health conditions. In addition, the choice of laparotomy versus laparoscopy depends on the surgeon’s skill and comfort with either procedure. As laparoscopic surgical techniques have advanced and improved over time, the laparoscope has become a popular and important tool in female sterilization.

Technique

There are wide variations in preoperative preparation, the majority of which are not crucial to the success of the operation. Unless there are significant medical problems (diabetes, hypertension, pulmonary conditions, etc.) or excessive obesity (200 lb (90 kg) or over), or both, there is no reason why laparoscopic tubal sterilization cannot be performed as an outpatient, same-day procedure. The operation should take place in an operating room equipped and staffed for general anesthesia, and for exploratory laparotomy, if it proves necessary. Although a cross-match is unnecessary, blood bank accessibility is prudent.

Laparoscopic sterilization can be performed under local anesthesia, but most laparoscopists favor a short-acting general endotracheal anesthesia. It is unnecessary to shave either the abdomen or perineum, but the bladder must be emptied with either in-and-out catheterization just prior to the procedure or an indwelling catheter left in place during the surgery. At laparoscopy, it is often helpful to elevate and rotate the uterus via a transvaginal intrauterine manipulator.