Male and female sterilization

Transcription

1 Current Obstetrics & Gynaecology (2003) 13, 38^ 44 c 2003 Elsevier Science Ltd doi: /cuog available online at on Male and female sterilization Susan Brechin* and Alison Bigrigg w *SubspecialtyTrainee in Sexual and Reproductive Health and w Director of the Sandyford Initiative,The Sandyford Initiative, 6 Sandyford Place, Glasgow,G3 7NB, UK KEYWORDS female sterilization; vasectomy; failure rates; counselling Summary Male and female sterilizationis usedin manycountries worldwide as a permanent method of contraception. Failure rates for female sterilization are a ected by age at sterilization and by the method of tubal occlusion. Laparoscopic sterilization has low complication rates but is unavailable in parts ofthe developing world due to the lack of facilities, equipment and expertise. Less invasive techniques are being developed, such as hysteroscopic tubal occlusion and administration of intrauterine agents. Failure rates for vasectomy are10 timeslower thanthose for female sterilization.complications such as pain, haematoma and granuloma formation may occur.nursing sta and doctors can provide counselling prior to sterilization. Failure rates, irreversibility, complications and alternative methods of contraception should be discussed and documented. Counselling should allow men and women to provide informed consent for sterilization and reduce the incidence of regret and requests for reversal. c 2003 Elsevier Science Ltd INTRODUCTION It is acknowledged that men and women should have an equal partnership in ensuring their reproductive health. A statement from the Platform for Action (1995), developed in Beijing at the Fourth World Congress on Women states: the human rights of women, include their right to have control over, and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence. Equal relationships between men and women in matters of sexual relations and reproduction, including full respect for the integrity of the person, require mutual respect, consent and shared responsibility for sexual behaviour and its consequences. The majority of contraceptives currently available however, have been developed primarily for women. Although male contraceptives are being developed, the only methods currently available are limited to the male condom, vasectomy or withdrawal. Worldwide, 150 million women and 50 million men have opted for sterilization as a permanent method of contraception.compared to vasectomy, female sterilization is 20 times more likely to be associated with major complications, is10 times more likely to fail and is 3 times more expensive. Although vasectomy is safer, more effective and less expensive, female sterilization still accounts for more than two-thirds of sterilization Correspondence to: SB.Tel.: ; Fax: ; suebrechin@hotmail.com or Susan.Brechin@glacomen.scot.nhs.uk procedures performed worldwide. In many developing countries vasectomy is infrequently used as a method of birth control. This is partly due to lack of awareness and advertising campaigns have sought to inform both men and women of this method. When counselling men and women about their contraceptive choices it is important that alternative contraceptive options are discussed and can be provided. Sterilization does not provide any proven positive health bene ts but many other e ective contraceptive methods do and should be considered prior to sterilization. Counselling should allow men and women to make informed choices with regard to their fertility and reproductive health. This review aims to provide a summary of the failure rates, complications and myths surrounding male and female sterilization.we will also explore the information required to provide informed consent, attitudes towards sterilization and psychosexual issues. FEMALE STERILIZATION Female sterilization involves occlusion of the Fallopian tubes, impeding sperm transport to the ampulla of the tube, where fertilization of the ovum occurs. Many methods have been used to block the Fallopian tubes: silicone rubber band application, spring clip application, unipolar or bipolar coagulation of the Fallopian tubes and interval or postpartum partial salpingectomy. One of the most commonly used methods of laparoscopic tubal occlusion is the Filshie clip, which comprises a

2 MALE AND FEMALE STERILIZATION 39 titanium clip with an inner rubber lining that expands as tubal necrosis occurs to maintain pressure on the tube. It is applied to the Fallopian tube,1^2 cm from the cornua, destroying approximately 4 mm of each tube. General anaesthesia The majority of laparoscopic female sterilization procedures are carried out as day cases under general anaesthesia. Sterilization has been carried out, in carefully selected women, under local anaesthesia. The procedure is carried out using a local anaesthetic, lignocaine with adrenaline, that is in ltrated from the skin down to the peritoneum at subumbilical and suprapubic sites. Intravenous sedation is used if required. Local anaesthetic, without adrenaline, is applied to the Fallopian tubes at the end of the procedure.using this method, laparoscopic sterilization without general anaesthesia is well tolerated. Complications of laparoscopy Laparoscopic surgery is associated with a risk of bowel damage (0.4 per 1000) and major vessel damage (0.2 per 1000) necessitating laparotomy. Intraperitoneal carbon dioxide has been used to reduce the risk of injury. However, as many as 39% of injuries occurring during laparoscopic procedures are due to insertion of the trochar. Injuries are therefore just as likely to occur during laparoscopic sterilization as during more complex laparoscopic surgery. In the developing world, due to lack of equipment, facilities and expertise in laparoscopic surgery, most sterilization procedures are carried out using a mini-laparotomy. A Cochrane Database Review has shown that minor morbidity was found to be signi cantly less with laparoscopic sterilization compared to mini-laparotomy. Most studies comparing the two methods however, were of limited power and were unable to demonstrate signi cant di erences in rarer but serious complications. Pain relief after sterilization Pain following sterilization is thought to be a result of tubal ischaemia. A number of randomized controlled trials have investigated post-operative pain relief. Local anaesthetic has been administered in a number of ways: skin in ltration around the wound site; direct application into the Pouch of Douglas; direct injection into the Fallopian tubes; or covering Filshie clips with anaesthetic gel prior to their application to the Fallopian tubes. All methods have been shown to signi cantly reduce the post-operative pain as measured by visual analogue scales. Most women require at least simple oral analgesia post-operatively. Failure of sterilization The US Collaborative Review of Sterilization (CREST), was a multicentre, prospective cohort study of women undergoing sterilization. It has been important in providing information about failure rates, ectopic risk and regret following sterilization procedures. Follow-up of women in the CREST study was good, with 73% of women followed up for 8 years and 57.7% for 14 years. Self-reported pregnancies, occurring after sterilization but ending in uncon rmed spontaneous abortion were, however, excluded from the nal statistical analysis. The lifetime failure rate for female sterilization is 1 in 200. However, failure rates vary with age at sterilization and with the method of tubal occlusion used. Avariety of methods of tubal occlusion were used throughout the CREST study including postpartum partial salpingectomy, bipolar diathermy of tubes (not recommended for use by the Royal College of Obstetricians and Gynaecologists (RCOG)) and spring clip application. The failure rate for tubal occlusion was 1.3% (143 failures). This is higher than the 0.5% rate usually quoted. The 10 year cumulative lifetime-risk of sterilization failure, at all ages and for all types of sterilization, was found to be16.6 per 1000 (95% con dence interval (CI) = 13.5^19.7).The highest probability of failure, 36.5 pregnancies per 1000 procedures, was found with spring clip application. The younger a womanis at the time of sterilization, the greater is her likelihood of sterilization failure. Since the average age of menopause is around 50 years, a woman sterilized at the age of 25 will potentially be fertile for a further 25 years, during which time sterilization may fail. Awoman sterilized at the age of 45 years may only have 5 years in which failure could result in pregnancy. Failure rates were lowest, at 18.5 per 1000, in women over the age of 40. Sterilization may fail during the initial procedure, or later due to re-canalization of a tube. Early failures may also occur as a result of the woman being pregnant at the time of sterilization. A prospective study of 802 consecutive women attending for sterilization identi ed 21 women (2.6%) with a positive pregnancy test on the day of the scheduled sterilization. The majority of these women (81%), had a recent history of amenorrhoea or menstrual irregularity. This highlights the importance of adequate history taking and pregnancy testing, where appropriate, prior to sterilization. It is also the responsibility of the clinician to ensure that contraception has been used up to and even immediately following sterilization. Pregnancies have occurred due to the removal of an intrauterine contraceptive device (IUD) at the time of sterilization. An IUD primarily prevents pregnancy by inhibiting fertilization. However, a secondary contraceptive e ect of the IUD is that it will inhibit implantation. An IUD therefore, should only be removed at the time of sterilization, particularly at mid-cycle, if there has been

3 40 CURRENTOBSTETRICS & GYNAECOLOGY no unprotected intercourse in the preceding 7 days. Otherwise a fertilized ovum beyond the tubal occlusion may implant. There is a lack of evidence looking at failure rates of sterilization procedures carried out at the time of termination of pregnancy, during a Caesarean section or in the immediate postpartum period. Risk of ectopic pregnancy Sterilization failures may result in intrauterine or extrauterine pregnancies. In the CREST study, one-third of all pregnancies occurring following sterilization were ectopic. The risk of ectopic pregnancy, for all methods of tubal occlusion, was 7.3 per1000 procedures. Bipolar diathermy procedures in women under the age of 30 were associated with a 31.9 per 1000 risk of ectopic pregnancy, whilst postpartum partial salpingectomy was associated with a risk of only 1.2 per The clinical presentation and outcomes of women with ectopic pregnancy are the same regardless of whether or not the woman has been previously sterilized. Clinicians may have a higher clinical suspicion of ectopic pregnancy in women presenting with amenorrhoea following sterilization and indeed serial measurement of human chorionic gonadotrophin (hcg) is performed less often in sterilized women with an uncon rmed intrauterine pregnancy than in women who have not been sterilized. This re ects a higher index of suspicion of ectopic pregnancy and quicker recourse to diagnostic laparoscopy in this group. Menstrual disturbance Many myths have surrounded the risk of menstrual abnormalities following sterilization. No increase in the incidence of menstrual irregularity has been shown in women undergoing sterilization compared to women whose husbands had undergone vasectomy. Compared to women who had not been sterilized, women who had been sterilized were found to have: fewer days bleeding (odds ratio (OR) 2.4, 95% CI1.1^5.2), lower volume of blood loss (OR 1.5, 95% CI 1.1^2.0), less dysmenorrhoea (OR 1.3, 95% CI 1.0 ^1.8), more cycle irregularity (OR 1.6, 95% CI 1.1^2.3), but no di erence in cycle length. However, despite this, women who had been sterilized were found to be four times more likely to have a hysterectomy than women whose husbands had had a vasectomy. The 5-year cumulative rate of hysterectomy in sterilized women was 8% while in women whose husbands had been sterilized the 5-year cumulative rate of hysterectomy was 2%. Women opting for sterilization, following many years on the combined oral contraceptive pill, may not welcome the return to ovulatory menstrual cycles and should be warned of the possibility of cycle irregularity, dysmenorrhoea and menorrhagia. Many studies have looked at other symptoms, known as the post-tubal sterilization syndrome, which include premenstrual syndrome, menstrual bleeding and pain. When controlling for variables such as age, parity, obesity, previous contraceptive use, time since sterilization or type of sterilization there appears to be no signi cant changes in symptoms following sterilization. Taking a gynaecological history is essential to allow a method of contraception to be chosen that may perhaps o er an improvement in bleeding patterns as well as e ective contraception. Objectively measured menstrual blood loss can be reduced by up to 90% with the progestogen releasing intrauterine contraceptive system (IUS) and by 40 ^ 46% with the combined oral contraceptive pill. Amenorrhoea can be achieved in over 50% of women using the contraceptive injection medroxyprogesterone acetate. Ovarian carcinoma There is some evidence that tubal occlusion may reduce the risk of developing ovarian cancer in women with the BRCA1 gene mutation. A strong inverse relationship has been suggested between sterilization and ovarian cancer (OR 0.33, 95% CI 0.16 ^ 0.64) although the biological mechanism for this is unclear. New developments in female sterilization Less invasive methods of tubal occlusion have been investigated as potentially safe and e ective methods of sterilization. These have included hysteroscopic insertion of various substances ranging from silicone (Ovabloc) and microcoils (STOP) to micro-inserts (Essure pbc). The STOPdevice is made of a stainless steel inner coil with a dynamic expanding outer coil made from Nitinol and bres of polyethylene terephthalate (PET). The outer coil attaches itself to the Fallopian tubes. The PET bres produce an in ammatory response that extends to cause tubal occlusion. The device is delivered via a 5- French gauge hysteroscope. However, e cacy studies have not been published. A clinical trial using the Essure pbc implant, which dynamically expands to ll the Fallopian tubes, has been performed. These implants were found to be easy to insert hysteroscopically and no pregnancies occurred after 1894 woman-months of use. These methods have the potential to be developed as permanent, less invasive methods of achieving tubal occlusion. Treatment of the Fallopian tubes with Ovabloc silicone intratubal polymer has been used in clinical trials. X-ray images are required following the procedure in order to ensure correct placement. In women followed up for 36 months after the procedure there was a failure rate of 8 per1000 women. Initially this method was felt to possibly

4 MALE AND FEMALE STERILIZATION 41 provide a reversible method of sterilization, however, this has been questioned. Studies carried out in small numbers of women who had had the procedure indicate that cellular and cilliary changes occur within all portions of the Fallopian tubes immediately after insertion and these persist for at least 15 months after removal. Other methods of tubal occlusion have been used in developing countries but are not licensed in the United Kingdom. Recently reviews of the use of quinacrine pellets, inserted into the uterine cavity in the proliferative phase of the menstrual cycle (day 6^14) and repeated the following cycle, have been performed.quinacrine causes brosis of the endothelial lining of the proximal part of the Fallopian tubes. The endometrium is spared because high levels of zinc are present there, which prevent quinacrine ^DNA complexes from forming and hence prevent subsequent brosis.the contraceptive injection, medroxyprogesterone acetate150 mg, is given intramuscularly along with the rst treatment of quinacrine. This is rstly to provide adequate contraception until the method is e ective and secondly to relax tubal musculature to allow quinacrine solution into the tubes. Studies in developing countries have shown failure rates of between1and 2%. This method has been used in over women in Vietnam, India and other regions with no case fatalities reported. Common side e ects included abdominal pain, headache and mild fever and ibuprofen or other antiprostaglandins are used routinely. In developing countries, where mortality from surgical sterilization is high and where major complication rates vary between 2^ 6% this method of quinacrine sterilization, which can be carried out with low cost and by non-medical personnel, may have a place. MALE STERILIZATION (VASECTOMY) Vasectomy is a procedure which aims to occlude or divide the vas deferens (vas), blocking the passage of spermatozoa from the epididymis. Currently, 5% of the world s married couples rely on vasectomy: 13^15% of couples in Australia, Korea and the Netherlands, 17% in the USA and UK, 31% in New Zealand and 41% in Nepal. Traditionally, vasectomy is carried out using either two incisions, either side over the scrotum, or one midline incision.this allows isolation, division or occlusion of the vas deferentia. Division of the vas however, can be combined with thermal luminal fulgaration or proximal fascial interposition without the need for removal of tissue. The no-scalpel technique is now widely used and allows the vasectomy to be performed through a puncture into the scrotum, avoiding a skin incision. Supervised training is required to develop the skill to use this technique. Anaesthesia The majority of vasectomies are performed under local anaesthesia, thus avoiding the need for general anaesthesia. They can be carried out within a hospital or a community setting. General anaesthesia may be required however, when di culties with the procedure are anticipated: e.g. the vas are di cult to palpate, following previous surgery or after a previous failed procedure. Time to achieve azoospermia Adequate contraception needs to be used following the procedure until two consecutive seminal samples are obtained. These should be no less than 4 weeks apart and both clear of sperm. It can take up to 20 ejaculations to clear sperm from the ejaculate and in developing countries where laboratory facilities are unavailable other contraceptive methods can be discontinued after this time. If testing is undertaken 3 and 4 months after vasectomy, 87% of men will be azoospermic. If nonmotile sperm persist in the ejaculate following this a fresh sample should be examined by the regional laboratory to ensure there are no motile sperm. If motile sperm persist following vasectomy the procedure has failed and needs to be repeated. Vasectomy failure rates Early failure rates occur in less than1% of men, but vary with the surgeon s experience and, to a lesser extent, with surgical technique. The overall failure rate is 1 in 2000 for early failures. Failure can also occur due to failure of other contraceptive methods in the initial post-operative period before two clear seminal analysis samples are obtained. If the procedure fails initially and the vas are not completely divided then the seminal sample will continue to contain sperm. Recanalization can occur up to 10 years following the procedure in 1 in 5000 men. The development of anti-sperm antibodies however, may continue to prevent sperm having the capacity to successfully fertilize an ovum. Complications Early complications occur in 1^6% of men and include haematoma, wound infection, sperm granuloma, epididymitis^ orchitis and congestive epididymitis. Wound haematoma and staphylococcal wound infection are the most common side e ects. It has been recognized that most men will develop wound haematoma to a degree, but large problematic haematoma formation is rare. This may be limited by adequate scrotal support and by the avoidance of physical exercise for up to 3^ 4 days following the procedure.

5 42 CURRENTOBSTETRICS & GYNAECOLOGY Chronic testicular pain is a recognized problem following vasectomy and has been found to be the most common late complication. It is a common reason for dissatisfaction. Epididymitis can occur in up to 6% of men following vasectomy and is usually not infective but congestive. Non-steroidal anti-in ammatory drugs (NSAIDs) are useful in the treatment of this post-vasectomy syndrome. Sperm granuloma consist of a mass of degenerating spermatozoa surrounded by macrophages. The epididymal duct is distended and this pressure e ect can lead to pain. Granuloma are a site of sperm phagocytosis and of presentation of spermatozoal autoantigens to the immune system and may be responsible for the anti-sperm antibody production that is seen in up to 60% of patients after vasectomy. Prostatic cancer The cause of prostatic cancer is unknown. A link between vasectomy and prostatic cancer is not proven. The incidence of prostatic cancer in elderly men, aged 65^74 in the UK is 3 per The mortality rate from prostatic cancer in this age group is1in1000. Multivariate risks in men who have had a vasectomy have been studied in relation to cancers, but the results were not signi cant. The relative risk (RR) for prostatic cancer was 1.2 (95% CI 0.6 ^2.7), for lung cancer RR 1.3 (95% CI 0.8 ^ 2.1) and for testicular cancer RR 0.8 (05% CI 0.4 ^1.9). A signi cant increase was noted for pancreatic cancer with a RR1.8 (95% CI1.0 ^3.1).These gures are from a hospital surveillance study provide little support for vasectomy being associated with an increase in cancer risk. Testicular cancer There is no evidence that vasectomy predisposes to testicular cancer. Small studies have reported a higher pickup rate after vasectomy and suggested that their growth may have been accelerated, but this has not been substantiated. A large Danish population cohort study looking at over men who had vasectomy carried out showed that cancer rates for testicular cancer and other cancers were similar to that expected nationally. Cardiovascular disease Studies have failed to provide evidence of an increase in cardiovascular disease following vasectomy.the Atherosclerosis Risk in Communities (ARIC) Cohort study looked at evidence of clinical and subclinical cardiovascular disease in Caucasian men, aged 45^64 years, who were followed up for an average of 9 years. In ammatory and coagulation markers, carotid intimal ^ medial thickness, carotid plaque, peripheral vascular disease, coronary heart disease and stroke were investigated. Of the men studied, 20% had undergone vasectomy, on average 16 years previously. Multivariate analysis showed no associations between vasectomy and any of these markers regardless of time since vasectomy. New methods of male sterilization Techniques such as the no-scalpel method have already been developed and are widely used. These less invasive methods aim to reduce post-operative complications such as haematoma formation and pain, reduce operating time and lead to a shorter recovery time. Other non-invasive techniques are also being developed. Vasbased techniques include: chemical injections, injectable plugs and the use of stryrene maleic anhydride (SMA). The SMA method is the only potentially reversible method being developed. The SMA polymer is injected into the vas, reducing the ph su ciently to kill sperm as they pass through.fertility can be restored quickly by ushing the SMA with dimethyl sulphoxide (DMSO) or more slowly by allowing the SMA to dissolve over a period of 3 months to 5 years depending on the dose administered. Animal and limited human trials have suggested it to be safe. PSYCHOSEXUAL ISSUES OFMALE AND FEMALE STERILIZATION A World Health Organization ( WHO) Task Force has looked at the impact of new hormonal methods of contraception for men on sexual desire, feelings and behaviour. The e ects of hormonal contraception for women on mood, libido and depressive symptoms have also been investigated. However, there is a lack of large-scale, methodologically sound research into the psychological impact of sterilization procedures on men and women. Studies often fail to take into account pre-existing psychosexual morbidity, which may be present prior to sterilization. The number of women reporting psychosexual problems following sterilization is di cult to estimate. Small retrospective studies have suggested that a woman s post-sterilization psychological condition is signi cantly worse if sterilization is carried out immediately following delivery or termination of a pregnancy than following interval sterilization. An estimated 1% of men report psychosexual problems following vasectomy.research from India suggested noalterationinlibidoinmenorwomenfollowingsterilization. Men should be reassured that there is no evidence for any alteration in testosterone production following vasectomy. The quantity, colour and consistency of the ejaculate also remains unchanged.

6 MALE AND FEMALE STERILIZATION 43 REGRETAND REVERSAL Although rare, regret following sterilization does occur and may be due to a number of psychosocial factors. With large numbers of women being sterilized every year worldwide, the problems of regret and the requests for reversal following sterilization are not insigni cant problems. Analysis of CREST data has suggested that regret following female sterilization was more commonly expressed by women who were sterilized under the age of 30. One in ve women under the age of 30 expressed regret up to 14 years following sterilization. Only one in six women over the age of 30 expressed regret. Regret did not appear to be in uenced by mode of delivery or recency of last delivery. Clinicians have expressed reservations regarding requests for sterilization in young women, particularly if nulliparous. However, regret in young women appeared less likely if nulliparous. Analysis of CREST data has suggested that 14.3% of women requested reversal of sterilization up to 14 years after sterilization, but con dence intervals were wide (12.4 ^ 40.4). Women aged 18 ^24 years were 3.5 times more likely to request reversal than women over the age of 30 (adjustedrate ratio 3.5,95% CI 2.8^ 4.4). Studies have tried to identify factors that may identify, in advance, those women most likely to request reversal. Young age at sterilization, new partnerships, pre-existing emotional problems and a history of unreliable contraceptive use increased the likelihood of request for reversal. Successful pregnancy following sterilization reversal may vary with the type of tubal occlusive method used, with the use of microsurgery and with the age of the woman. Successful re-anastomosis following reversal procedures varies between 30 and 70%, but the successful pregnancy rates are lower. Regret following vasectomy is also rare, but requests for reversal do occur and are also related to new partnerships.with microsurgical techniques, using operating microscopes, the vas deferens can be rejoined accurately in most men (vasovasotomy). A third of men however, will be found to have no sperm in the vas during examination of seminal uid intra-operatively. In these cases a vasoepididymostomy, joining of the vas to a single epididymal tubule, may be required to bypass the suspected blockage. The successful reversal and subsequent pregnancy rates decrease with time since vasectomy. Up to 3 years after vasectomy, reversal will result in 97% of men regaining spermatozoa in the ejaculate and up to 76% will achieve a pregnancy. With a reversal 15 or more years later, only 71% of men will have evidence of sperm in the ejaculate and only 30% will achieve a pregnancy. Overall, approximately 50% of couples achieve a pregnancy following vasectomy reversal. The average time from vasectomy reversal to pregnancy is 12 months. However, it is not until 24 months following reversal that the highest percentage of pregnancies is achieved. Prior to reversal of any sterilization procedure it is important to assess the reproductive function of both partners, luteal phase progestogen to assess ovulation and seminal analysis to assess sperm function. COUNSELLING AND INFORMED CONSENT Most of these speci c issues relating to male and female sterilization should be discussed during counselling. It is important to discuss the failure rate for female sterilization (1 in 200) and for vasectomy (1 in 2000). Speci cally, the risk of ectopic pregnancy following procedure failure should be outlined. The irreversibility of the procedure and probable success of reversal procedures should be discussed. Women should be informed of the operative risk of laparoscopy and the need for laparotomy. Men should be informed of local complications such as haematoma, wound infection, epididymitis^ orchitis, sperm granuloma and chronic pain. It is also prudent to discuss the myths associated with sterilization such as menstrual disturbances, libido, cancer, regret and change in circumstance. Many men and women fear unintended pregnancy far more than sexually transmitted infection and they should be made aware of the need to practice safe sex if entering a new sexual relationship. Alternative contraceptive methods should also be discussed and documented prior to the decision being made for sterilization. Facilities should be available for the provision of these alternative methods of contraception. Detailed protocols can be used and incorporated into counselling, which ensures adequate information is provided to all patients. Counselling need not be provided only by medical sta. Family Planning nurses often provide counselling for men prior to vasectomy, particularly in Family Planning settings. With their expertise in Family Planning and contraceptive methods, the counselling role of the nurse could be expanded to provide counselling prior to female sterilization. Counselling should aim to provide men and women with enough information to allow them to be able to give informed consent. Medical litigation often occurs following sterilization procedures and this can be minimized by providing adequate written and verbal information before obtaining and documenting informed consent. Men and women who are unable to give informed consent for sterilization cannot be forced to undergo this procedure by their family or by health care professionals. In the UK, Government legislation allows adults with mental incapacity to have a guardian legally appointed,

7 44 CURRENTOBSTETRICS & GYNAECOLOGY to ensure health and medical care. However, even these legally appointed guardians cannot give consent for sterilization procedures. Worldwide, controversies have arisen from reports of alleged forced sterilization. In India Sterilization Camps have been described and in Thailand Sterilization Fairs. These camps have been described as innovative ways of providing safe, permanent methods of birth control to men and women who may not otherwise have had the opportunity to use sterilization to limit family size. However, they have also been described as an infringement of human rights, when food supplies and wages have been dependent on consent to sterilization. ATTITUDES TO STERILIZATION Worldwide, the number of female sterilization procedures far outweigh vasectomies. In many developing countries vasectomy is particularly rare. However, vasectomy, because it can be carried out under local anaesthesia, may provide an acceptable option for many couples where hormonal contraceptives and alternative longer-acting contraceptives are unavailable. Vasectomy may also be an acceptable option in places where female sterilization procedures cannot be carried out under safe conditions. Advertising campaigns have been introduced in many countries aimed especially at men. Increasing awareness of vasectomy by media campaigns in developing countries has been shown to increase the uptake of this method. TRAINING Adequate supervision of training is required for clinicians undertaking sterilization procedures. In the UK, doctors performing laparoscopy independently should be competent to Level 2 in the RCOG Minimal Access Surgery Report. They should be capable of two laparoscopic methods of tubal occlusion and have achieved this level of competency during their training. No UK national standards for training in vasectomy have been established and neither the Royal College of Surgeons or the Joint Committee for HigherTraining in Urology mentions vasectomy in their curricula. At present, the RCOG suggests that 10 supervised procedures should be performed before practising independently. The RCOG and the Faculty of Family Planning and Reproductive Health Care (FFPRHC) are developing a Special Skills Module in Male Sterilization. Training in vasectomy is available to medical personnel working in the developing world. CONCLUSIONS Sterilization procedures continue to provide an e ective and permanent method of contraception for many couples worldwide when other methods are either unacceptable or unavailable. Adequate counselling and the provision of information regarding alternative options will allow men and women to continue to make informed choices regarding their fertility. PRACTICE POINTS * Menandwomenshouldbemadeawareofallofthe contraceptive options available and their noncontraceptive bene ts before opting for sterilization. * Adequate contraception must be used until the procedure has been successfully performed to avoid unintended pregnancy. * Informed consent can only be given once all the bene ts and risks of the procedure have been fully discussed. * Adequate training of medical personnel is essential in order to ensure sterilization procedures are performed safely and e ectively. FURTHER READING Anonymous Male and Female Sterilisation. RCOG Guideline Summary No. 4. London: RCOG,1999. CoadySA,SharrteAR,ZhengZJ,EvansGW,HeissG.Vasectomy,in- ammation, atherosclerosis and long term follow up for cardiovascular diseases: no associations in the atherosclerosis risk in communities study. J Urol 2002; 167: 204 ^207. FiddesTM,Williams HW, Herbison GP. Evaluation of post-operative analgesia following laparoscopic application of Filshie clips. Br J Obstet Gynaecol1996; 3: 1143^1147. Hillis SD, Marchbanks PA, Tylor LR, Peterson HB. Post-sterilization regret: ndings of the US Collaborative Review of Sterilization. Obstet Gynecol1999; 93: 889^895. Moller H, Knudsen LB, Lynge E. Risk of testicular cancer after vasectomy: cohort study over 73,000 men. Br Med J 1994; 309: 295^299. Peterson HB, Jeng G, Folger SG et al.the risk of menstrual abnormalities after tubal sterilisation. US Collaborative Review of Sterilization Working Group. N Engl J Med 2000; 343:1681^1687. Peterson HB, Xia Z, Hughes JM et al.the risk of pregnancy after tubal sterilization: Findings from the US Collaborative Review of Sterilization. Am J Obstet Gynecol1996;174: 1161^1170. Peterson HB, Xia Z, Hughes JM et al.the riskof ectopic pregnancy after tubal sterilization.us Collaborative Review of SterilizationWorking Group. N Engl J Med1997; 336: 762^767. Rosenberg L, Palmer JR, Zauber AG et al.the relation of vasectomy to the risk of cancer. Am J Epidemiol1994; 140: 431^ 438. Schmidt JE, Hillis SD, Marchbanks PA, Jeng G, Peterson HB. Requesting information about and obtaining reversal after tubal sterilization: ndings from the US Collaborative Review of Sterilization. Fertil Steril 2000;74: 892^898.