Changing status of tubal sterilization

Changing status of tubal sterilization An evaluation

of fourteen

LAURA

E.

EDWARDS,

ERICK

Y.

HAKANSON,

years’

experience

M.D. M.D.

St. Paul, Minnesota A series of 1,150 female patients undergoing tubal sterilization over a 14 year period were evaluated for trends as to age, parity, and indications as well as to safety and surgical risk. The tubal ligation to delivery ratio decreased front 1:17.4 in 1958 to 1967 to 1:4.3 in 1970 to 1971. Average parity decreased from 7.8 to 4.2. In the first 10 year period, only 3.5 per cent were less than 25 years of age, while 31.7 per cent were in this age group in 1971. This change reflects an evolution in podicy which does not discriminate on the basis of age, parity, or marital status.The total morbidity and complication rate was 10.0 per cent. Serious complications occurred in 2.6 per cent of the patients. The over-all failure rate was 0.17 per cent.

0 R I G I N A L L Y used for strict medical and eugenic indications, tubal sterilization is rapidly becoming simply another method of contraception requested by a greater number of patients each year. Nationwide surveys in the United States in 1963 and 1966 showed the incidence of puerperal sterilization to be 3.2 and 2.9 per cent, respectively.‘, 2 Several independent large series reported similar incidences.3-5 In 1962 to 1963, some institutions reported a tubal ligation to delivery ratio of 1: 17.9 to 1: 13.ga6 Bopp and Hall’ demonstrated a rise in the tubal ligation to delivery ratio from I:421 in 1959 to I :5.1 in 1967 to 1968 in their institution. This trend is apparently worldwide since other countries are reporting increased utilization of tubal sterilization.8~9 Although tubal sterilization has always been available in our hospital, it was only From the Department of Obstetrics and Gynecology, St. Paul-Ramsey Hospital. Received for publication July 11, 1972. f;;;pted for publication August 31, Reprint requests: Dr. Laura E. Edwards, Dept. of Ob./Gyn., St. Paul-Ramsey Hospital, St. Paul, Minnesota 55101.

since 1958 that it became an integral part of the family planning program. The following review of our experience was undertaken to evaluate the trends at our hospital over the past 14 years. Clinical material Frequency. From January, 1958, to December, 1971, 1,150 tubal sterilization procedures were performed. Table I indicates that the 5.8 p’er cent incidence of tubal Jigations in the first 10 years was considerably above the nationwide reported incidence of 2.9 to 3.2 per cent. Thirty-nine per cent (451 cases) of the tubal Iigations have been performed in the last two years. In 1970 to 1971, the ratio of tubal ligations to deliveries was 1:4.3 or 23.2 per cent. Fig. 1 compares the incidence of total tubal ligations and postpartum tubal ligations. The slight decreasein 1971 from 1970 is a reflection of the increasing number of vasectomies performed in the Vasectomy Clinic which was begun in July, 1970, as a joint project of the Obstetric, Gynecology, and Urology Departments. Forty vasectomies were performed in 1970, 289 in 1971. and an estimated 500 in 1972.

348

Edwards

and

Febnmy Am. J. Obstet.

Hakanson

Table 1. Incidence of tubal ligations 1 No. 1 TL/DEL 1 1958-1967 1968-1969 1970-1971 Total TL/DEL

500 199 451 1,150 = tubal

ligation/delivery

1: 1: 17.4 9.2 1: 4.3 1:ll.l

% 5.8 10.8 23.2 8.9

I. 1973 Gynecol.

od. Cornual resection was used in 4.6 pet cent (53 cases) and the Irving method in 3.3 per cent (38 cases). In addition, the Uchida method was used in 5 instances (0.4 per cent) and the Aldridge “reversible” procedure in one case (less than 0.1 per cent).

ratio.

Results

Indications. Indications for the procedure were divided into eugenic, medical, and voluntary (Table II). Eugenic indications averaged 4.9 per cent. Thirty-nine patients or 69.6 per cent of these were done becauseof mental retardation. Voluntary indications comprised 66.2 per cent in the first 10 year period and 73.6 per cent in the last 2 year period. Age and number of living children. Table III indicates the average age and number of living children. The average number of living children has decreased from 6.5 in the first 10 year period to 3.6 in 1971. Fig. 2 demonstrates the change in parity during the years of the study. The average age for the entire series was 30.9 with a small decrease in the last 4 years. Changing age patterns are demonstrated in Table IV. Whereas in the first 10 year period only 3.5 per cent were lessthan 25 years of age, 3 1.7 per cent were in this age group in 1971. Concomitantly, the group over 30 years old has dropped from 69.0 per cent in the first 10 year period to 36.1 per cent in 1971. These figures reflect our present policy of not discriminating on the basisof age, parity, or marital status against any patients requesting voluntary sterilization. Operative procedures. A total of 73.5 per cent (845 patients) of our tubal sterilizations were accomplished at the time of delivery at cesarean section, in the early puerperium. or at the time of therapeutic abortion. In the remaining 26.5 per cent (305 patients), the procedure was performed at intervals of time more than 6 weeks post partum (Table V) . Table VI indicates the surgical techniques used in our series. Of these, 91.6 per cent were Pomeroy procedures with all of the vaginal sterilizations performed by this meth-

In this series of 1,150 procedures, no deaths occurred. One hundred and fifteen patients or 10.0 per cent had a morbid and/ or complicated course. Whereas postpartum or interval abdominal sterilization had morbidity and complication rates of 7.8 and 7.4 per cent, respectively, interval vaginal opoperation had a 11.5 per cent rate; and sterilizations done at cesarean section, 21.4 per cent. Sterilizations done at the time of therapeutic abortion had a total complication rate of 25 per cent when done abdominally and 33.3 per cent when done vaginally (Table VII) . Morbidity and complications are detailed in Table VIII. Minor morbidity and complications occurred in 85 patients. One-day fever was diagnosed when the temperature rose to a minimum of 100.4O F. subsequentto the first 24 hours post partum. Standard morbidity is defined as temperature to at least 100.4° F. on any 2 days including the first 24 hours. Thirty patients or 2.6 per cent had serious complications (Table IX) . One third of the serious complications occurred in patients undergoing sterilization at time of cesarean section or therapeutic abortion although these categories represented only 8.1 per cent of the total. There were two known failures in our series, representing a failure rate of one in 575 or 0.17 per cent. One failure occurred 20 months after a vaginal tubal procedure. The other was a high-risk, para 3-O-8-2 patient with a history of repeated pulmonary emboli and thrombophlebitis. She would accept only a “reversible” procedure and was the only patient on whom an Aldridge operation was performed. She was admitted several months later with an incomplete abortion. On repeat operation, the fimbriated ends of the tubes were found free in

Volume Number

115 3

Tubal

30%-

sterilization

349

1

25%-

7

Total Tubal Ligations

20% I

15%

I

I

I

-_

/ /

Post

Partum

Tubal Ligations

OL

1 19581967

Fig. 1. Tubal partum tubal

1968I

sterilization/delivery ligations.

1969 I ratio.

Solid

19701 line,

total

1941 tubal

ligations.

Dashed

post-

line,

b PARA 7 or MORE

90 80 70

) PARA 4, 5 or 6 60 50 40 30

) PARA 3 or LESS

20 10 0 YEAR

N

26

17

32 Fig.

Table II.

Indications

E,ugenic Medical Obstetric Psychiatric Medical Voluntary

40

49

2. Parity

33

41

of women

39 sterilized

70

83

89

110

at St. Paul-Ramsey

249 202

1080 TOTAL

Hospital

for sterilization

No.

70

17 152 46 28 78 331

3.4 30.4 9.2 5.6 15.6 66.2

19684969 NO. I 19 62 17 :i 118

1970-1971 % 9.5 31.1 8.5 8.0 14.6 59.6

NO.

17 28 56 332

I

% 4.4 22.0 3.8 6.2

12.0 73.6

350

Edwards

and

Table III. Age

February 1, 1973 Am. .J. Obstet. Gynecol.

Hakanson

and

number

of living children 1 1968-1970 11971

1 1958-1967 Age

(Range 13-48) Living children

30.2 4.5

32.1 6.5

29.7 3.6

Table IV. Age range

Ages < 25 Yeats 25-30 Years > 30 Years

13.1 41.4 45.5

2;:: 69.0

Table V. Time

31.7 32.2 36.1

No.

1 %

of operation

1 Post pattum At cesarean Hysterotomy abortion

19.7 38.1 52.2

section or therapeutic

Interval Total

752 70

65.4 6.1

23 305

2.0 26.5

1,150

100.0

Table VI. Type of operation

Tvfie

1

No.

I

%

Pomeroy

Abdominal Vaginal

Combined Irving

Uchida Cornual Aldridge Total

753 293 7 38 5 53

1 1,150

91.6 3.3 0.4 4.6

0.1 100.0

the abdominal cavity, and a Pomeroy procedure was done. Since the majority of procedures were done in the last 4 years, a longer follow-up is continuing in order to achieve a more accurate failure rate. Because of costs, it is of importance to consider the length of hospitalization. Seventy-one per cent were discharged on or before the third postoperative day (fourth postpartum day) in the case of postpartum tubal sterilizations. The majority of vaginal tubal sterilization patients were discharged on the second postoperative day.

Comment In the young patient who has completed her family but still has 20 to 30 years of I potential fertility, the use of oral contraceptives and intrauterine devices is impractical, expensive, and potentially hazardous. For such women, we believe that the preferred method is permanent sterilization, It has therefore become our policy not to discriminate on the basis of age, parity, or marita1 status against any patient undergoing the procedure. This policy is reflected in the increasing incidence of tubal sterilization in our hospital. The current tubal ligation to delivery ratio is 1:4.3 (1970 to 1971) which is higher than any reported to date in the English literature. The first quarter of 1972, this was 1:3.6. Sixty-nine per cent of our patients were 30 years of age and over in the first 10 years of the study. Recent reports give figures ranging from 60 to 77 per cent in this age range.4 In 1971, a marked decline to 36 per cent in this age range occurred with a further drop to 28 per cent in the first quarter of 1972. This was paralleled by an increase in the under 25 years old category to. 3 1.7 per cent. Indications did not change as much as expected during the study period. Obstetric indications decreased from 9.2 per cent in the first 10 year period to 3.8 per cent in the latest time period. Medical indications decreased slightly, and the voluntary category rose slightly in the last 2 year period. This surprisingIy small change undoubtedly reflects the fact that all sterilizations done primarily for parity were classified as voluntary in all three periods. Thus, even though minor medical reasons may have been used more often in the earlier period to justify sterilization, there still was a large majority that were voluntary. However, this decision by the patient and the physician occurred at a significantly higher age and parity in the earlier years of the study. The relatively large number in the eugenic category is a reffection of the fact that some patients were referred to this hospital strictly for sterilization.

Volume Number

115 3

Table

Tubal

VII.

Number

with

morbidity

sterilization

351

and complications

Puerperal

No.

of patients

Total uatients No morbidity or complications Morbidity or complications Serious complications

Table VIII.

With cesarean section

Postpartum abdominal

Interual Abdominal

Therapeutic Vaginal

abortion

Abdominal

Vaginal

752

70

27

278

a

15

693 (92.2%)

.55 (78.6%)

15 (92.6%)

246 (88.5%)

2 (75%)

10 (66.7%)

59 (7.8%) 9 ji.296j

15 (21.4%) 5 (7.1%)

2 (7.4%) 0 (0%)

;; i;b$" . 0

:! (25%) 0 (0%)

5 (33.3%) 5 (33.3%)

Type of morbidity and complications Puerperal Postpartum abdominal

Tme

With cesarean section

lnterval Abdominal

Therapeutic

abortion

Vaginal

Abdominal

Vaginal

Total

Morbidity

One-day fever Standard Urinary tract infection Infections Pelvic Wound Respiratory

5 4 20

? i 2

0 1 0

0 1 15

0 0 1

0 0 0

7 8 3a

10 8 4

2 4 1

0 1 0

10 1 1

0 0 0

1 0

L’2 14 6

21 1

31 0 1 i

0 0 0 0 0

0 1 2 1 5

0I 0 0 0 0

50 0 1 0 0

; 2 6 a 6

Hematologic

Anemia Transfusion needed Intra-abdominal bleeding Hema toma Thromboembolic Other

Table IX. Number

t 1

with and type of serious morbidity and complications Puerperal Postpartum abdominal

Pduic

With cesarean section

Interval

Therapeutic

Abdominal

Vaginal

Abdominal

abortion Vaginal

Total

infection

Endometritis with temperature over 100.4” for more than 48 hours Pelvic cellulitis, abscess Wound infection requiring readmission Sickle cell crisis

2 0

0 0

0 0

1 4

0 0

0 0

3 4

1 0

0 0

0 0

I 1

0 0

0 0

L’ I

1 1 1

4 0 0

0 0 0

0 1 2

0 0 0

5 0 1

9 2 4

2 2

1 0

0 0

1 0

0 0

0 0

4 "

Hemorrhage

Transfusion required Laparotomy required Hematoma, large Thromboembolic

Phlebitis requiring anticoagulants Pulmonarv embolus

352

Edwards

and

Fcbnmy Am. J. Obstrt.

Hakanson

The method preferred has been the Pomeroy method by either the abdominal or vaginal route. Because of the reported increased failure rate of the Pomeroy method when utilized at the time of cesarean section by Prystowsky and Eastman, cornual resection and, in the last 3 years, the Irving method have been employed in these cases. Although there have been no known failures with the cornual method in our series, Garb’slo massive review of sterilization failures indicated an unacceptably high failure rate of nearly 3.0 per cent. There is but one reported failure, an abdominal pregnancy 13 years later, following sterilization by the Irving method. I1 Hence, the failure rate of this method is less than I : 1,000. With the recent report by Husbands, Pritchard, and Pritchardzl of only one failure in 400 Pomeroy tubal sterilizations done at the time of cesarean section, the earlier concept may not be supportable. However, the patients in their series have not had long-term followup, and failures occurring as late as 13 years have been reported.” A majority of the postpartum sterilization procedures were accomplished in the immediate puerperium. However, it has long been our custom to do postpartum tubal ligations on the third or fourth day post partum or even later when necessary, and there has been no particular danger in doing so. This is in keeping with conclusions reached from 3 bacterial and histologic studies on postpartum oviducts at the time of tubal sterilization published in 1970.13-*5

REFERENCES

Starr, S., and Kosasky, H. J.: AM. J. OBSTET. G~~~~0~.88:944.1964. Boutware, T. M., and Ensor, H. C.: Obstet. Gynecol. 29: 147, 1967. Hibbard, L.: Calif. Med. 107: 504, 1967. McElin, T. W., Buckingham, J. C., and Johnson, R. E.: Axs. J. OBSTET. GYNECOL. 97: 479, 1967. I5 . Haynes, D. M., and Wolfe, W. M.: AM. J, OBSTET. GYNECOL. 106: 1044, 1970. 6. Radman. H. M.: South. Med. J. 58: 953, 1965.

1, 1973 Gynecol.

Mabray and associates,lG in reporting 734 patients undergoing tubal sterilization in a charity hospital service, similarly concluded that the procedure was associated with a low morbidity rate which did not rise appreciably as time post partum increased. Our experience confirms the experience of Sogolow’? and others showing increased morbidity and complication rates when vaginal sterilization is done at the time of therapeutic abortion when gestational age is greater than 8 weeks. We, therefore, feel that the procedure is contraindicated under these circumstances. Sterilizations are not done in the immediate puerperal period when there are medical or obstetric contraindications, for example, premature rupture of the membranes with the attendant high incidence of endometritis, severe pre-eclampsia, heart disease, or diabetes out of control. Like all surgical procedures, tubal sterilization is accompanied by a definite risk of morbidity and complications. However, the order of this risk suggests that it is acceptable in terms of the risk of repeat pregnancy, even when the procedure is done for voluntary reasons. Since a perfect contraceptive is not yet available, sterilization must, of necessity, play a major role in achieving the individual goals of family planning and the general goals of population control. In this context, we feel that it is our responsibility to make this procedure as easily available as possible to all women without prejudice.

7. 8. 9. 10. 11. 12.

Bopp, J. R., and Hall, D. G.: Obstet. Gynecol. 35: 760, 1970. Buckle, A. E. R., and Loung, K. C.: J. Biosoc. Sci. 3: 289, 1971. Lu, T., and Chun, D.: J. Obstet. Gynaecol. Br. Commonw. 74: 875. 1967. Garb, A. E.: Obstet.’ Gynecol. Survey 12: 291, 1957. Hornstein, S., and Kay, S. A.: Obstet. Gynecol. 13: 337, 1959. Husbands, M. W., Pritchard, J. A., and Pritchard, S. A.: AM. J. OBSTET. GYNECOL. 107: 966, 1970.

Volume Number

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13. Spore, W. W., Moskal, P. A., Nakumura, R. M., and Mishell, D. R.: AM. J. OBSTET. GYNECOL. 107: 572, 1970. 14. Rubin, A., and Czernobilsky, B.: Obstet. Gynecol. 36: 199, 1970. 15. Mustafa. M. A., and Pinkerton, J. H. M.:

Tubal

sterilization

353

J. Ohstet. Gynecol. Br. Commonw. 77: 171. 1970. 16. Mabray, C. R., Makinak, L. R., and Flowers, C. E.: Obstet. Gynecol. 36: 204, 1970. 17. Sogolow, S. R.: Obstet. Gynecol. 38: 888, 1972.