lnt J Gynaccol O bstet 16: 488- 492, 19 79
Sterilization of Women: Benefits vs Risks Jacques E. Rioux Department of Gy necology and Obstetrics, Faculty of Medicine, Laval University, Laval University Hospital, Ste-Foy, Quebec, Canada
ABSTRACT
Rioux J E (Dept of Gynecology and Obstetrics, Faculty of Medicine, Laval University, Laval University Hospital, Ste-Foy, Quebec, Canada). Sterilization of women: benefits vs risks. lntj Gynaecol Obstet 16: 488- 492, 1979 Voluntary sterilization is the birth control method most widely practiced throughout the world. The last ten years have witnessed great improvements in techniques and perfection of innovations, explaining the important role that it now plays in the regulation of fertility. Different methods are examined and it is concluded that hysterectomy is the best, if medically indicated; conventional laparotomy is not justified unless required by concomitant intraabdominal pathology; minilaparotomy is mostly suitable postpartum; colpotomy is better left to specialists; laparoscopy is ideal for nonpregnant patients; culdoscopy is a relic of the past; and hysteroscopy, although still experimental, may be the way of the future. Th e advantages ofvoluntary sterilization lie in its remarkable and immediate efficiency, freedom from ongoing motivation, the convenience of a one-time operation, the absence of side effects and the reduction of total costs. Its disadvantages are the complexity of aTry surgical intervention for a woman, its indisputable finality, its uncertain legality and the risks inherent in aTry operation. Hysterectomy and tubal ligation are practically never fatal, so this argument does not influence the choice of either method. However, incidence of morbidity is higher follo wing hysterectomies, which must therefore be justified. The balance is clearly in Javor of voluntary sterilization for the woman who is convinced that the size of her family is complete.
INTRODUCTION Voluntary sterilization is the most widely used method of contraception in the world (2). In 1977, an estimated 80 million couples turned to it to control their fertility. The large increase noted in Table I from 20 million in 1970 is due largely· to improvement in methods of female sterilization and the discovery of new techniques. For example, 9.5 million couples in the USA are sterilized. Of this
lnt.J Gynaecol Obstel 16
number, 49% are male and 51 % female. In 1970, however, 80% of the 942 000 sterilizations performed were vasectomies. In Canada there are 1 million sterilized couples, but of these cases, 98% are female and only 2% male. For purposes of comparison, let us add that, in India, out of 22 million (the population of Canada) couples sterilized, 67% are male and 33% female. METHODS OF FEMALE STERILIZATION Hysterectomy Although hysterectomy is a major surgical procedure, it plays a specific role as a method of sterilization. However, since morbidity and the rate of complications are distinctly higher than for simple tubal occlusion, indications for hysterectomy must be particularly evident; it must not be performed s"olely to cause sterility (8) , Indications considered sufficient to justify a contraceptive hysterectomy are: (a) presence of cervical carcinoma in situ, (b) meno- and/or metrorrhagia, (c) prolapse of the uterus with or without urinary incontinence, (d) uterine leiomyomas, (e) chronic pelvic inflammation, (f) endometriosis, (g) severe dysmenorrhea and (h) dyspareunia. If indicated, the vaginal approach, with or without prophylactic antibiotic coverage, is preferable because of reduced operating and hospitalization time. In addition, morbidity rates are reduced. The abdominal approach must sometimes be used, however, if the uterus is very distended by leiomyomas, if there is an adnexal mass, if past history reveals the existence of infection, endometriosis, cesarean or any other process that could cause the formation of adhesions, or if sterilization must be combined with an abortion of 15 weeks' gestation or beyond. Because oft~e high morbidity associated with cesarean-hysterectomy, it should be performed only when pathology exists to justify it (8). Tubal occlusion Tubal occlusion can be performed surgically, either abdominally, through a more or less large
Sterilization of women
Table I. Approximate number of couples in the world using contraception (in millions)8 • 1970
1977
Voluntary sterilization 20 Oral contraception 30 Condom 25 Intrauterine device 12 Diaphragm, spermicides, rhythm, withdrawal, etc 60 147 All methods • Source of data : C. P. Green (2).
Contraceptive Method
80 55
35 15
65 250
incision, vaginally by means of anterior or posterior colpotomy or by the endoscopic method, which can also be done either abdominally or vaginally. Before very briefly reviewing the techniques of female sterilization, mention should be made of their chronology in relation to pregnancy or abortion. In the USA, for example, 550 000 of the 1 045 000 sterilizations performed in 1976 were for women. Of this number, approximately 60% were performed postpartum, with the majority using the abdominal approach via supraumbilical minilaparotomy; 40% were for nonpregnant women and were mostly performed by endoscopy. I. Conventional laparotomy. In 1978 it is not logical to use a conventional laparotomy solely to block the tubes. In fact, both cosmetic (Pfannenstiel) and low midline incisions lead to morbidity and to the possibility of postoperative complications that cannot justify their use. If the abdomen has to be opened for any other related pathology, however, it goes without saying that the opportunity should be taken to perform the sterilization if the patient wishes it. The Pomeroy technique is the least c:;omplicated and fastest and is very effective. It consists of forming a loop in the tube, tying it with an absorbable suture and excising the rest of the loop. The long-term result is that the distal and proximal ends draw apart when the suture material dissolves and endto-end restoration of patency is, therefore, unlikely. The MadLener technique is just as simple aqd easy, but not as effective. The base of the tubal loop is crushed before ligating with a nonabsorbable material. The result is that the suture holds the raw surfaces of the two ends of the tube in contact for quite a long period of time. Simple restoration of patency is then possible. The method has been discarded because of the high failure rate. The ALdridge technique is interesting in that it was invented in order to be reversible. The parietal peritoneum is opened, forming a little pocket in which the tubal fimbria is buried. It is then held in place with separate stitches between the peritoneum
489
and the tubal serosa. If the patient should one day want to have her fertility restored, the fimbriae are simply removed from their pouches in the hope that they are functional and free of adhesions. The Cook technique is to bury the proximal end of a previously sectioned tube into the round ligament. The Irving method buries the proximal end in the uterine muscle and the distal end in the folds of the broad ligament. The Uchida method involves burying the proximal end of the tube in the folds of the broad ligament which have been separated by injecting a physiologic serum. Finally, mention should be made of saLpingectomies. In a total salpingectomy, the entire tube is removed; in a partial one, either a proximal , medial or distal segment is removed . The latter is also called Kroener's fimbriectomy and has been done on rather a wide scale, since it is performed as easily vaginally as abdominally. 2. Minilaparotomy. If the use of the minilaparotomy (ie, of an incision less than 3 em long) is desired, an endouterine cannula allowing anterior and posterior mobility of the uterus must be introduced to make the technique easier. In this way the tubes can be brought to the incision, thus facilitating their identification. Naturally, in using such a small incision, it is quite difficult to explore the abdominal cavity and only the simplest methods can be used, including electrocoagulation, clips and rings. 3. Colpotomy. SOme of the surgical methods mentioned above can be performed by colpotomy, ie, by opening the vagina either anteriorly or posteriorly. A 2- 3-cm incision is made in one of the cuide-sacs and the tubes can then be located and blocked, using special instruments. The advantage of a colpotomy is that it leaves no visible scar. In expert hands it is rapid and easy, requiring only local anesthesia. 4. Endoscopic methods. Among the endoscopic techniques are: abdominal laparoscopy (known as celioscopy in Europe); culdoscopy, in which the abdomen is penetrated through the posterior cul-desac; and hysteroscopy, in which a natural entry, the cervical opening, is used. Laparoscopy is examination of the interior of the abdominal cavity by means of a small telescope which transmits both images and the light necessary for visualization (4). For a complete exploration and for performing certain techniques, the abdomen must be distended with a gas. When laparoscopy is performed in order to sterilize the woman, the necessary instruments can be introduced either by the laparoscope itself or through a second opening if this method is preferred. In any case, the instrument thus introduced could be special forceps carrying an lnt J Gynaecol Obstet 16
490
Rioux
electric current that causes segmentary coagulation of the tube. This coagulation can be done with either a high-frequency current, unipolar or bipolar, or a very low-voltage current used to heat an element which carries out the coagulation by means of electric heat. Two other very ingenious nonelectric ways have been developed over recent years: (a) Hulka clips, plastic clips held closed by means of a spring that applies constant pressure on the tubal segment, or (b) a Yoon ring that literally ties the tube and blocks it by causing sclerosis of the strangled loop. These laparoscopic techniques, all of which seem to have about the same failure rate, are used impartially in certain areas. In others, one particular approach may be emphasized, depending on the results obtained and the operator's skill and preference. Culdoscopy is performed vaginally, passing through the posterior cul-de-sac while the patient is in the genupectoral position. The surrounding air forming the pneumoperitoneum and the right-angle position of the lens of the culdoscope make orientation more difficult for the surgeon. Almost all of the techniques described for use in laparoscopy are appropriate for culdoscopy, which apparently is taught less and less and, we believe, is bound to disappear. At first glance, hysteroscopy seems to be the most innocuous of all these techniques. A telescope is introduced by way of the cervical canal into the uterus, which is then distended by means of either a liquid or gaseous substance, and the tubal ostia are located. Unfortunately, precise localization of the ostia can be done in only 75% of all cases. Once this has been accomplished, the tube can be blocked, again either by electric current or diathermy, or by electric heat. All sorts of experiments have been conducted on nonelectric methods involved with insertion of a plug in the intramural part of the tube. Other investigators advocate the injection of a sclerosing substance which would result in permanent tubal occlusion. Several substances have been tested. However, since the failure rate is too high, at present these experimental procedures should be undertaken only by expert hysteroscopy researchers in university institutions, for patients who have been well advised and are prepared for failure .
BENEFITS Some of the advantages of sterilization (listed below) are intangible and difficult to evaluate, others are evident and important for women (3). lnt j Gy naecol Obstet I 6
1. The methods used are very reliable; the failure rate is almost nil. 2. Once the patient has been motivated to make her decision, it is final. Because there is no need to maintain the high degree of motivation required for temporary methods, their disastrous dropout rate is avoided. Women who change their minds do not get pregnant without undergoing surgery to restore patency (5). 3. The operation is practical because the woman is inconvenienced only once. There are none of the periodic follow-up visits that are so often forgotten and which require an army of social workers to seek out the patients. 4. The postpartum procedure does not lengthen the stay in the hospital. 5. Secondary effects are minimal, especially when compared to those caused by other methods (7). 6. The initial cost seems high, but it is incurred only once and, in the final analysis, is much lower than that of temporary methods if the numerous visits to the doctor and the drug store are taken into account. 7. Finally, the method deals with those who are bearing children and it is effective immediately, while sterilization of the husband is no guarantee against possible pregnancy in the wife.
RISKS It cannot be denied that there are disadvantages and risks associated with female sterilization, some of them very serious. I. Doubtless, the techniques are much more complicated for women than for men. For example, the endoscopic approaches are ideal for industrialized countries, but their complexity and the high cost of instruments represent a major drawback for developing nations. 2. All of these methods are permanent, yet we are living in a time of great family instability, with one divorce for every three marriages. Sterilized women who are changing partners may be faced with a perplexing situation. 3. These operations are strictly voluntary and optional; their legality is not certain. 4. There are still m~or religious taboos preventing sqme operations and bitterly disapproving others. 5. There are risks in everything; even love is dangerous. When a woman has sexual relations with a man, she is laying her life on the line. This is also true when she is sterilized. When a sterilized woman has intercourse with a man, the risks are greatly
Sterilization of women
491
Table II. Risk of death resulting from sexual intercourse for 1 million women 20-34 years of age, during a one-year period, as related to contraceptive method 8 • Mortality Secondary to Contraceptive Method Maternal Mortality Method Pregnancies Total None 900 000 180 0 180 Intrauterine device 30 000 6 12 18 Oral contraceptives 5000 1 20 21 Diaphragm 120 000 24 0 24 Voluntary sterilization Tubal occlusion 10 000 2 25 27 Hysterectomy 0 0 25 25 8 Table from A. C. Barnes (1 ); figures from author.
Table Ill. Risk of death resulting from sexual intercourse for 1 million women aged 35-44 years, during a oneyear period, as related to contraceptive method 8 • Mortality Secondary to Contraceptive Method Pregnancies Maternal Mortality Method Total None 700 000 210 0 210 Intrauterine device 20 000 6 12 18 Oral contraceptives 3000 1 340 342 Nonsmokers 40 41 Smokers 300 301 Diaphragm 100 000 30 0 30 Voluntary sterilization 9000 Tubal occlusion 3 25 28 0 Hysterectomy 0 25 25 8 Table from A. C. Barnes (1 ); figures from author.
reduced. In other words, when speaking of the dangers of contraception, those of noncontraception must definitely not be forgotten. Table II shows the mortality rates that should be expected when I million women have sexual relations with I million men in the course of one year (1). The first column on the left lists the forms of contraception likely to be used; the second, the number of pregnancies to be expocted if the currently accepted failure rates are taken into account; the third, the number of maternal deaths according to the North American rates; and the fourth, the number of deaths secondary to the contraceptive method itself. Finally, the last column summarizes the total number of deaths that could occur among these I million women. These figures are approximate, of course, but logical. The risk of death resulting from sexual intercourse is also shown in Table III, but in this case the I million women are aged 35 to 44 years and the figures lean distinctly in favor of sterilization.
CONCLUSION Any form of contraception is better than unplanned conception that results in multiparity. Even if the risks were equal, with contraception a popu-
lation decrease is obtained. This is even more important for developing countries. Viel (9) estimated that in Chile in 1974, if all pregnancies over five in women older than 30 had been prevented, the maternal mortality rate would have been reduced by 50% and the infant mortality rate by 13%. He concluded by saying, "There is no other single measure that would have a greater effect on infant and maternal mortality than the prevention of grand multiparity." The popularity of sterilization is obvious. Women are choosing this method at increasingly younger ages and with fewer and fewer children. When the family is complete, it is the best form of contraception possible.
REFERENCES I. Barnes AC: Discussion of paper by Haynes DM and Wolfe
WM : Am J Obstet Gynecol /06:1050, 1970. 2. Green CP: Voluntary sterilization: world's leading con traceptive method . Population Reports, Specia l Topic Monograph No. 2, 1978. 3. Langley II: Sterilization of women : panel discussion. Am J Obstet Gynecol /0/:345, 1968. 4. Phillips JM (ed): Laparoscopy. Williams & Wilkins Co, Baltimore, 1977. 5. Phillips JM (ed): Microsurgery in Gynecology. American
In I j Gynaecol Obslet /6
492
6. 7.
8. 9.
Rioux
Associa tion of Gynecologic La pa roscopists Publications, Downey, CA, 19 77 . Rioux JE : La sterilisation chirurgicale de Ia femme: le passe, le present et le futur. Union Med Can 107.·11 , 1978. Ri oux JE : Late complications of fem a le sterilization : a review of the litera ture and a proposal for further research. J Reprod Med 19:329, 1977. Shepard MK: Female contracep tive sterilization . Obstet Cynecol Surv 29:739, 1974. Viel B: Voluntary sterili zation : a problem of public health . International Planned Pa ren thood Federation/Western Hemisphere Region News Service 5:2, 1977.
lntj Gynaecol Obstet / 6
10. Yuzpe AA: Choosing a sterilization procedure: laparoscopic tuba l sterilization. J Reprod Med 15: !!9 , 1975.
Address for reprints: Jacques E. Rioux Dept of Gynecology and Obstetrics Laval University Hospital 2705 Laurier Blvd Ste-Foy, Quebec Canada G1V 4G2
Sterilization of Women: Benefits vs Risks Jacques E. Rioux Department of Gy necology and Obstetrics, Faculty of Medicine, Laval University, Laval University Hospital, Ste-Foy, Quebec, Canada
ABSTRACT
Rioux J E (Dept of Gynecology and Obstetrics, Faculty of Medicine, Laval University, Laval University Hospital, Ste-Foy, Quebec, Canada). Sterilization of women: benefits vs risks. lntj Gynaecol Obstet 16: 488- 492, 1979 Voluntary sterilization is the birth control method most widely practiced throughout the world. The last ten years have witnessed great improvements in techniques and perfection of innovations, explaining the important role that it now plays in the regulation of fertility. Different methods are examined and it is concluded that hysterectomy is the best, if medically indicated; conventional laparotomy is not justified unless required by concomitant intraabdominal pathology; minilaparotomy is mostly suitable postpartum; colpotomy is better left to specialists; laparoscopy is ideal for nonpregnant patients; culdoscopy is a relic of the past; and hysteroscopy, although still experimental, may be the way of the future. Th e advantages ofvoluntary sterilization lie in its remarkable and immediate efficiency, freedom from ongoing motivation, the convenience of a one-time operation, the absence of side effects and the reduction of total costs. Its disadvantages are the complexity of aTry surgical intervention for a woman, its indisputable finality, its uncertain legality and the risks inherent in aTry operation. Hysterectomy and tubal ligation are practically never fatal, so this argument does not influence the choice of either method. However, incidence of morbidity is higher follo wing hysterectomies, which must therefore be justified. The balance is clearly in Javor of voluntary sterilization for the woman who is convinced that the size of her family is complete.
INTRODUCTION Voluntary sterilization is the most widely used method of contraception in the world (2). In 1977, an estimated 80 million couples turned to it to control their fertility. The large increase noted in Table I from 20 million in 1970 is due largely· to improvement in methods of female sterilization and the discovery of new techniques. For example, 9.5 million couples in the USA are sterilized. Of this
lnt.J Gynaecol Obstel 16
number, 49% are male and 51 % female. In 1970, however, 80% of the 942 000 sterilizations performed were vasectomies. In Canada there are 1 million sterilized couples, but of these cases, 98% are female and only 2% male. For purposes of comparison, let us add that, in India, out of 22 million (the population of Canada) couples sterilized, 67% are male and 33% female. METHODS OF FEMALE STERILIZATION Hysterectomy Although hysterectomy is a major surgical procedure, it plays a specific role as a method of sterilization. However, since morbidity and the rate of complications are distinctly higher than for simple tubal occlusion, indications for hysterectomy must be particularly evident; it must not be performed s"olely to cause sterility (8) , Indications considered sufficient to justify a contraceptive hysterectomy are: (a) presence of cervical carcinoma in situ, (b) meno- and/or metrorrhagia, (c) prolapse of the uterus with or without urinary incontinence, (d) uterine leiomyomas, (e) chronic pelvic inflammation, (f) endometriosis, (g) severe dysmenorrhea and (h) dyspareunia. If indicated, the vaginal approach, with or without prophylactic antibiotic coverage, is preferable because of reduced operating and hospitalization time. In addition, morbidity rates are reduced. The abdominal approach must sometimes be used, however, if the uterus is very distended by leiomyomas, if there is an adnexal mass, if past history reveals the existence of infection, endometriosis, cesarean or any other process that could cause the formation of adhesions, or if sterilization must be combined with an abortion of 15 weeks' gestation or beyond. Because oft~e high morbidity associated with cesarean-hysterectomy, it should be performed only when pathology exists to justify it (8). Tubal occlusion Tubal occlusion can be performed surgically, either abdominally, through a more or less large
Sterilization of women
Table I. Approximate number of couples in the world using contraception (in millions)8 • 1970
1977
Voluntary sterilization 20 Oral contraception 30 Condom 25 Intrauterine device 12 Diaphragm, spermicides, rhythm, withdrawal, etc 60 147 All methods • Source of data : C. P. Green (2).
Contraceptive Method
80 55
35 15
65 250
incision, vaginally by means of anterior or posterior colpotomy or by the endoscopic method, which can also be done either abdominally or vaginally. Before very briefly reviewing the techniques of female sterilization, mention should be made of their chronology in relation to pregnancy or abortion. In the USA, for example, 550 000 of the 1 045 000 sterilizations performed in 1976 were for women. Of this number, approximately 60% were performed postpartum, with the majority using the abdominal approach via supraumbilical minilaparotomy; 40% were for nonpregnant women and were mostly performed by endoscopy. I. Conventional laparotomy. In 1978 it is not logical to use a conventional laparotomy solely to block the tubes. In fact, both cosmetic (Pfannenstiel) and low midline incisions lead to morbidity and to the possibility of postoperative complications that cannot justify their use. If the abdomen has to be opened for any other related pathology, however, it goes without saying that the opportunity should be taken to perform the sterilization if the patient wishes it. The Pomeroy technique is the least c:;omplicated and fastest and is very effective. It consists of forming a loop in the tube, tying it with an absorbable suture and excising the rest of the loop. The long-term result is that the distal and proximal ends draw apart when the suture material dissolves and endto-end restoration of patency is, therefore, unlikely. The MadLener technique is just as simple aqd easy, but not as effective. The base of the tubal loop is crushed before ligating with a nonabsorbable material. The result is that the suture holds the raw surfaces of the two ends of the tube in contact for quite a long period of time. Simple restoration of patency is then possible. The method has been discarded because of the high failure rate. The ALdridge technique is interesting in that it was invented in order to be reversible. The parietal peritoneum is opened, forming a little pocket in which the tubal fimbria is buried. It is then held in place with separate stitches between the peritoneum
489
and the tubal serosa. If the patient should one day want to have her fertility restored, the fimbriae are simply removed from their pouches in the hope that they are functional and free of adhesions. The Cook technique is to bury the proximal end of a previously sectioned tube into the round ligament. The Irving method buries the proximal end in the uterine muscle and the distal end in the folds of the broad ligament. The Uchida method involves burying the proximal end of the tube in the folds of the broad ligament which have been separated by injecting a physiologic serum. Finally, mention should be made of saLpingectomies. In a total salpingectomy, the entire tube is removed; in a partial one, either a proximal , medial or distal segment is removed . The latter is also called Kroener's fimbriectomy and has been done on rather a wide scale, since it is performed as easily vaginally as abdominally. 2. Minilaparotomy. If the use of the minilaparotomy (ie, of an incision less than 3 em long) is desired, an endouterine cannula allowing anterior and posterior mobility of the uterus must be introduced to make the technique easier. In this way the tubes can be brought to the incision, thus facilitating their identification. Naturally, in using such a small incision, it is quite difficult to explore the abdominal cavity and only the simplest methods can be used, including electrocoagulation, clips and rings. 3. Colpotomy. SOme of the surgical methods mentioned above can be performed by colpotomy, ie, by opening the vagina either anteriorly or posteriorly. A 2- 3-cm incision is made in one of the cuide-sacs and the tubes can then be located and blocked, using special instruments. The advantage of a colpotomy is that it leaves no visible scar. In expert hands it is rapid and easy, requiring only local anesthesia. 4. Endoscopic methods. Among the endoscopic techniques are: abdominal laparoscopy (known as celioscopy in Europe); culdoscopy, in which the abdomen is penetrated through the posterior cul-desac; and hysteroscopy, in which a natural entry, the cervical opening, is used. Laparoscopy is examination of the interior of the abdominal cavity by means of a small telescope which transmits both images and the light necessary for visualization (4). For a complete exploration and for performing certain techniques, the abdomen must be distended with a gas. When laparoscopy is performed in order to sterilize the woman, the necessary instruments can be introduced either by the laparoscope itself or through a second opening if this method is preferred. In any case, the instrument thus introduced could be special forceps carrying an lnt J Gynaecol Obstet 16
490
Rioux
electric current that causes segmentary coagulation of the tube. This coagulation can be done with either a high-frequency current, unipolar or bipolar, or a very low-voltage current used to heat an element which carries out the coagulation by means of electric heat. Two other very ingenious nonelectric ways have been developed over recent years: (a) Hulka clips, plastic clips held closed by means of a spring that applies constant pressure on the tubal segment, or (b) a Yoon ring that literally ties the tube and blocks it by causing sclerosis of the strangled loop. These laparoscopic techniques, all of which seem to have about the same failure rate, are used impartially in certain areas. In others, one particular approach may be emphasized, depending on the results obtained and the operator's skill and preference. Culdoscopy is performed vaginally, passing through the posterior cul-de-sac while the patient is in the genupectoral position. The surrounding air forming the pneumoperitoneum and the right-angle position of the lens of the culdoscope make orientation more difficult for the surgeon. Almost all of the techniques described for use in laparoscopy are appropriate for culdoscopy, which apparently is taught less and less and, we believe, is bound to disappear. At first glance, hysteroscopy seems to be the most innocuous of all these techniques. A telescope is introduced by way of the cervical canal into the uterus, which is then distended by means of either a liquid or gaseous substance, and the tubal ostia are located. Unfortunately, precise localization of the ostia can be done in only 75% of all cases. Once this has been accomplished, the tube can be blocked, again either by electric current or diathermy, or by electric heat. All sorts of experiments have been conducted on nonelectric methods involved with insertion of a plug in the intramural part of the tube. Other investigators advocate the injection of a sclerosing substance which would result in permanent tubal occlusion. Several substances have been tested. However, since the failure rate is too high, at present these experimental procedures should be undertaken only by expert hysteroscopy researchers in university institutions, for patients who have been well advised and are prepared for failure .
BENEFITS Some of the advantages of sterilization (listed below) are intangible and difficult to evaluate, others are evident and important for women (3). lnt j Gy naecol Obstet I 6
1. The methods used are very reliable; the failure rate is almost nil. 2. Once the patient has been motivated to make her decision, it is final. Because there is no need to maintain the high degree of motivation required for temporary methods, their disastrous dropout rate is avoided. Women who change their minds do not get pregnant without undergoing surgery to restore patency (5). 3. The operation is practical because the woman is inconvenienced only once. There are none of the periodic follow-up visits that are so often forgotten and which require an army of social workers to seek out the patients. 4. The postpartum procedure does not lengthen the stay in the hospital. 5. Secondary effects are minimal, especially when compared to those caused by other methods (7). 6. The initial cost seems high, but it is incurred only once and, in the final analysis, is much lower than that of temporary methods if the numerous visits to the doctor and the drug store are taken into account. 7. Finally, the method deals with those who are bearing children and it is effective immediately, while sterilization of the husband is no guarantee against possible pregnancy in the wife.
RISKS It cannot be denied that there are disadvantages and risks associated with female sterilization, some of them very serious. I. Doubtless, the techniques are much more complicated for women than for men. For example, the endoscopic approaches are ideal for industrialized countries, but their complexity and the high cost of instruments represent a major drawback for developing nations. 2. All of these methods are permanent, yet we are living in a time of great family instability, with one divorce for every three marriages. Sterilized women who are changing partners may be faced with a perplexing situation. 3. These operations are strictly voluntary and optional; their legality is not certain. 4. There are still m~or religious taboos preventing sqme operations and bitterly disapproving others. 5. There are risks in everything; even love is dangerous. When a woman has sexual relations with a man, she is laying her life on the line. This is also true when she is sterilized. When a sterilized woman has intercourse with a man, the risks are greatly
Sterilization of women
491
Table II. Risk of death resulting from sexual intercourse for 1 million women 20-34 years of age, during a one-year period, as related to contraceptive method 8 • Mortality Secondary to Contraceptive Method Maternal Mortality Method Pregnancies Total None 900 000 180 0 180 Intrauterine device 30 000 6 12 18 Oral contraceptives 5000 1 20 21 Diaphragm 120 000 24 0 24 Voluntary sterilization Tubal occlusion 10 000 2 25 27 Hysterectomy 0 0 25 25 8 Table from A. C. Barnes (1 ); figures from author.
Table Ill. Risk of death resulting from sexual intercourse for 1 million women aged 35-44 years, during a oneyear period, as related to contraceptive method 8 • Mortality Secondary to Contraceptive Method Pregnancies Maternal Mortality Method Total None 700 000 210 0 210 Intrauterine device 20 000 6 12 18 Oral contraceptives 3000 1 340 342 Nonsmokers 40 41 Smokers 300 301 Diaphragm 100 000 30 0 30 Voluntary sterilization 9000 Tubal occlusion 3 25 28 0 Hysterectomy 0 25 25 8 Table from A. C. Barnes (1 ); figures from author.
reduced. In other words, when speaking of the dangers of contraception, those of noncontraception must definitely not be forgotten. Table II shows the mortality rates that should be expected when I million women have sexual relations with I million men in the course of one year (1). The first column on the left lists the forms of contraception likely to be used; the second, the number of pregnancies to be expocted if the currently accepted failure rates are taken into account; the third, the number of maternal deaths according to the North American rates; and the fourth, the number of deaths secondary to the contraceptive method itself. Finally, the last column summarizes the total number of deaths that could occur among these I million women. These figures are approximate, of course, but logical. The risk of death resulting from sexual intercourse is also shown in Table III, but in this case the I million women are aged 35 to 44 years and the figures lean distinctly in favor of sterilization.
CONCLUSION Any form of contraception is better than unplanned conception that results in multiparity. Even if the risks were equal, with contraception a popu-
lation decrease is obtained. This is even more important for developing countries. Viel (9) estimated that in Chile in 1974, if all pregnancies over five in women older than 30 had been prevented, the maternal mortality rate would have been reduced by 50% and the infant mortality rate by 13%. He concluded by saying, "There is no other single measure that would have a greater effect on infant and maternal mortality than the prevention of grand multiparity." The popularity of sterilization is obvious. Women are choosing this method at increasingly younger ages and with fewer and fewer children. When the family is complete, it is the best form of contraception possible.
REFERENCES I. Barnes AC: Discussion of paper by Haynes DM and Wolfe
WM : Am J Obstet Gynecol /06:1050, 1970. 2. Green CP: Voluntary sterilization: world's leading con traceptive method . Population Reports, Specia l Topic Monograph No. 2, 1978. 3. Langley II: Sterilization of women : panel discussion. Am J Obstet Gynecol /0/:345, 1968. 4. Phillips JM (ed): Laparoscopy. Williams & Wilkins Co, Baltimore, 1977. 5. Phillips JM (ed): Microsurgery in Gynecology. American
In I j Gynaecol Obslet /6
492
6. 7.
8. 9.
Rioux
Associa tion of Gynecologic La pa roscopists Publications, Downey, CA, 19 77 . Rioux JE : La sterilisation chirurgicale de Ia femme: le passe, le present et le futur. Union Med Can 107.·11 , 1978. Ri oux JE : Late complications of fem a le sterilization : a review of the litera ture and a proposal for further research. J Reprod Med 19:329, 1977. Shepard MK: Female contracep tive sterilization . Obstet Cynecol Surv 29:739, 1974. Viel B: Voluntary sterili zation : a problem of public health . International Planned Pa ren thood Federation/Western Hemisphere Region News Service 5:2, 1977.
lntj Gynaecol Obstet / 6
10. Yuzpe AA: Choosing a sterilization procedure: laparoscopic tuba l sterilization. J Reprod Med 15: !!9 , 1975.
Address for reprints: Jacques E. Rioux Dept of Gynecology and Obstetrics Laval University Hospital 2705 Laurier Blvd Ste-Foy, Quebec Canada G1V 4G2
