The safety and efficacy of tubal sterilization: an international overview.

This article presents a synthesis of some of the major published studies on the efficacy and safety of tubal sterilization. The conclusions of this overview are that tubal sterilization is a safe operation, long-term sequelae of tubal sterilization have not been well documented, and the risk of pregnancy following tubal sterilization is less than 1 in 100. Continued study is needed to determine how to make a safe and effective procedure even safer and more effective.

PIP: Over the past decade, tubal sterilization has emerged as one of the world's most frequently used methods of fertility control. It is estimated that up to 1980 over 60 million women had been surgically sterilized, making an understanding of the risks and benefits of tubal sterilization a matter of global concern. The current consensus, derived from international morbidity and mortality studies, is that tubal sterilization is a safe operation. Several large national studies, including ones conducted in the United Kingdom, have determined that major complication rates for tubal sterilization are low, on the order of 1-6/100 procedures. Several recent studies have demonstrated that death attributable to tubal sterilization is rare but does occur. 2 national studies of laparoscopic sterilization done in the United States and in Great Britain estimate case fatality rates for laparoscopic sterilization of 10 deaths and 2 deaths/100,000 procedures, respectively. Several studies have been conducted which address not only the risk of death but also the causes of death associated with tubal sterilization. In the United States, the Centers for Disease Control (CDC) has identified 27 deaths attributable to tubal sterilization that occurred since 1977. The single leading cause of these deaths was cardiorespiratory arrest during general anesthesia. The question whether tubal sterilization predisposes a woman to menstrual disturbances was raised as early as 1951. Since that time a variety of reports have suggested that observed differences in menstrual function after sterilization can be attributed to factors other than sterilization procedure, e.g., menstrual problems prior to sterilization; oral contraceptive use before sterilization; previous pelvic inflammatory disease; or age alone, the woman being older following sterilization than she was before sterilization. Intrauterine pregnancies and ectopic pregnancies are 2 concerns regarding the efficacy of tubal sterilization. Intrauterine pregnancies are unplanned and usually unwanted after sterilization. Although a substantial percentage of pregnancies after sterilization are ectopic gestations, there is no evidence that a woman's absolute risk of ectopic pregnancy is increased by having a sterilization performed.

Mortality risk associated with female sterilization.

The mortality risk associated with female sterilization in an analysis of 255 812 procedures performed in developing countries from 1973 to 1979 is reviewed. Fifteen sterilization-related deaths were reported during this period. The overall mortality was 5.86/100 000 procedures. The most common cause of death was the result of anesthetic complications, with infection in second place. The risk of death by procedure was higher with culdoscopy than with minilaparotomy or laparoscopy. The authors believe that low mortality figures are realistic and can be achieved in developing countries when experienced surgical teams are provided with adequate facilities, observe strict medical standards, utilize minilaparotomy and laparoscopy and avoid general and spinal anesthesia.

PIP: A review was conducted of the mortality risk associated with female sterilization in an analysis of 255,812 procedures performed in developing countries over the 1973 to 1979 period. The information presented is based on a review of the clinical data and individual death reports gathered since the International Project/Association for Voluntary Sterilization (IPAVS) was organized. In this analysis, 89,006 women were sterilized by laparoscopy and 94,699 by minilaparotomy. These 2 techniques represent almost 77.5% of the total 255,812 cases. The majority of female sterilizations were performed on an interval basis. About 20% were reported as postpartum procedures. The average age of acceptors were 30-36 years and the average parity was 4-6. 15 sterilization-related deaths were reported during this period. The overall mortality was 5.86/100,000 procedures. Anesthetic complications was the most common cause of death. Infection was the 2nd most frequent cause of death. The risk of death by procedure was higher with culdoscopy than with minilaparotomy or laparoscopy.