Case 25: Permanent contraception

 

Case 25: Permanent contraception

CASE 25: PERMANENT CONTRACEPTION

History

A couple attends the antenatal clinic requesting sterilization. They have three children, aged

10, 7 and 5, all born by caesarean section. The oldest son has Asperger’s syndrome. Until

now they have been using the contraceptive pill but as she is slightly overweight (body mass

index 29) and has a family history of cardiovascular disease, her GP has advised her to seek

an alternative. She tried the levonorgestrel intrauterine system (IUS) but had it removed after

6 months due to irregular bleeding.

She is aged 38 and is otherwise healthy. She does not smoke and takes no other medication.

Her husband is supportive and initially planned a vasectomy but after initial consultation

decided that he could not go through with it due to his fear of the procedure.

They have read widely on the Internet and decided that laparoscopic sterilization is the most

suitable method for them in view of its reliability and permanence.

Examination

Blood pressure is 150/85. The body mass index is 29. On abdominal inspection the caesarean

section scars are noted as well as an appendectomy scar.

The abdomen is soft and non-tender with no palpable masses. Speculum examination is

unremarkable and on bimanual examination the uterus is normal size, mobile and anteverted.

Questions

• How would you establish whether sterilization really is an appropriate choice for

this couple?

• If you agree with her request for laparoscopic sterilization in principle, how would

you counsel regarding the procedure before agreeing to proceed?

• Are there any other suitable contraceptive options that this woman should consider

apart from laparoscopic sterilization?100 Cases in Obstetrics and Gynaecology

60

ANSWER 25

Appropriateness of sterilization

The fact that this couple’s youngest child is 5 years old would suggest that they have had

time to consider having further children and have definitively decided against this. It

may be that the eldest child with Asperger’s means that they are particularly keen to

avoid pregnancy due to their involvement with his care. However in counselling couples

regarding sterilization, it is important to encourage them to consider whether there are

any circumstances under which their decision might change, e.g. the death of an existing

child (or children) or the breakup of their relationship and wanting to have a child with

a new partner.

Assuming that these have been considered and other non-permanent contraceptive options

offered, or as in this case of the levonorgestrel IUS having been tried, then sterilization is a

reasonable and effective choice.

Counselling before laparoscopic sterilization

In addition to an explanation of the laparoscopic sterilization procedure, the following points

should be discussed and documented before consent for sterilization is obtained:

• Sterilization should be considered a permanent procedure. Reversal of tubal sterilization has low success rates (maximum 60 per cent).

• Up to 10 per cent of women regret their decision for sterilization.

• The failure rate of laparoscopic sterilization is 2 in 100 women who have been sterilized for one year.

• If a pregnancy does occur after sterilization then there is an increased risk of this

being an ectopic pregnancy. Early ultrasound scan is therefore recommended in

such circumstances.

• Laparoscopy carries associated risks of bleeding, infection, injury to bowel or bladder or blood vessels (3 in 1000 risk of significant harm), thrombosis and anaesthetic

complications. These risks may be increased in this case due to the woman’s previous surgery, blood pressure and body mass index.

• There is a small chance that sterilization procedure will be impossible due to technical difficulty, in which case she should be asked to give consent for open sterilization

though a mini-laparotomy incision.

Alternatives to laparoscopic sterilization

Transcervical hysteroscopically performed sterilization is a relatively new method of sterilization. It involves the insertion of small flexible inserts into the fallopian tubes via a hysteroscope. These inserts cause a fibrotic reaction within the tubes so that within 3 months

the tubes are occluded. The occlusion needs to be confirmed with hysterosalpingography

however before alternative contraception can be stopped.

In this woman’s case this should be considered particularly as she is overweight, mildly

hypertensive and has had four previous abdominal operations, such that her risks of surgery

are significant.