LA CONSULTA SEMANAL

ABRIL 2000

CONSULTA

Cad. Saúde Pública, Julho 1999, vol.15 no.3. [Texto completo] 

Impact of contraceptive methods on women's lives: the case of tubal ligation 

Osis, Maria José Duarte, Faúndes, Anibal, Sousa, Maria Helena de et al 

This study focused on the long-term consequences of tubal ligation on women's lives. Women 30 to 49 years old living in Campinas, State of São Paulo (Brazil), were interviewed: 236 sterilized at least five years prior to the interview and 236 non-sterilized women. Their experiences with the currently used contraceptive methods were compared with regard to satisfaction, benefits, and damage attributed to the method, feelings of regret, and perception of effects on their health, body, menstruation, sex, affective and family life, job, studies, economic status, and self-esteem. Scores were created to compare the groups in relation to self-esteem, well-being/quality of life, relationship with partner, and gender issues. Satisfaction with the currently used contraceptive method was significantly higher among sterilized women, although they more frequently reported having regretted being sterilized at some moment in time. Relatively more sterilized women felt that the contraceptive method had improved their sex lives and economic status, while producing a negative effect on their menstruation. No significant difference was observed between the groups with regard to the scores studied. 

Semin Laparosc Surg 1999 Jun;6(2):112-7 

Laparoscopic sterilization. 

Filshie M 

Academic Department of Obstetrics and Gynaecology, University Hospital, Nottingham, England. 

Laparoscopic female sterilization is still the leading method of family planning for patients who have completed their family. Mechanical methods include clips and rings and are preferred because they are safe and efficient and can be used on a day case basis. Appropriate training ensures improved results with fewer complications. Clips and rings have an improved reversal potential. 

Obstet Gynecol Clin North Am 1999 Mar;26(1):83-97 

Laparoscopic tubal sterilization. Methods, effectiveness, and sequelae. 

Ryder RM, Vaughan MC 

Division of Gynecology, Eastern Virginia Medical School, Norfolk, USA. 

The following statements summarize the material presented herein. 1. Although laparoscopic tubal ligation remains an effective and widely available form of birth control throughout the world, cumulative failure rates may be higher than previously reported, and patients should be appropriately counseled, with special attention to younger women. 2. Proper surgical technique is important in reducing failure rates, particularly with regard to applying clips or using bipolar cautery. Teaching institutions should employ strict guidelines for instructing residents in the most effective techniques. 3. Although overall rates of ectopic pregnancy are lower after tubal ligation (as is true with any form of birth control), should pregnancy ensure from a failed procedure, there is a 30% to 80% chance of ectopic pregnancy. Consideration should be given to earlier ultrasound and documentation of the location of the pregnancy. 4. There is little evidence to support PTLS from a biologic standpoint. The data on increased hysterectomies in post-tubal patients may be a result of multiple factors, particularly for women aged less than 30 years at the time of occlusion. 5. Although the majority of women report satisfaction with sterilization, thorough counseling for all women cannot be overemphasized. Women aged less than 30 years should be completely aware of all alternatives and possibly encouraged to try another method prior 

Fundación Mexicana para la Salud (1997) [Texto completo] 

Análisis de 2 mil casos de salpingoclasia bilateral con anestesia local y sedación en el Hospital General Regional

"Vicente Guerrero" de Acapulco, Gro. Dr. Jesús de la Fuente Molina Dr. Valdemar Galeana Reyes Dra.
Elizabeth Saldaña Ortiz Dr. José Luis Herrera Sabino 

Br J Obstet Gynaecol 1997 Jan;104(1):71-7 

Laparoscopic sterilisation: opinion and practice among gynaecologists in Scotland. 

Penney GC, Souter V, Glasier A, Templeton AA 

Department of Obstetrics and Gynaecology, Maternity Hospital, Aberdeen, UK. 

OBJECTIVES: 1. To produce a list of evidence-based criteria for good quality care relating to female laparoscopic sterilisation. 2. To assess the level of agreement with each criterion among gynaecologists in Scotland. 3. To obtain an overview of current sterilisation practice for comparison with the agreed criteria. DESIGN: 1. Agreement with criteria assessed by questionnaire survey; 2. Overview of current practice obtained by questionnaire survey and by casenote review. SETTING: Scotland. SAMPLE: 1. Questionnaire survey: all 132 consultant gynaecologists in NHS practice. 2. casenote review: 988 consecutive women sterilised in 12 representative hospitals. RESULTS: The response rate to the questionnaire survey was 94%. A list of 15 evidence-based criteria was produced, covering patient selection, information and counselling, techniques of tubal occlusion and timing of sterilisation. All 15 suggested criteria gained an overall balance of support among responding gynaecologists. Similar impressions of current practice were gained from the questionnaire survey and from the casenote review. Aspects of practice which measured up well to the agreed criteria included: only 6% of women sterilised were younger than 25 years of age; over 85% of casenotes included clear documentation that women had been counselled regarding failure rate and intended permanency; 88% of sterilisations were performed, or directly supervised by, a gynaecologist of consultant or senior registrar status; and only 2% of sterilisations were undertaken in combination with induced abortion. Aspects of practice which compared poorly with the agreed criteria, and for which recommendations for change have been made, included: only 22% of casenotes mentioned that the option of vasectomy had been discussed; only 30% of gynaecologists indicated that they provide locally produced information leaflets as an adjunct to counselling; four methods of tubal occlusion (including unipolar diathermy) were in use; and there were wide variations among hospitals in the use of day-case care, ranging from 19% to 99%. CONCLUSIONS: A list of criteria for good quality care in relation to sterilisation has been validated by agreement among Scottish gynaecologists. Current practice (as assessed by questionnaire survey and casenote review) has been compared with the criteria and some recommendations for change in practice have been made. Following dissemination of these results and recommendations, re-audit will be undertaken in order to identify any changes. 

Salud Publica Mex 1996;38:13-19. [Texto completo] 

Efecto de las prácticas anticonceptivas sobre la fecundidad en la región fronteriza de Chiapas, México. 

Nazar-Beutelspacher A, Halperin-Frisch D, Salvatierra-Izaba B. 

Objetivo. Estimar el efecto de las prácticas anticonceptivas sobre la fecundidad en la región fronteriza de Chiapas, México. Material y métodos. Durante 1994 se realizó un estudio epidemiológico de corte transversal en una muestra representativa de 1 560 mujeres no indígenas de 15 a 49 años en la región fronteriza de Chiapas. Se estimaron la prevalencia de uso de métodos anticonceptivos y las tasas globales de fecundidad (TGF) por tamaño de la localidad de residencia (rurales, intermedias y urbanas). Se comparó la TGF entre las mujeres nunca usuarias y alguna vez usuarias de métodos anticonceptivos. Resultados. La TGF estimada para la región fue de 3.67 y varió de 4.14 para áreas rurales a 3.36 para áreas urbanas. No se observaron diferencias en la TGF (3.74 y 3.88) ni en el promedio de hijos nacidos vivos (3.47 y 3.48) entre usuarias alguna vez y nunca usuarias de métodos anticonceptivos. Conclusiones. El mayor efecto de las prácticas anticonceptivas en la fecundidad se observó en áreas rurales. El uso tardío de métodos anticonceptivos, así como la edad de unión más temprana entre las usuarias son factores que influyen para dar por resultado un escaso efecto en la fecundidad. 

J Gynecol Surg 1995 Fall;11(3):159-64 
Laparoscopic silastic band sterilization failures. 
Adelson MD, Graves WL, Ahn YW 
Department of Obstetrics and Gynecology, State University of New York Health Science Center, Syracuse, USA. 
Silastic band laparoscopic sterilization was introduced in the early 1970s as an alternative to unipolar cautery laparoscopy. Banding eliminates burn injury and reduces tubal destruction. However, in comparison with other methods, the success of Silastic banding may depend more on tubal morphology. This case-control study of 70 banding failures and 140 controls matched for age, gravidity, and date of procedure reveals that morphologic abnormalities of pelvic organs (adhesions or tubal thickening) or a history of a disease known to cause such abnormalities (pelvic inflammatory disease) increases the risk of
sterilization failure. The risk of failure is further increased if the procedure is performed immediately postpartum or postabortion rather than as an interval procedure. 

Adv Contracept 1995 Sep;11(3):187-206 
A review of safety, efficacy, pros and cons, and issues of puerperal tubal sterilization--an update. 

Chi IC, Petta CA, McPheeters M 
Family Health International, Research Triangle Park, NC 27709, USA. 
This review focuses on the safety, efficacy, pros and cons of tubal sterilization procedures performed during the puerperium period while the woman is still in hospital. Findings from four previous reviews are synthesized, and the results published in more recent literature are evaluated. The review finds that tubal sterilization performed while the woman is still on the delivery table, or during a woman's early puerperium while she remains hospitalized, is operationally easy and medically safe, and does not adversely affect lactation. However, reported pregnancy rates are generally higher in puerperal tubal sterilization than in interval sterilization, especially when the mechanical tubal occlusion technique is used. The Pomeroy method, and its modifications via minilaparotomy, is highly recommendable. On the other hand, electrocoagulation via laparoscopy is associated with high efficacy, but a potentially increased risk of complications and difficulties in tubal reversal. Tubal sterilizations can be easily and safely performed at cesarean delivery in selected cases. Tubal sterilization performed during puerperium has a number of advantages over short-acting contraceptive methods, which require strict compliance, for postpartum use. However, candidates for puerperal tubal sterilization need to be carefully screened and counseled, since post-sterilization regret is more likely to occur. Unsettled issues for puerperal tubal sterilization and a number of practical problems that need to be addressed before initiation of a puerperal tubal sterilization program in a maternity clinic/hospital are discussed. 

J Gynecol Surg 1994 Spring;10(1):15-20 
The benefits of using the loop ligature (Endoloop) laparoscopic sterilization procedure in a residency program. 
Parsons MT, Hill DA 
Department of Obstetrics and Gynecology, University of South Florida, College of Medicine, Tampa. 
This study was conducted to determine the impact of the addition of the loop ligation (Endoloop) technique on choice of sterilization surgery in our residency teaching program and to investigate significant differences between this technique and other methods performed at our hospital. A retrospective study of all patients undergoing interval tubal sterilization at Tampa General Hospital in 1989 and 1991 was undertaken. Data were analyzed to determine the frequency of sterilization methods and differences between the loop ligation method and the other procedures performed; p values of less than 0.05 were considered significant. Sixty-one patients in 1989 and 75 in 1991 qualified for the study. Five methods of interval sterilization were performed: loop ligation, minilaparotomy, colpotomy, laparoscopic bipolar fulguration, and Silastic ring application. The frequency of the loop ligature technique increased from 0% in 1989 to 40% in 1991. There were no significant differences in operative time and complication rate among the loop method and other procedures. The loop ligature (Endoloop) method of laparoscopic sterilization does not significantly change the length of surgery, blood loss, or complication rate compared to the other laparoscopic techniques used in our residency program. This method provides a definitive tissue diagnosis, eliminates the risk of thermal injury, theoretically provides an opportunity of later tubal reanastomosis, and subjectively helps develop laparoscopic skills. 

J Gynecol Surg 1993 Winter;9(4):187-90 
A program of instruction in operative laparoscopy in a residency in obstetrics and gynecology. 
Letterie GS, Hibbert ML, Morgenstern LL 
Department of Obstetrics and Gynecology, Seattle, Washington. 
Operative laparoscopy has found an increasingly innovative role in contemporary gynecologic practice. Residency programs must now formulate protocols for training in laparoscopic surgery on which subsequent credentialling may be safely recommended. This report describes a program of instruction in operative laparoscopy and the number of procedures required to develop technical skills at each year level of a 4-year residency. The objective of the program was to develop clinical judgment and technical skills in operative laparoscopy during the first 3 resident years. The main outcome measurement was the safe performance of complicated operative laparoscopy during the fourth resident year. This program emphasized progressive, graded responsibility in operative laparoscopy to develop skills in both the principles and practice of laparoscopic surgery. Principles were taught through didactic sessions in laparoscopic instruments and techniques, assignment of reading lists for each year level, and a review of videotapes to assist in decision making for each procedure. Skills in technique and development of manual dexterity were taught over 4 years as follows. Postgraduate year (PGY) 1: restricted to diagnostic procedures emphasizing the development of basic eye-hand coordination using a video monitor system; PGY2: incorporation of principles of laparoscopic hemostasis and laparoscopic tubal ligation; PGY3: operative laparoscopy using multiple puncture sites, sharp dissection, and suture techniques; PGY4: progressively more complicated procedures to include salpingectomy, salpingostomy, and segmental resection for ectopic pregnancies; oophorectomy for benign disease, appendectomy, and adhesiolysis. 

J Gynecol Surg 1992 Fall;8(3):143-58 
Breaking new ground or just digging a hole? An evaluation of gynecologic operative laparoscopy. 
Howard FM 
Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, New York. 
The gynecological surgical procedures that may be accomplished via operative laparoscopy have dramatically increased in the past decade. Ideally, strong evidence of advantages over traditional surgical approaches should be presented for each surgical procedure before widespread use occurs. Such evidence is generally lacking. This review of recent publications concludes that laparoscopic operations for tubal ectopic pregnancy have been demonstrated generally to be preferable to laparotomy. Although evidence is very suggestive, clear superiority of laparoscopy has not been proven for endometriosis, ovarian cystectomy, oophorectomy, distal salpingostomy, or adhesiolysis for infertility. There is not adequate evidence to reach a conclusion on the use of laparoscopic myomectomy for fertility. When appropriately indicated, vaginal hysterectomy seems preferable to abdominal or laparoscopic hysterectomy, and preliminary evidence suggests that laparoscopic hysterectomy may have some advantages over abdominal hysterectomy. There is no evidence that laparoscopic tubal sterilization is better than minilaparotomy tubal sterilization. Much more scientific study of operative laparoscopic procedures is needed before universal change to these procedures can be fully endorsed. 

Acta Eur Fertil 1992 Sep-Oct;23(5):215-20 
Operative laparoscopy for tubal pathology. 
Carollo G, Petronio M, Carlino L, Pulizzotto R, Ubaldi F 
Istituto Materno Infantile, Universita degli Studi di Palermo. 
Tubal pathology has represented in the last years, the main indication to operative laparoscopy, mainly as a consequence of the widespread use of this technique in the treatment of the ectopic pregnancy. Furthermore, operative laparoscopy has been widely applied to the treatment of the distal tubal pathology for infertility, when IVF/ET failed or was not accepted. The Authors discuss the rationale for these applications of operative laparoscopy and also the possibility of performing by laparoscopy demolitive interventions on the tubes. 

Obstet Gynecol Surv 1992 Feb;47(2):71-9 
Performing tubal sterilizations during women's postpartum hospitalization: a review of the United States and international experiences. 
Chi IC, Gates D, Thapa S 
Family Health International, Research Triangle Park, NC 27709. 
A considerable number of tubal sterilizations have been performed while women are still in hospital after delivery in the United States as well as in other countries. There are few review papers exclusively on this sterilization modality. This paper provides a comprehensive review of results reported from recent studies of this approach, and answers the pertinent medical and related questions such as: To achieve maximum safety, what is the best time to perform the procedure during the women's postpartum hospitalization? Specifically, is it advisable for the procedure to be performed while the woman is still on the delivery table? What surgical approach and tubal occlusion technique are preferred? What are the risks that the women undergoing sterilization immediately or soon after delivery may incur the short- and long-term medical sequelae, and to conceive accidental pregnancy? What effect does sterilization have on lactation? And how should the women be screened and counseled to prevent poststerilization regret, generally thought to be more likely to occur in women after postpartum sterilization? Newly-developed mechanical tubal occlusion techniques have been included for consideration. Practical guidelines are given in this paper to help service providers achieve maximum safety and satisfaction for their patients with this convenient and low-cost method of postpartum sterilization. 

Obstet Gynecol 1991 Aug;78(2):209-12 
Morbidity and vaginal tubal cautery: a report and review. 
Smith RP, Maggi CS, Nolan TE 
Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta. 
Vaginal tubal sterilization was once the procedure of choice for interval sterilization. This technique fell out of favor in part because of a perceived increase in morbidity over the evolving laparoscopic techniques. Complications should be minimized by the advent of routine antibiotic prophylaxis and improved operating techniques that allow shorter procedure times. We retrospectively reviewed 240 vaginal tubal sterilization procedures performed by a single physician. Long-term follow-up (more than 5 years) was available in over half the study group (52%). Half of all operations were completed in 12 minutes or less, with an average time of 14.5 minutes. The planned vaginal procedure was completed in all but two cases, both of which required laparotomy secondary to dense adhesions. Median estimated blood loss was 20 mL. No postoperative infection was encountered. These data suggest that vaginal tubal sterilization may still be a safe alternative for interval sterilization. 

Ginecol Obstet Mex 1990 Nov;58:315-9 
[Tubal ligation with post-partum minilaparotomy]. 
de la Garza Quintanilla C 
Ensenanza del Hospital de Gineco Obstetricia de Garza. 
This is a review of 209 cases of salpingochlasia by minilaparotomy, post-partum. Frequency was 13.2%. The larger group was 20 to 29 years of age, 52%; 14.3% were unmarried. Multiparae were most frequent, 52.2%. One previous section 3.5%; with four to six live children, 54%. No previous anticonceptive method, 91%; pre-natal control, 69%. With anemia, Hb less than 10 g, 11%, and only 3.5% required blood transfusion. Eutocic delivery, 89%. Ruptured membranes, before delivery, less than six hours, 97%. Anesthesia during delivery, 59.1%; it was epidural anesthesia, as well as for the salpingochlasia in 100%, without complications. The indication was completed parity in 100%, the technique mostly used was Pomeroy's in 77.3%. There were no pre, trans or post-operative complications. The interval between delivery and salpingochlasia in first 12 hours, 98% and from surgery to hospital discharge, 12 to 24 hours, 89.2%. Hospital stay was two days, 90%. Pomeroy's technique failure, 0.6% and for Kroener's, 2.1%. Two pregnancies occurred out of 1,238 months-woman observation. 

Ginecol Obstet Mex 1990 Nov;58:315-9 
[Tubal sterilization by postpartum minilaparotomy]. 
de la Garza Quintanilla C 
This is a review of 209 cases of salpingochlasia by minilaparotomy, post-partum. Frequency was 13.2%. The larger group was 20 to 29 years of age, 52%; 14.3% were unmarried. Multiparae were most frequent, 52.2%. One previous section 3.5%; with four to six live children, 54%. No previous anticonceptive method, 91%; pre-natal control, 69%. With anemia, Hb less than 10 g, 11%, and only 3.5% required blood transfusion. Eutocic delivery, 89%. Ruptured membranes, before delivery, less than six hours, 97%. Anesthesia during delivery, 59.1%; it was epidural anesthesia, as well as for the salpingochlasia in 100%, without complications. The indication was completed parity in 100%, the technique mostly used was Pomeroy's in 77.3%. There were no pre, trans or post-operative complications. The interval between delivery and salpingochlasia in first 12 hours, 98% and from surgery to hospital discharge, 12 to 24 hours, 89.2%. Hospital stay was two days, 90%. Pomeroy's technique failure, 0.6% and for Kroener's, 2.1%. Two pregnancies occurred out of 1,238 months-woman observation. 

Am J Obstet Gynecol 1985 Dec 1;153(7):755-9 
A comparative clinical trial of the tubal ring versus the Rocket clip for female sterilization. 
Aranda C, de Badia D, Mahran M, Feldblum PJ 
Studies of application of the Rocket clip compared with the tubal ring were conducted at three sites. Procedures were randomly assigned to the patients; 332 women were sterilized with the tubal ring and 331 were sterilized with the Rocket clip.The occlusion devices were applied via a minilaparotomy incision. Surgical difficulties and injuries and technical failures occurred with comparable frequency in the two groups. There were two method failures in each tubal occlusion group; the 24-month life-table pregnancy rate was 1.0 per 100 women in the tubal ring group and 0.9 per 100 in the Rocket clip group.
The Rocket spring-loaded clip appears to be as safe, effective, and easy to apply as the tubal ring for tubal occlusion. 

Clin Reprod Fertil 1985 Jun;3(2):81-97 
A comprehensive review of female sterilisation--tubal occlusion methods. 
Chick PH, Frances M, Paterson PJ 
Female sterilisation using tubal occlusive methods are reviewed. The various techniques, failure rates, mortality, short and long-term morbidity, psychosexual effects and reversibility are discussed. Tubal occlusion is an effective method of female sterilisation but if failure should occur ectopic pregnancies are more likely if tubal diathermy, and less likely if Fallope rings or Filshie clips have been used for the original sterilisation procedure. Mortality rates are low and occur as a once-only risk when compared to ongoing contraception. Short-term morbidity rates are low when sterilisation is performed via the laparoscope, with single portal entry being more likely to result in complications. Mini-laparotomy and laparotomy also have low morbidity levels but complication rates are much higher when a transvaginal approach is used. There is no increase in morbidity when tubal sterilisation is performed at the time of pregnancy termination, providing uterine evacuation is not performed by hysterotomy. In the majority of cases no menstrual disturbance is noted; however, a small increase in menstrual disorders as a direct result of tubal sterilisation cannot be excluded absolutely. Sterilisation does not affect sexual satisfaction. Regret is more likely if the sterilisation is performed (i) post-termination or in the puerperium, (ii) when there is marital disharmony and (iii) for medical rather than social reasons. Low parity is not associated with regret except in cultures where high parity is prized. Microsurgical methods of reversal have higher pregnancy and lower ectopic rates than macrosurgical techniques. Successful reversal is inversely related to the degree of tubal destruction at the initial operation. 

Am J Obstet Gynecol 1983 Mar 15;145(6):684-94 
Menstrual pattern changes following laparoscopic sterilization with different occlusion techniques: a review of 10,004 cases. 
Bhiwandiwala PP, Mumford SD, Feldblum PJ 
A comparison is made of menstrual pattern changes reported by 10,004 women undergoing interval and postabortion sterilization by the laparoscopic occlusive techniques of unipolar electrocoagulation, the tubal ring, the prototype spring-loaded clip, and the Rocket clip. Controlling for prior contraceptive use, the menstrual patterns in these women sterilized by the four techniques were compared with respect to six parameters: cycle regularity, cycle length, menstrual flow duration, amount of flow, dysmenorrhea, and intermenstrual bleeding. The majority of women reported no menstrual changes subsequent to sterilization. When changes were experienced, they occurred in equal proportions in opposite directions. Depending on the parameter, from 15% to 79% of the menstrual pattern changes seen within 6 months after sterilization in women who were using oral contraceptives or intrauterine contraceptive devices at the time of sterilization could be attributed to the discontinuation of those methods of contraception. There were no significant differences between the several occlusion technique groups with respect to the proportion of women who reported changes in their menstrual patterns after sterilization.