Tubal sterilization is remarkably safe. The Collaborative Review of Sterilization (CREST) study, a 1983 review of 9,475 interval sterilizations from multiple centers in the United States, reported a total complication rate of 1.7 per 100 procedures (281). Complications were increased by use of general anesthesia, previous pelvic or abdominal surgery, history of PID, obesity, and diabetes mellitus. The most common significant complication was unintended laparotomy for sterilization after intra-abdominal adhesions were found. In another series, 2,827 laparoscopic sterilizations were performed with the Silastic band using local anesthesia and intravenous sedation (286). Only four cases could not be completed (a technical failure rate of 0.14%), and laparotomy was never needed. Rarely, salpingitis can occur as a complication of the surgery. This occurs more often with electric coagulation than nonelectric techniques. Risk of death with female sterilization was 1 to 2 per 100,000 sterilizations in the last national study that was based on data from 1979 to 1980 (281). Almost half of the deaths were from complications of general anesthesia, usually related to the use of mask ventilation. When general anesthesia is used for laparoscopy, endotracheal intubation is mandatory because the pneumoperitoneum increases the risk of aspiration. International data from the Association for Voluntary Surgical Contraception show a similar record of safety from third world programs: 4.7 deaths per 100,000 female sterilizations and 0.5 deaths per 100,000 vasectomies (287).
Sterilization Failure Many “failures” occur during the first month after surgery and are the result of a pregnancy already begun when the sterilization was performed. Contraception should be continued until the day of surgery, and a sensitive pregnancy test should be routinely performed on the day of surgery. Because implantation does not occur until 6 days after conception, a woman could conceive just before the procedure and there would be no way to detect it. Scheduling sterilization early in the menstrual cycle obviates the problem but adds to the logistic difficulty. Another cause of failure is the presence of anatomic abnormalities, usually adhesions surrounding and obscuring one or both tubes. An experienced laparoscopic surgeon with appropriate instruments usually can lyse the adhesions, restore normal anatomic relations, and positively identify the tube. In some circumstances successful sterilization will not be possible by laparoscopy, and the surgeon must know before surgery whether the patient is prepared to undergo laparotomy, if necessary,
Table 10.8 Ten-Year Life-Table Cumulative Probability of Pregnancy per 1,000 Procedures with Different Methods of Tubal Sterilization, United States, 1978–1986
From Peterson HB, Xia Z, Hughes JM, et al. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996;174:1164 [Table II], with permission.