The same negative feedback of sex steroids that blocks ovulation in women suppresses spermatogenesis in men, but it will produce loss of libido and potentially extinguish sexual performance. The principle was first demonstrated in 1974 using oral estrogen and methyl testosterone (275). Testosterone given alone can suppress sperm production to very low levels while maintaining normal libido and sexual performance. Over many years investigators have studied long-acting testosterone salts for male contraception (276). Ethnicity is an important predictor of efficacy of sperm suppression with testosterone therapy. Asian men virtually always achieve azoospermia or oligospermia when treated with testosterone undecanoate (TU) monthly injections, whereas only 86% of Caucasian men achieved azoospermia or oligospermia or with similar testosterone regimens (277). In a Chinese trial, 1,045 men were treated with monthly TU 500 mg. Only 4.8% failed to suppress to a sperm count less than 1 × 106 per mL. The cumulative pregnancy rate was only 1.1 per 100 men at 30 months (278). In Caucasian populations testosterone was combined with progestins to further suppress gonadotropin and improve efficacy. In an important trial with Caucasian men, etonogestrel subdermal implants and TU injections were compared to placebo implants and injections. Only 3% failed to suppress to a sperm count of less than 1 × 106 (279). Side effects that were more common in the medicated group than placebo included acne, night sweats, libido changes (usually increased), and weight gain. Theoretical risks include atherogenesis and prostate cancer but long-term trials will be needed to determine if risk is real. Liver cancer is a concern with long-term androgen therapy (280).
Surgical sterilization is the most common method of fertility control used by couples, with more than 180 million couples having tubal sterilization or vasectomy (4,281) Laparoscopic and hysteroscopic techniques for women and vasectomy for men are safe and readily available throughout the United States. The mean age at sterilization is 30 years. Age younger than 30 years when sterilized, conﬂict within the marriage, and divorce and remarriage are predictors of sterilization regret, which may lead to a request for reversal of sterilization (281).
Female Sterilization Hysterectomy is no longer considered for sterilization because morbidity and mortality are too high in comparison with tubal sterilization. Vaginal tubal sterilization, which was associated with occasional pelvic abscess, is rarely performed in the United States. Five procedures are used in the United States.
1.
Tubal sterilization at the time of laparotomy for a cesarean delivery or other abdominal operation 2.
3.
4.
5.
Figure 10.10 Pomeroy technique for tubal sterilization.
Postpartum tubal sterilization at the time of cesarean delivery adds no risk other than a slight prolongation of operating time; cesarean birth poses more risk than vaginal birth, and planned sterilization should not inﬂuence the decision to perform a cesarean delivery.
Minilaparotomy can be performed in the immediate postpartum state. The uterus is enlarged, and the fallopian tubes lie in the midabdomen, easily accessible through a small, 3-to 4-cm subumbilical incision.
Interval minilaparotomy, first described by Uchida, was rediscovered and popularized in the early 1970s in response to an increased demand for sterilization procedures and a simpler alternative to laparoscopy (282). Still widely practiced in lower resource settings, it is uncommon in the United States because of widespread availability of the endoscopic techniques.