Reversal of Sterilization Reversal of sterilization is more successful after mechanical occlusion than after electrocoagulation, because the latter method destroys much more of the tube. With modern microsurgical techniques and an isthmus-to-isthmus anastomosis, the first-year pregnancy rate is about 44% (301). A retrospective review comparing microsurgical reanastomosis to in vitro fertilization (IVF) found similar total pregnancy rates, but a higher live birthrate with IVF because 10% of the pregnancies after microsurgery were ectopic (301). Hysteroscopic sterilization by the Essure™ and Adiana™ procedures should be considered irreversible. Reversal was not reported and would have to involve cornual resection and reimplantation of the fallopian tubes, a procedure with a very low success rate. IVF appears to be the only alternative for these women.
Late Sequelae of Tubal Sterilization
Increased menstrual irregularity and pain are attributed to previous tubal sterilization. Study of the problem is complicated by the fact that many women develop these symptoms as they age, even though they did not have tubal surgery and are treated with OCs that reduce pain and create an artificially normal menstrual cycle. Women who discontinue OC use after tubal sterilization will experience more dysmenorrhea and menstrual irregularity, which is unrelated to the sterilization. The best answer available comes from the CREST study (302). A total of 9,514 women who underwent tubal sterilization were compared with 573 women whose partners had undergone vasectomy. Both groups were followed up to 5 years with annual standardized telephone interviews. Women who underwent tubal sterilization were no more likely to report persistent changes in intermenstrual bleeding or length of the menstrual cycle than women whose partners had vasectomy. The sterilized women reported decreases in days of bleeding, amount of bleeding, and menstrual pain but were slightly more likely to report cycle irregularity (OR, 1.6; 95% CI, 1.1–2.3). In summary, the CREST study provided good evidence that there is no posttubal ligation syndrome.
Noncontraceptive Benefits of Tubal Sterilization
In addition to providing excellent contraception, tubal ligation is associated with reduced risk for ovarian cancer that persists for as long as 20 years after surgery (303).
Vasectomy About 500,000 vasectomies are performed each year in the United States (281). Vasectomy is a highly effective method. The literature on efficacy is often difficult to interpret because most studies report failure as failure to achieve azoospermia, rather than long-term pregnancy rates among the relevant women. Vasectomy is not effective until all sperm are cleared by the reproductive tract. It is estimated that up to half of pregnancies after vasectomy occur during this time (304). In addition, not all pregnancies after vasectomy can be attributed to the men who had the operation. The best long-term information comes from the CREST study. The cumulative probability of failure was 7.4 per 1,000 procedures at 1 year and 11.3 at year 5, and comparable to the failure rate of tubal sterilization (281).