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This study was undertaken to assess the effects of different tubal occlusion procedures on ovarian function. Three groups of subjects randomized to tubal occlusion by laparoscopy and Yoon ring (24 subjects), minilaparotomy and Yoon ring (19 subjects) and minilaparotomy and Pomeroy (22 subjects), and one separate control group of 26 healthy subjects not using any form of contraception were studied in a prospective design. The characteristics of the menstrual patterns were studied for one year after sterilization. Determination of the circulating progesterone levels were made on days 15, 20 and 25 of menstrual cycles initiated 1, 3, 6 and 12 months following the tubal ligation. In the analysis of the bleeding pattern there was a statistically significant difference in the mean segment length and in the longest bleeding-free interval in the subjects who had been sterilized by minilaparotomy with Yoon ring, when compared to the other two study groups and to the control group. However, the magnitude of this difference in number of days was not considered clinically significant. There was no statistically significant difference in the percentage of ovulatory cycles within the study and the control groups, or when the results of the study groups were compared with each other or to the control group.

PIP: This study was undertake to assess the effects of different tubal occlusion procedures on ovarian function. 3 groups of subjects randomized to tubal occlusion by laparoscopy and Yoon ring (24 subjects), minilaparotomy and Yoon ring (19 subjects) and minilaparotomy and Pomeroy (22 subjects), and 1 separate control group of 26 healthy subjects not using any form of contraception were studied in a prospective design. The characteristics of the menstrual patterns were studied for 1 year after sterilization. Determination of the circulating progesterone levels were made on days 15, 20, and 25 of menstrual cycles initiated 1,3,6 and 12 months following the tubal ligation. In the analysis of the bleeding pattern there was a statistically significant difference in the mean segment length and in the longest bleeding-free interval in the subjects who had been sterilized by minilaparotomy with Yoon ring, when compared to the other 2 study groups and to the control group. However, the magnitude of this difference in number of days was not considered clinically significant. There was no statistically significant difference in the % of ovulatory cycles within the study and the control groups, or when the results of the study groups were compared with each other or to the control group. (Author's).

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PIP: This study presents information about the postpartum sterilization program of a teaching hospital in Nuevo Leon, Mexico, and compares results to data reported in the literature. 147 patients undergoing sterilization between February-August 1984 were included. 6 of the women were under 20 years old, 18 were 21-25, 63 were 26-30, 30 were 31-35, and 30 were 36 or over. 22 had had 1-3 children, 81 had 4-6, 27 had 7-9, and 17 had over 9. 96.6% were married. 92 had never used a contraceptive method, 47 had used pills, 7 had used IUDs, and 1 had used a barrier method. Only 29 had been born in the Nuevo Leon metropolitan area but 126 were current residents. 101 had incomplete or complete primary educations, 8 had secondary educations, 36 were illiterate, and 2 had professional educations. Only 38 had prenatal health care preceding the delivery. Hemoglobin levels in 20 cases were less than 9.0, 28 were 9.1-10.0, 45 were 10.1-11.0, 34 were 11.1-12.0, and 20 were 12.1 or above. 17.6% of patients required preoperative transfusions of packed blood. The indication for sterilization was multiparity in 96.6% of cases. 13 patients had epidural anesthesia during delivery, 1 had a subarachnoid block, and 133 had no anesthesia. 139 had epidural blocks during the sterilization operation, 6 had subarachnoid blocks, and 2 had general anesthesia. There was 1 case of cardiorespiratory arrest but recovery was satisfactory. The only obstetric complication was 1 perforation of the jejunum, which was repaired. There were no other cases of pre- or postoperative complications except for 21 cases of difficulty in providing epidural anesthesia. The Pomeroy technique was used in 139 sterilizations, fimbriectomy in 5, and salpingectomy in 5. Umbilical hernioplasties were done in 3 patients without complications. The interval between surgery and leaving the hospital was between 12-24 hours in 83.7% of cases. The interval between delivery and sterilization was 12-24 hours in 71.4% of cases. Only 9 cases required more than 4 days of hospitalization. The immediate postpartum is not considered the optimal moment for female sterilization because of the increased vulnerability of the patient. The experience with this series suggests that for some patients, tubal sterilization by minilaparotomy in the immediate postpartum is a valuable method because it meets the demand for definitive contraception among high parity women of low socioeconomic level and with limited access to medical care. It requires only brief hospitalization and involves very low rates of morbidity.^ieng

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PIP: A sample of 1003 records of surgical sterilizations was studied from among the 9400 performed between July 1972-June 1982 at a university hospital in Nuevo Leon, Mexico. 12 patients were aged 15-19, 104 were 20-24, 244 were 25-29, 291 were 30-34, 267 were 35-39, and 85 were 40-45. Not all patients met the recommended conditions of being at least 25 years old and/or having at least 3 pregnancies. 11.6% of the patients were sterilized because of psychiatric problems, multiparity, 2 previous cesarean sections or on request of the spouse. 95.5% of the women were married, 2.1% were single, 1.6% lived in free union and .8% were widowed. 14.0% were illiterate, 57.7% had incomplete primary educations, 19.3% had completed primary school, 2.5% had incomplete secondary or technical schooling, and .3% had professional studies. 27 women had had 0-2 pregnancies, 336 had 3-5, 336 had 6-8, 198 had 9-11, and 106 had 12 or more. The maximum number of pregnancies was 20 and the average was 7.1/woman. 6 women had preoperative hemoglobin levels of 6.0 g or less, 12 had 7.0 g, 44 had 8.0, 119 had 9.0 g, 756 had 10.0, and 566 had 11.0 g or higher. Transfusions were given to all women with less than the minimum level of 10.0 g. 460 of the operations were postpartum, 334 were transcesarean, and 209 were interval procedures. 696 operations were done by the Pomeroy method, 52 by modified Pomeroy, 27 by fimbriectomy, 16 by salpingectomy, and 2 by the Uchida method. Among laparoscopic methods, 82 were done by cauterization and 128 with Yoon rings. 392 postpartum and 286 transcesarean operations were performed using the Pomeroy technique, while 82 interval sterilizations were done using cauterization and 107 using Yoon rings. Epidural anesthesia was used in 457 postpartum and 325 transcesarean procedures, while general anesthesia was used in 175 interval sterilization. There were few transoperative complications. There were 2 cases of failure to achieve salpingoclasy, 4 cases of hemorrhage, 1 case of burning of the visceral wall, 1 case of anesthetic accident, and 12 cases of other complications. Among postoperative complications there were 15 cases of abdominal pain, 1 each of fever and infection, and 1 of other complication. There was 1 pregnancy among the 1003 cases. All the procedures were performed by physicians in training.^ieng

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PIP: 50 women undergoing tubal sterilization by the modified Pomeroy technique at a hospital in Toluca, Mexico, were selected at random and followed for 6 months postoperative to detect changes in menstrual patterns. The women had normal menstrual histories and had not used contraceptive medications for at least 3 months prior to operation. Analgesia was provided by peridural block with 2% lidocaine. There were 45 cases of interval and 5 of immediate postpartum sterilization. The women ranged in age from 25 to 44 years and averaged 34.5.16 women, or 32%, had altered menstrual patterns. There were 12 cases of hypermenorrhea and 1 each of oligomenorrhea, polymenorrhea, amenorrhea, and proiomenorrhea. Age at menarche, parity, and obstetric history were unrelated to menstrual changes. Changes in menstrual patterns after surgical tubal occlusion have been attributed to damage in the uterine and ovarian blood vessels leading to reduced blood supply and ultimately to abnormal maturation of ovarian follicles and hormonal changes. Psychogenic factors may play a role. The extent of surgical damage after various techniques of tubal occlusion and the materials used for suturing should be assessed as possible sources of local or regional inflammation that could have repercussions in blood perfusion and nervous function.^ieng

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PIP: A literature review was undertaken of clinical stuides to determine the frequency of menstrual alterations or various psychosocial effects after surgical tubal sterilization. The most frequently mentioned symptoms following bilateral salpingocalsy or salpingectomy are increased menstrual blood loss, dysmenorrhea, dispareunia, pelvic pain, oligemenorrhea, polymenorrhea, and preclimacteric syndrome in some cases. Uribe and colleagues attributed the high frequency of abdominal pain in tubal occlusions achieved with mechanical devices such as rings to the compression pain produced by uncut nerve edings, which do not occur with electrocoagulation or the Pomeroy technique. Alderman and colleagues found that only 6.5% of their patients experienced increased menstrual flow after sterilization, but Rioux found confirmation of menstrual changes to be difficlut and Chamberlain reported change in 2.6-51% of patients, perhaps related to previous use of contraceptives. Radwanska and colleagues found that patients sterilized by electrocoagulation or tubal ligation had a lower average level of serum progesterone in the midluteal cycle phase, 9.4 +or- 4.7 ng/ml compared to 17.4 +or- 7.1 ng/ml for controls. Donnez found that patients sterilized by electrofulguration had an average of 8.5 +or- 6 ng/ml of progesterone in the midluteal phase compared to 15.4 +or- 6.3 ng/ml for those sterilized using Hulka clips. The largest proportion of women with menstrual alterations or pain were younger, lower parity women who were sterilized for medical reasons. Menstrual changes and pelvic symptoms following sterilization are subjective and difficult to evaluate. Some authors cite the rarity of longterm sequelae of sterilization, but others used radioimmunoassay techniques to demonstrate changes in serum progesterone levels that may be linked to alterations in function of the ovaries or corpus luteum following sterilization. Other authors believe that most negative sequelae could be minimized or eliminated with better patient selection and counseling.^ieng

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PIP: Vaginal tubal ligation is a simple procedure, offers minor surgical risks, and has few contraindications. The authors consider it the surgical contraceptive of choice in selected cases. From July 1975 to March 1983 the authors performed 155 tubal ligations by the vaginal route after posterior colpotomy. For each patient opinions were sought from at least 3 physicians, who advised regarding the medical or psychological need for sterilization. The median age was 35 years, with ages ranging from 23 to 48. Median parity was 5.3, with 57 patients having 6 or more children. All were from low socioeconomic backgrounds. 140 tubal sterilizations were done by the Pomeroy method, in 14 by the Pomeroy method on 1 side and fimbriectomy on the other, and in 1 patient a bilateral fimbriectomy was performed. In 3 patients the tubal ligation was completed by abdominal route because of difficulty of vision during colpotomy. All patients recovered well postoperatively, with minimal pain. All received antibiotic therapy with penicillin for 5 days following surgery. Average duration of surgery was 42 minutes. There were no occurrences of lesions, hemorrhages, abcesses, or infection of incisions. With an average follow-up of 41.2 months, the incidence of problems was 0.65%. Contraindications against using the vaginal route include a history of pelvic inflammatory disease, anterior gynecological surgery, alterations in the mobility or size of the uterus, and presence of adnexal tumors. Colpotomy presents several advantages: it is well accepted by the patient because there is no abdominal scar, it is an efficient method that does not require special apparatus such as optical or mechanical equipment, it is associated with minimal morbidity, and there are few complications. Additionally, surgery is of short duration, postoperative pain minimal, and it is economical because hospitalization time is short, with rapid convalescence. Disadvantages observed were: it is not applicable to all patients and requires major surgical training to perform; it requires an extended period of postoperative sexual abstinence, usually 4 weeks. This procedure cannot be used during the immediate postpartum period, with a recommended interval of 6 weeks. Tubal sterilization using posterior colpotomy, in view of the advantages and results obtained, is recommended for selected cases.^ieng

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PIP: The results of 1393 cases of female sterilization are presented in the article. Several techniques of tubal ligation were employed, postpartum and postabortum minilaparotomy, Pomeroy method, and fimbriectomy. Operative procedures are given in details for every technique. Main reason for sterilization was permanent contraception; 92% of patients belonged to low socioeconomic classes, were about 34 years old, with parity over 5, and most with antecedents of abortion and of cesarean section. There were no complications; late morbidity was only 1.47%, and mainly caused by transvaginal surgery. Minilaparotomy was found to give better results than conventional laparotomy; average time for the procedure was 10'. Hospital stay was 3.2 days, and paracervical block was used in over 92% of cases.^ieng

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PIP: The article compares and comments on the results of 2 surveys on female sterilizations conducted between 1971-75 in Valdivia, and in 1975 in Santiago, Chile. Sterilizations were performed either by laparoscopy, 32.3% of cases, or by the Pomeroy method, 67.7% of cases. Most women were married, about half from urban areas, of average age 34 and average parity 4.7, with low educational and socioeconomic status. Belief in the catholic faith did not influence attitude toward sterilization. Socioeconomic reasons were most often cited for seeking the procedure, since most contraceptive methods previously used had resulted in failure. The attitude of partners toward sterilization was favorable in about 75% of cases. Side effects were pain in 24% of cases; sexual relations seemed to be unchanged for the most part.^ieng

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PIP: This article lists 4 responses from doctors practicing in Brazil (Rio de Janeiro, Fortaleza, Sao Paulo, and Porto Alegre), to a questionnaire dealing with several specific techniques utilized in female sterilization. 2 respondents favored laparoscopy on the basis of its numerous advantages, the others preferred laparotomy, citing the expensive equipment and unusual expertise required by the other technique. The respondents generally favored the Pomeroy technique. There was no objection to performing sterilization by cesaren incision, however some variations were suggested as to timing and modus operandi. The respondents were all vehemently opposed to the use of hysterotomy for the specific purpose of sterilization. For techniques involving the ovaries rather than the Fallopian tubes, there was general agreement that until further experience is gained, work on the Fallopian tubes is preferable. 2 respondents described their procedures in the use of laparoscopy for sterilization purposes, the others acknowledged they had no expertise in the matter. None of the respondents use hysteroscopy for sterilization pruposes.^ieng

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PIP: A study of 100 postpartum tubal ligation cases is presented. The frequency of delivery was 0.41%. The Pomeroy method was used in all cases. 87% of the patients were of a low socioeconomic status. The pregnancy average was 8.43% and the live children average was 7. Medical indications along with multiparity were relevant in 84%. There was no postoperative morbidity and late morbidity was 3%. (author's modified)^ieng

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