5.8: Sterilization

Learning Objectives

By the end of this section, you will be able to:

• Explain the female sterilization procedures, their efficacy, and their reversibility
• Explain the male sterilization procedure, its efficacy, and its reversibility

Sterilization, the permanent removal of the ability to become pregnant, is one of the most effective methods of contraception. Female sterilization is used by 18.6 percent of persons aged 15 to 49 years (ACOG, 2021). Male sterilization is used by only 4.5 percent of U.S. men (CDC, 2017). Sterilization is 99 percent effective for both males and females. The choice of sterilization should not be taken lightly, nor should one make this decision assuming that it can be reversed.

Female Sterilization

The term female sterilization used to describe a surgical procedure that permanently terminates fertility in a person with a uterus. Before the person chooses sterilization, education about the procedure and its permanent nature should be provided. During times of psychologic stress, such as after a difficult birth or during a divorce or separation, a person may not think clearly and should not make permanent decisions regarding their health. The nurse and health-care provider should provide clear, factual information that allows the person to truly give informed consent.

Essure

Essure was a device introduced in 2002 for permanent sterilization. Coils (Figure 5.17) were inserted into the fallopian tubes that caused scarring of the tubes, not allowing sperm to reach the ova (U.S. Food and Drug Administration [FDA], 2022). Essure was marketed as a minimally invasive office procedure that was permanent, nonhormonal, highly effective, and took only 45 minutes to place (FDA, 2022). According to the U.S. Food and Drug Administration (2022), adverse effects of Essure were reported, with 69,249 reports from 2002 to 2022. The most common reported symptoms were pain, abdominal pain, heavier menses, hemorrhage, foreign body or fragments found in patient, perforation, headaches, fatigue, weight fluctuations, depression, anxiety, hypersensitivity, rash, and hair loss (FDA, 2022). Other adverse events consisted of possible nickel allergy, migration of the device, device breakage, dislodged device, implant failure (4,578 reported pregnancies, with half ending in pregnancy losses, occurred with Essure in 20 years), difficulty with removal, and difficulty with insertion (FDA, 2022). Essure was removed from the market in Europe in 2017 and in the United States in 2019 (FDA, 2022). Bayer, the company that sold Essure, settled a $1.6 billion lawsuit in 2020; the FDA mandated that post market studies continue to monitor the safety of those persons who had the Essure device implanted (FDA, 2023).

Figure 5.17 Essure Permanent Birth Control Essure coils placed into the fallopian tubes stopped sperm from fertilizing an egg. (CC BY 4.0; Rice University & OpenStax)

Tubal Ligation

Voluntary female sterilization is done by tubal ligation (Figure 5.18), a surgical procedure in which the fallopian tubes are permanently blocked, clipped, or removed. This procedure can be done anytime a person with a uterus is not pregnant, but most often is performed in the hospital after birth because the uterus is already enlarged, and the tubes are easy to locate. During this procedure, the tubes are located, ligated, and clipped (Mills et al., 2021). Complications of tubal ligation can include bowel perforation, pain, infection, hemorrhage, and adverse anesthesia effects (ACOG, 2023c).

Figure 5.18 Tubal Ligation The fallopian tubes connect the ovaries to the uterus. A person whose fallopian tubes are ligated can no longer get pregnant because the egg cannot travel to the uterus. (CC BY 4.0; Rice University & OpenStax)

Consent and When It Is Needed

The decision for a tubal ligation is a permanent one. Many health-care providers will ask if a patient desires permanent sterilization during the first pregnancy visit. This allows the person and provider plenty of time to discuss the tubal ligation procedure and its permanence. Informed consent is then obtained. Patients with Medicaid insurance are required to consent 30 days prior to the procedure to give the person choosing permanent sterilization time to consider the permanence of their decision.

Clinical Judgment Measurement Model

Evaluate Outcomes of Tubal Ligation

The nurse will evaluate the outcomes of the education provided regarding tubal ligation. The following are questions the nurse can ask to determine if the education was successful:

1. How are you feeling about no longer having children in the future?
2. Do you have someone available to help you while you are recovering from your surgery?
3. Did you inform your job of how long you would be off work?

By asking these questions, the nurse can determine that the patient understands they will no longer be able to get pregnant, will need assistance after the surgery, and will need to take a few days off work.

Efficacy

Female sterilization is more than 99 percent effective at preventing pregnancy. Because a person with a uterus still has fallopian tubes in place, there is an increased risk of ectopic pregnancies if the procedure fails (ACOG, 2023c). Tubal ligation is effective immediately after the surgical procedure, and there is no need for a backup method of contraception.

Postoperative Care

Postoperative care for tubal ligation consists of keeping incisions clean and dry to avoid wound infection. The nurse provides patient education consisting of avoiding baths, swimming pools, or hot tubs until wounds have healed; avoiding lifting more than 10 pounds until follow-up with provider; returning to work in several days, depending on the provider’s instructions; and returning to a regular diet (Jacobson et al., 2022). Nurses give anticipatory guidance noting that patients will likely feel shoulder pain, abdominal bloating and cramping, and possible bleeding from the vagina. Nurses instruct patients to call the provider if they experience severe abdominal pain, heavy vaginal bleeding, fever, chills, shortness of breath, or incisions that are red, swollen, and painful with a discharge (Jacobson et al., 2022).

Male Sterilization

Permanently blocking the small tubes in the scrotum that carry sperm to prevent pregnancy in a surgical procedure called a vasectomy is called male sterilization. Besides the external condom, this is the only other male contraceptive method. In the United States, 4.5 percent of women 15 to 44 years of age utilize male sterilization as their contraceptive method (CDC, 2017). Ideally, both partners will discuss the procedure and give consent; however, only the male is required to sign a consent. The health-care provider will counsel the couple on the permanence of the procedure and stress that it should not be thought of as reversible.

A vasectomy is a relatively minor procedure often done with the patient under local anesthesia in an outpatient setting, in which a small opening is made in each side of the scrotum to sever the vas deferens. Ligation or cautery of the vas deferens prevents sperm from reaching the ejaculate (Figure 5.19). Postprocedure care includes resting for 2 to 3 days and applying a cold pack to the scrotum to reduce swelling. Sperm remains in the ejaculate for approximately 3 months, or 15 to 20 ejaculations. Sperm must be absent from the ejaculate for sterilization to be achieved (Zeitler & Rayala, 2021). The patient should be advised to use a barrier method of contraception until sterilization is confirmed. The person will return to the clinic for a sperm count to verify that no sperm are present in the ejaculate. Side effects of vasectomies include pain, infection, hematomas, and spontaneous reanastomosis (reconnecting of the vas deferens) (Zeitler & Rayala, 2021).

Figure 5.19 Vasectomy During a vasectomy, the vasa deferentia are cut and sealed to prevent sperm from passing through and fertilizing an egg during intercourse. (CC BY 4.0; Rice University & OpenStax)

Informed Consent

The decision for a vasectomy is a permanent one. Many health-care providers will discuss the desire for permanent sterilization during the first pregnancy visit, and most health-care providers will discuss both tubal ligation and vasectomy. For couples desiring vasectomy, they are provided with referrals for health-care providers proficient in that procedure. Informed consent is similar to tubal ligation in which the couple understands the vasectomy is a permanent sterilization and should not be considered reversible.

Efficacy

The failure rate of vasectomies is between zero and 2 percent (Zeitler & Rayala, 2021). Failure can be caused by surgical errors, unprotected intercourse before zero sperm count has been verified, or reconnection of the vas deferens. The nurse will provide education regarding the importance of returning for follow-up and a postprocedure sperm count. Vasectomy is a safe and cost-effective option for permanent contraception in people with male anatomy (Zeitler & Rayala, 2021).

Postoperative Care

The nurse educates the person to rest for several days after vasectomy and use an ice pack to reduce pain and swelling. A mild analgesic such as ibuprofen (Motrin) or acetaminophen (Tylenol) can also be taken to reduce pain. The nurse instructs the person to call the office for extreme pain, fever, discharge from the incision, or other signs of infection.