Margaret F. McCann

Risks and Benefits of Culdoscopic Female Sterilization

This paper reviews the risks and benefits of the culdoscopic approach to female sterilization in an analysis of 2153 culdoscopic sterilization procedures performed at 11 centers in nine countries. Inability to occlude the tubes as planned was reported for approximately 6.0% of the cases including 1.4% in which one or both tubes could not be occluded by any technique. Surgical difficulties were reported for about 13.0% of the procedures, and surgical complications, of which the most frequent was torn or bleeding tubes, occurred in 2.0% of the cases. Pregnancy rates were significantly higher for patients whose tubes were occluded by tantalum clips (7.7 per 100 women at 12 months), indicating that this is not the preferred technique of tubal occlusion; the 12‐month life table pregnancy rates were 0.1 per 100 women for tubal ring and 0.0 for Pomeroy and fimbriectomy. Comparison of these data with similar pooled data on laparoscopy and minilaparotomy indicates that culdoscopy is associated with greater technical difficulty and morbidity. Thus, abdominal procedures will continue to be preferred for use in most large‐scale programs.

Laparoscopy and minilaparotomy: two major advances in female sterilization.

n Laparoscopy and minilaparotomy have contributed significantly to the rapidly escalating popularity of female sterilization. This paper reviews these procedures and personnel requirements and compares their safety and efficacy, using data collected by the International Fertility Research Program. It concludes that minilaparotomy with the ligation method of tubal occlusion is the surgical sterilization procedure that can be offered practically, safely, and effectively to the greatest number of women worldwide.n

Training: An Integral Adjunct to the Introduction of Newer Methods of Fertility Regulation

The provision of new technologies of fertility control that are known to be safer, simpler, and more effective may at first result in higher complication rates, particularly if training in the new techniques is inadequate. This was illustrated by analysis of data on several fertility control methods collected by the International Fertility Research Program. Various studies showed significantly higher complication rates earlier in the series than later, including one study in which complication rates fell dramatically after clinical training was provided. Another study showed the highest complication rate among the physicians performing the fewest number of cases. Finally, one analysis documented greater variability in several clinical criteria among the participating physicians than between the two pieces of equipment being compared. These data document that it is essential to train physicians and other staff members in the proper use of new equipment and techniques if the potential improvements offered by new technologies in fertility regulation are to be realized.

Experience with minilaparotomy in the Philippines.

This paper presents the socio‐demographic characteristics, medical histories, and clinical data on 651 women sterilized by interval minilaparotomy procedures in Manila, Philippines. About two thirds of the procedures were performed with local anesthesia; the Pomeroy technique was used for tubal ligation. In 2.8% of the patients, salpingectomy or fimbriectomy was performed on one side because of surgical difficulties and complications. Surgical difficulties were encountered in 19.8% of the procedures; adhesions (4.3%) and bowel interference (4.0%) were the most frequent causes of surgical difficulty. Complications occurred during surgery in 1.7% of the procedures. Early postoperative complications were noted in 9.1% of the cases. None of the patients required readmission to the hospital. While 612 women were followed up at 6 months, 299 were followed up at 12 months. One woman (0.2%) became pregnant after sterilization; at repeat minilaparotomy, ligation of the left round ligament rather than the tube was observed. Pelvic surgery, other than pregnancy‐related surgery, during the year following sterilization was reported for one patient who underwent exploratory laparotomy with appendectomy and oophorocystectomy. Menstrual pattern changes were minimal. The results of this study suggest that tubal ligation via minilaparotomy is practical, safe, and effective.

Progestin-only oral contraception: A comprehensive review: VI. Cardiovascular disease

n In order to provide information for the appropriate package insert labeling of progestin-only oral contraceptives (POC) in the US, a comprehensive review was made of norgestrel (0.075 mg) and norethindrone (0.35 mg), with the clinical differences indicated where applicable. The goal of this review was to cite primary sources for virtually all research specific to POPs since 1975. Conclusions and the types of studies which support these conclusions are given for each major section. The introductory chapter discusses the advantages and disadvantages of POCs and the magnitude and prevalence of their use. Future trends are also predicted. Chapter 2 considers the mode of action, including ovulation prevention; suppression of midcycle gonadotropin peaks; changes in cervical mucus, the endometrium, and the fallopian tubes; and clinical implications. Chapter 3 covers pharmacology (pharmacokinetics, pharmacodynamics and potency, and clinical implications). The next chapter presents information on efficacy and pregnancy outcomes in terms of pregnancy rates, compliance and efficacy, ectopic pregnancies, the outcome of pregnancies conceived while using POCs, and fertility following discontinuation. Chapter 5 focuses on metabolic effects, specifically lipid metabolism, carbohydrate metabolism and diabetes, coagulation factors, and blood pressure. Cardiovascular disease is considered in the next chapter, and chapter 7 presents findings on endometrial, ovarian, cervical, breast, and other cancers. A host of other medical considerations are discussed in chapter 8, including persistent ovarian follicles; reproductive tract infections; abnormal vaginal bleeding; uterine fibroids; gestational trophoblastic disease; benign breast disease; diseases of the liver, gallbladder, and bowel; endocrine dysfunction; epilepsy; bone density; sickle cell disease; ocular effects; surgery; and overdose. The last 4 chapters cover interactions with drugs and laboratory tests, common side effects, breast feeding, and effective use of POCs. Information on precautions and contraindications, indications, use instructions, and instructions for appropriate actions after missing a pill is appended.n

Advances in Sterilization Equipment

From the array of sterilization procedures that are safe, simple and effective, the service provider must select procedures that fit his or her logistical criteria, which include the cost and maintenance of equipment, availability of supplies, and training of the requisite personnel. In this paper, these criteria are discussed for each of the various sterilization procedures. Information about female sterilization equipment for conventional postpartum laparotomy, minilaparotomy, colpotomy, laparoscopy, and culdoscopy is presented, together with facts about the related tubal occlusion techniques. The standard ligation techniques for male sterilization are compared with the newer electrocoagulation and thermocoagulation methods. A variety of methods for both female and male sterilization that are in the research stage are also mentioned. It is concluded that, from a programmatic point of view, vasectomy and postpartum ligation via laparotomy are the optimal sterilization procedures. For women who have not recently been pregnant, minilaparotomy with a standard tubal ligation technique is recommended, except in large teaching hospitals where laparoscopy can be performed efficiently.