As a Faculty of Family Planning representative on the development group for the RCOG guideline Male and Female Sterilisation, one of my abiding thoughts about our discussions is how health professionals should not impose their own values on others, or apply rigid rules for those requesting sterilisation.
Provided that couples (or individuals) have the mental capacity to understand the implications, have been given the information they need and are not making hasty decisions, especially at a time of crisis or under pressure from another person, then we should accede to their request.
The guideline states that there are no absolute contraindications to sterilistion. Regret after sterilisation is relatively common, however, and we should be aware of any preventable factors. The most common reason, breakdown of relationships, is largely unpreventable. However, care should be taken when advising those under 25 and those seen soon after a pregnancy.
Some individuals may not have considered in enough detail alternative long-acting reversible contraceptive methods. Methods such as subdermal implants, injectables, the intrauterine system and the copper T 380 IUD are as effective as tubal occlusion. Hence the important message in the guideline that counselling and advice should be provided within the context of a service providing a full range of information about and access to such alternatives.
Readers may find the new failure rate quoted for tubal occlusion surprising. Studies have shown that pregnancies after tubal occlusion extend for many years afterwards due to recanalisation. Failure rates as low as 1 in 1000 previously quoted now have to be revised to a lifetime rate of 1 in 200.
This makes the failure rate for vasectomy of 1 in 2000 (after two clear semen tests) look even better. Hence the other rule that both vasectomy and tubal occlusion should have been discussed with all patients who are currently in a relationship.
It is debatable whether this will happen in hospitals where it is assumed that the woman or man is presenting herself or himself for sterilisation. Women in particular should be aware that vasectomy carries a lower failure rate and less procedure-related risk, as it is usually carried out under local anaesthesia.
The term 'tubal occlusion' is used throughout the guideline; we felt that this should become everyday parlance because the word sterilisation implies a degree of permanence that can be misleading.
A small but important point about tubal occlusion is that it is recommended that women are advised to continue to use effective contraception until their post-procedure period. So, for instance, an IUD should not be removed at the time of operation but at a later follow-up appointment which will probably be in general practice.
One of the driving forces behind the development of this guideline was litigation. New consent forms are included (see below) and GPs who perform vasectomy would be well advised to consider updating theirs accordingly. This and the use of accurate, impartial patient information leaflets are part of a medicolegal risk management strategy that GPs ignore at their peril.
|Consent form for vasectomy: from the RCOG guidelines 'Male and Female Sterilisation'|
In the absence of any explicit guidelines on the experience needed before performing vasectomies unsupervised, the consensus of the group was that at least 10 vasectomies should have been performed under supervision before practitioners attempt vasectomies alone.
- For details of how to obtain the guidelines see News story in this issue.