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Population Reports SERIES C

NUMBER 7

MAY 1976

STERILIZATION Department of Medical and Public Affairs The George Washington University Medical Center 2001 S Street NW Washington DC 20009

Tubal Sterilization -Review of Methods-

SUMMARY

Widespread demand for simple effective and inexpensive female sterilization procedures which can be performed on an outpatient basis has encouraged both medical practitioners and researchers to evaluate existing methshyods of tubal occlusion and to develop new ones Recent research has concentrated on

bull modification and improvement of older methods of tubal occlusion such as ligation and fulguration

bull application of clips and bands to the tubes bull introduction of chemicals and plugs into the tubes

Invention of equipment such as endoscopes and speshycially-tailored cannulae which now permit a variety of approaches to the tubes has contributed to the developshyment of new methods of tubal occlusion As a result the tracjitionallarge abdominal incision for sterilization (Iapashyrotqmy) has been replaced by a tiny abdominal incision (mihilaparotomy) or punctu re (Iaparoscopy) and by transshyvaginal (colpotomy culdoscopy) or transcervical apshyproaches (hysteroscopy blind delivery) which require no incision

These approaches permit occlusion of any part of the fallopian tube For example the infundibulum (distal fimbrial end of the tube) can be excised buried plugged or capped the ampulla or isthmus (middle of the tube) can be tied cut excised fulgurated clipped banded or buried and the interstitial portion of the tube (near the uterotubal junction) can be coagulated or blocked with chemicals or plugs (see Fig 1)

The choice of approach and the method of tu bal occlusion often depend upon the physicians prior training degree of skill and knowledge regarding the safety and effectiveshyness of the various methods Endoscopic approaches for example generally require more training and skill than other approaches while most transcervical approaches are still considered experimental and are less effective than those performed by other approaches Likewise cautery and some chemicals are associated with a higher risk of damage to structures adjacent to the tubes than ligation clips bands or plugs Methods performed through the vaginal cul-de-sac (eg colpotomy) are asso-

This report on tubal sterilization methods was prepared by Judith Wortman RN on the basis of published reports and articles unpublished papers personal interviews and corresponshydence

The assistance of the following reviewers is apshypreciated Elizabeth Connell William Droegeshymueller Jaroslav Hulka Theodore King R T Ravenholt Ralph Richart John Sciarra and J Joseph Speidel Frances G Conn is Executive Editor Comments and additional updated mateshyrial are welcome

ciated with a higher rate of infection than abdominal approaches Finally methods which interrupt (cut through) the tubes are associated with higher morbidity (eg bleeding) than those in which tube continuity is maintained

Potential for reversibility may be a factor in selecting a particular method of tubal occlusion Experience in both developing and developed countries indicates that most women desiring sterilization prefer a permanent method but many particularly in the younger age groups might welcome a means of sterilization that could be reversed

Although some plugs offer potential for reversibility beshycause theoretically they may be withdrawn from the tube reversibility has not been adequately assessed by tests in humans In animal experiments the tubal epithelium is sometimes destroyed beyond repair when plugs are reshymoved Clips or bands on the other hand destroy a narrow segment of tube but there is virtually no expeshyrience with reversibility Reversal would require a second operation to cut out the crushed section of tube and

CONTENTS

Ligation C-74 Fulguration C-78 Clips C-82 Bands C-84 Chemicals C-86 Solid Plugs C-89 Other Tubal Occlusion Methods C-91 Bibliography C-91

Part 1 of 2 parts-May 1976 mailing C-73

Population Reports is published bi-monthly at 2001 S Street NW Washington DC 20009 USA by the Population Information Program Science Communication Division Department of Medical and Public Affairs of the George Washington University Medical Center and is supported by the United States Agency for International Developshyment Helen K Kolbe Project Director Second class postage paid at Washington DC

anastomose (join) the two remaining ends Ligation is the procedure most often reversed successfully but the same operative procedure for anastomosis is required The use of cautery makes reversibility virtually impossible to achieve because a large segment of tube is destroyed Likewise most chemical methods are not reversible beshycause the epithelium is permanently damaged

Comparisons of the effectiveness of the various tubal occlusion procedures are difficult to make In many cases there are insufficient data and investigators do not conshysider life tables or the Pearl Index in computing failure rates (see Population Reports Series H Number 4 Janushyary 1976) Thus there is no basis for comparison among studies and only estimates can be made from published information

While great strides in knowledge about tubal physiology and in biomedical engineering have been made more research is needed to determi ne the practical ity effectiveshyness and applicability of the newer methods of tubal occlusion such as use of chemicals Until then traditional methods (eg ligation) are likely to remain popular

LIGATION

Tubal ligation (tying the fallopian tubes) to prevent passhysage of sperm and ova is one of the oldest forms of tubal occlusion Nearly a century of experience with this meshythod has eliminated the least effective techniques and the outcome of most of those remaining is now predictable Traditionally performed through a large 10 cm (3-4 inches) abdominal incision (laparotomy) today the tubes are ligated through a 25 cm abdominal incision (minilapashyrotomy) or a 3-5 cm vaginal incision (colpotomy) The amount of skill required to perform ligation the approach used and effectiveness vary according to the type of ligatio1 procedure performed (see Table 1)

Major Advantages

bull only average skill is reshyquired for most proceshydures

bull only simple instrumenshytation is required

bull morbidity is usually low

Failure rates per 100 woman years are computed using the Pearl formula

No of pregnancies x 1200 No of months of exposure

Major Disadvantage

bull most effective proceshydures are usually irreshyversible

bull the procedures pershyformed via laparotomy require hospitalization

Ligatic 1 techniques can be classified into one or a comt i shynation Jf the following categories according to the exte 1t of acti n on the fallopian tubes

bull sim Ie ligation bull liga on and crushing bull liga on division and burial bull liga on and resection bull liga on resection and burial

SIMPL LIGATION Simple ligation is seldom performfd today lecause of the high failure rate asso iated w ith Its use F rst proposed by Lungren (USA) in 1880 (90) simple ligatio preceded other ligation methods by almost t 10

decad s In 1895 DLihrssen (The Netherl nds) used a doubl ligature on each tube in an effort to prevent t 1e failure associated with single ligatures (119) Howevlr subse uent investigations have shown that hydrosalpi r1x (colle ion of fluid) frequently develops between the ttlO

ligatul )S and as a result reports of double ligation have disapf eared from the literature In one of the few recent report on simple ligation Purandare (India) who p rshyforms colpotomy for interval sterilization and laparotor y for p erperal sterilization uses nonabsorbable lin n threac to tie the tubes at the junction of the lateral 0 eshyth ird 0 ld medial two-thirds of the tubes Purandare recogshynizes I Ie possibility of failu re with his tech nique and ac ks up tht procedure by abortion He has not r ecently p bshylished ailure rates orthe percentage of abor ions requir d amon the total number of procedures perf rmed

tv ljor Advantages

bull sirr )Ie to perform bull 1011 morbidity bull hig ll potential for revershy

sib l ity

Ligation and Crushing

MADl NER TECHNIQUE This technique first report ed in 19 ) is easier to perform and results in less bleedi 19 than I lore extensive ligation procedures (144) However like si 1ple ligation the failure rate is higher than forthc se technq ues in which tubal continuity is interrupted In the Madl~ 1er technique the midsection of the tube is picked up to )rm a loop and the base of the loop is crushed wit a clam~ and ligated with nonabsorbable suture matel ial (eg ilk cotton) (see Fig 2) In a modification of t lis techn Jue adopted by some practitioners ~ he top of he loop i cut off

ul us interstitial isthmic-ampullary

infundibLlum

Major Disadvantage

bull high failure rate (up to 20 percent)

Fig 1 Anatomy of fallopian tube in relation to the uterus an ovary

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Like simple ligation the Madlener technique may be performed by the abdominal or vaginal route Recently its performance on an outpatient basis was reported in Taishywan where Ou uses a one finger technique which inshyvolves inserting a finger through a minilaparotomy incishysion (25 cm) to bring the tube onto the abdomen (102) However Chen (Taiwan) reports that the tubes are someshytimes difficult to locate by this blind technique (12) The Madlener technique has also been performed via laparoshyscopy using a prolene loop to ligate the tubes but this procedure requires endoscopic expertise and a high deshygree of skill to manipulate the instruments (39)

Failures following Madlener ligation are probably due to the reanastomosis and regeneration of tissue at the crushed portion of tube following penetration by the ligature Thus tubal patency is restored For this reason the International Planned Parenthood Federation Panel of Experts on Male and Female Sterilization (Bombay 1973) recommended that the tube not be crushed and that use of a nonabsorbable ligature alone would yield better results (67)

The failure rate varies according to the approach used It remains low with laparotomy or culdoscopy but increases with colpotomy (10) The reason for th is difference has not been explained Accounting for all approaches investigashytors have reported failure rates ranging from 1-2 percent (435290)

Major Advantages Major Disadvantage

bull low morbidity bull variable failure rate (deshybull simple to perform pending on approach bull may be performed by a used)

variety of approaches

Ligation Division and Burial

Ligation procedures which involve division of the tube and burial of the stumps are nearly 100 percent effective but are slightly more difficult to perform than I igation and division or ligation and resection In addition the more extensive a tubal occlusion procedure (eg those requirshying burial) is the higher the rate of morbidity such as bleeding Among the techniques in use today are those of Irving and Wood

IRVING TECHNIQUE Although it requires more time to perform than most ligation procedures I rving s technique is highly effective As he reported in 1924 the tubes are divided between two absorbable ligatures and the proxshyimal stump is buried in the uterine myometrium (58) (see Fig 2)

In 1950 Irving reported no failures among 814 women sterilized by his ligation procedure (59) There were also no failures among 1056 procedures in a literature review by Garb (43) and only one failure (05 percent) in 1966 procedures reviewed by Merz (90)

Major Advantage Major Disadvantages

bull nearly 100 percent effecshy bull performed by laparotshytive omy requiring abdomishy

nal incision and hospi shytalization

bull more complicated than many ligation proceshydures

bull poor potential for revershysibility

Fig 2 Often used tubal ligation techniques

WOOD TECHNIQUE A microsurgical technique (pershyformed under magnification) of ligation division and burial-first reported by Wood (Australia) in 1973-reshyquires above-average skill but it is highly effective and potentially reversible The procedure termed atraumatic midampullary sterilization involves division of the amshypullary portion of the tube ligation of the cut ends with absorbable suture and burial of the medial stump in a pocket cut in the mesosalpinx (portion of the peritoneum enclosing the tube)

Thus far the technique has only been used in Australia with a few patients However there have been no failures among 18 women most of whom have been followed-up for two years (151) Although reversal has not yet been attempted the Wood technique is potentially reversible because there is

bull no excision of the tube bull minimal interference with the blood and nerve supply

to the tube bull treatment of the ampulla (widest part of the tube)


bull potentially highly effecshy bull above average skill reshytive (data inadequate to quired date)

bull potentially reversible

Ligation and Resection

Procedures involving ligation and resection (removal) of a segment of tube are easier to perform and therefore are more widely used than those that require burial of the stumps Many techniq ues have been developed since Fritch first proposed ligation and resection in 1898 While some techniques have virtually disappeared from current practice among those still reported in the literature are

bull salpingectomy bull Pomeroy bull fimbriectomy

SALPINGECTOMY Of the ligation and resection techshyniques salp ingectomy-removal of the tube distal to a non absorbable suture placed near the uterus-is least often performed Because the procedure is extensive it offers little chance of reversibility and is associated with higher morbidity (eg bleeding) than many other ligation

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I

Table l-Comparison of Tubal Occlusion Methods Currently Used in Humans

o --J 0gt

Part of

Method Tube Treated

LIGATION Pomeroy isthmus

F i mbriectomy fimbria (distal)

Uchida ampulla

Madlener isthmus

Wood ampulla

Irving ampulla

Cornual resection cornual (proximal)

Salpingectomy lateral

C_~ I l i-~~

FULGURATION coagulate only isthmus coagulate amp divide coagulate amp excise

interstitial (uterotubal junction) isthmus

CLIPS Spring-loaded isthmus

TantJlum hcmocl ip~ i~t hmu

BANDS Falope Ringtrade isthmus

Possible Potential for Approaches Reversibility

minilaparotomya laparotomy coipotomy culdoscopy laparoscopy

mini laparotomy laparotomy colpotomy culdoscopy

minilaparotomy laparotomy

minilaparotomy laparotomy colpotomy culdoscopy

laparotomy


laparotomy

mini laparotomy laparotomy

-i i l ~f~Y

laparotomy colpotomy

good

poor

good

moderate

very good

good

poor

poor poor

unr 00

laparoscopy

hysteroscopy

moderate poor poor poor

culdoscopy poor

laparoscopy (other routes possible)

very good

mini laparotOnlY laparotomy colpotomy culdoscopy lapar U() fY

very Qood

Done with Standard

Equipment

yes yes yes no no

yes yes yes no

yes yes

yes yes yes no

no

yes yes

yes

yes yes

P

yes yes

no no no no

no

no

no no no no nCi

laparoscopy not tested no (other routes possible)

Degree of Skill

Required

average average above average high high

average average above average high

above average above average


above average

average

average

average average

Q r~np

average above average

high high high above average

high

In Range of Experimental Cost Failure

Stage Rate

no no no no

yes

no no no no

no no

no no no no

yes

no no

no

no no

nn

no no

no no no

yes

no

high no

a VPfilge no average no above average no high no hlg no

high no

low high high high t high t

low high high hight

low high

low high high high t

high

low high

high

low high

Inw

hIgh high

hight

hight

hight

hight

high t

high t

low high high high t hlgh t

high t

0-D4 (higher when performed by culdoscopy)

nil

(higher when performed post -partum)

nil

03-2 (higher-30shywhen performed by colpotomy)

nil

nil

28-3 2

0-19

20

1-2 01-2

0-D_6 10-25

30-40

02-D6

5-18

Incidence of

Morbidity

low low moderateb

low low

low low moderateb

low

low low

low low moderateb

low

low

low

moderate

moderate

low lOW

mOderateb

moderate high high moderate

low

low

low

nil low

Possible as

Outpatient Procedure

yes no no

yes yes

yes no no

yes

yes no

yes no no

yes

NR

yes no

no

yes no

ves no no

yes yes yes yes

yes

yes

ves no no

yes ye

yes

-5

c o a J

al sect

c o

( tl J

shy ~ [ 0 on

procedures It is performed via the abdominal or vaginal routes

In 1973 Stoot (The Netherlands) reported combining salpingectomy and cautery via colpotomy Two linen sutures were tied around the tube close to the uterus The more distal suture was also tied around the mesosalpinx The tube was then cut and the remaining stump cautershyized Hysterosalpingograms performed three months folshylowing the procedure showed one tube was patent in two (1 9 percent) of 106 women (140) However in a previous review of the literature Garb (USA) found that investigashytors reported no failures following salpingectomy (43)


bull effective (0-19 percent bull irreversible failures)

bull can be performed by either abdominal or vagshyinal routes

POMEROY TECHNIQUE The Pomeroy technique of tubal ligation is the most freq uently performed of all ligation techniques Although Pomeroy developed this technique in the early 20th century it was not unti I after his death that a description of it was published by his colshyleagues (7) The techniques simplicity and high degree of effectiveness have made it popular in all countries The technique requires picking up the tube near the midporshytion to form a loop ligating the base of the loop with absorbable suture and cutting off (resecting) the top of the loop As the suture material is absorbed the ends of the tube pull apart (128) (see Fig 2)

The IPPF Panel of Experts recommended the Pomeroy technique for tubal ligation using traditional abdominal or vaginal approaches (62) For many years the technique has been the procedure of choice in the immediate puershyperium at which time it is performed via laparotomy For interval sterilization Pomeroy ligation is performed via laparotomy colpotomy or culdoscopy and recently by minilaparotomy and laparoscopy

Clark Loeffler Gre~ne and Alexander have described Pomeroy ligation via laparoscopy whereby the tube is either tied within the abdomen or brought out through the abdominal puncture site for ligation (2 144581) Howshyever the procedure is complicated thus making this approach less attractive than simpler ones such as minishylaparotomy

Although the usual failure rate for Pomeroy ligation is low (0-04 percent) (4390 110 152) some investigators have reported failure rates ranging from 25 to 5 percent when the technique is performed at the time of cesarean section (43 103 110) No account has been given for the high failure rate when the technique is used at this time However in 1970 Husbands reported that among his patients the failure rate for the procedure performed at cesarean section is comparable to that for interval Pomeshyroy ligation He reported one failure (0 2 percent) in 400 patients 202 of whom were followed up for three years (57)

on on

raquo

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OlOl

OJ ~ ~ OJ

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C-77


bull simple to perform bull none bull highly effective (0-04

percent failure rate) bull possible in the immeshy

diate puerperium bull possible by the abdomishy

nal or vaginal route bull potentially reversible bull low morbidity

FIMBRIECTOMY Fimbriectomy removal of the distal (fimbrial) end of the tube can be easily performed by the vaginal route and is highly effective as an interval proceshydure Developed in 1935 by Kroener and reported in 1969 by his son the technique involves placement of a double silk ligature near the distal one-third of tube and excision of the fimbrial end (see Fig 2) Despite treatment of the distal part of the tube there is no interference with the ovarian blood supply

Fimbriectomy for interval sterilization is associated with a low failure rate For example Kroener encountered no failures among 146 women followed up for a minimum of six years (107)

Although fimbriectomy may be performed either through the abdomen or vagina the IPPF Panel of Experts favored the vaginal route as an interval procedure or following vaginal abortion because only the distal end of the tube needs to be exposed However the Panel stated it should only be performed when a nonreversible method is deshysired (67)

Uchida well known for his own tubal ligation technique has also developed a modification of the Kroener techshynique to prevent failures from recanalization associated with postpartum fimbriectomy In the Uchida technique the cut distal end of the tube is covered with serosa (a thin membrane) thereby providing an extra block to sperm or ova (145146) Using this technique Uchida encountered no failures in 405 postpartum fimbriectomies and no failures in 120 fimbriectomies performed following cesarshyean section (175)


bull nearly 100 percent effecshy bull less effective when pershytive as interval proceshy formed abdominally dure postpartum

bull easily performed via vaginal route (also posshysible via the abdominal route)

Ligation Resection and Burial

Ligation procedures which require burial of cut ends of the tube are more difficult to perform than simple ligation and division or excision Two ligation resection and burial techniques still practiced today are cornual resecshytion and the Uchida technique

CORNUAL RESECTION Cornual resection is an extenshysive procedure requiring laparotomy First reported by Neumann in 1898 cornual resection involves placing an absorbable ligature near the uterotubal junction incising the tube proximal to the ligature dissecting it free from the mesosalpinx and then removing 1 cm of tube After a

wed~ of surrounding uterine myometrium is excised to previ t endometriosis and ectopic pregnancy (1 44) the prox nal end of the distal segment of tube IS buried in the broa ligament (see Fig 2)

Aajor Advantage Major Disadvantages

bull or y a small amount of bull moderately high fail re tu e is exposed thus rate (28-32 perce-nt) pr ducing minimal inshy due to regeneration of te erence with broad tubal epithelium in the li~ ament or ovarian cornual area bl od supply bull profuse bleeding u_ushy

ally from the tube may be difficul t to con tro l

bull high risk f postope ashytive adhesions

bull reversibility unlikely bull requires laparoto y

UCH JA TECHNIQUE The Uchida technique of tu al occll ion is often performed in Japan where it prove to be e1fective The technique is also performed in so e other ountries (eg USA) but on a more limited scale

Uchid l (Japan) developed his technique of tubal li gation reseclion and burial in the mid-1940s It requires that he tube e brought out onto the abdomen through a sma I 1 cm or less suprapubic incision (minilaparotomy) Epishyneph ne-saline solution (11000) is injected beneath he seros in the ampulla of the tube which produces loal vaSCl ar spasm and ballooning of the mesosalpinx t us separ ting the serosal surface from the m cular port ion of thE tube The serosa is incised and stripp d back a 5 m segm nt of the proximal tube severed the short stu np ligatE I with nonabsorbable suture and a segment of t be remo ed The ligated stumps automatically bury he-mshyselver beneath the serosa The edge of the s rosal incis on is the gathered around the distal end of tu be and tied i a purSE string ligature so that the tube is left projecting irl to the a dominal cavity (145 146) (see Fig 2) Usi ng is tech nique Uchida claims he has seen no fai lures in 21 00 cases though many patients have not bee followed up after Jbal ligation

t ajor Advantage Major Disadvantage

bull hi~ Iyeffective bull more cOrlplicated to perform than most li gashytion procedures

FULGURATION

Fulguration (burning a segment of tube) is tubalocc lushysion n ethod used frequently in both developed and develshyoping countries during the past 15 years 1 some counshytries uch as the USA it has become more prevalent than ligatic 1 for accomplishing interval sterilizat ion (see Tallie 1) It 13 usually performed via an endoscope (a viewi g SCOpE inserted into the abdomen (Iaparosc py) or uter us (hyst coscoPy) or through the vaginal cul-de-sac (cl l shydoscc )y) Using a special instrument (eg grasping forshyceps irobe) burning heat is applied to a small pOint on or withir the tube by a concentration of electrical current Howe er to date there is no standardization of kind and amou t of current or length of time it must be applied in order 0 destroy the tubal lumen

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--

Table 2-Failures Following Laparoscopic Fulguration of the Fallopian Tubes in Selected Studies 1973-1976

Author Reference Number of Technique of Failures

amp Date Number Patients Tubal Occlusion Number Percent Comments

Edgerton 27 2018 coagulation division 12 06 9 luteal phase pregnancies 1974 and excision 3 operator errors

EI-Serour 28 82 coagulation and divi shy1975 sion

3 20 operator error 70 coagulation only

IVleeless 149150 1000 coagulation only 11 11 recanalization 1973 amp 1976 1600 coagulation division 01 luteal phase pregnancy

and recoagulation of the cut ends

Yuzpe 158 335 coagulation only 0middot 0 1974 I

middot Procedure performed during luteal rather than proliferative phase of the menstrual cycle at which time patient was pregnant No failures occurred following use of bipolar equipment

Major Advantages Major Disadvantages

bull effective bull risk of burns and perfoshybull outpatient procedure ration injury to adjacent bull does not require large structures

abdominal incision bull special equipment reshyquired (elect r ical source fulguration equipment)

bull equipment difficult to maintain

Laparoscopic Fulguration

Of all fulguration approaches laparoscopy is the most popular because in the hands of a properly trained physishycian it is not only quick but also highly effective Laparoshyscopy was first proposed as an approach to tubal occlushysion by ET Anderson (USA) in 1937 (4) and described by Power and Barnes (USA) in 1941 (111) Although the technique was improved by Palmer (France) during the 1940s it was not until the 1960s following development of modern laparoscopes which use fiberoptic light bundles to transmit cold light from an external source directly into the abdomen that laparoscopic fulgu ration of the falloshypian tubes became widely used

Once the abdomen is insufflated with 2-4 liters of gas (pneumoperitoneum) and the tip of the laparoscope is introduced into the abdomen through a small puncture the fulgurating instrument can either be inserted through a speCial channel in the scope or through a second tiny puncture (see Fig 3) The tube is then picked up and either coagulating or cutting current applied The choice of current depends upon whether or not the practitioner intends to divide the tube Coagulation current causes cellular dehydration and charring without division while the intense heat of cutting current causes the tube to divide Both kinds of current are potentially dangerous coagulating current may produce sparks which burn adjacent structures (37 124 130) and cutting current may

also result in bleeding from the cut ends of the tube (37 124130) Edgerton an experienced laparoscopist uses a mixed current for both electrocoagulation and cutting This produces blanching hemostasis and cutting with very little charring and without the sparking which causes burns (27)

Because burns of the bowel or other adjacent structures have been reported following laparoscopic fulguration many investigators now prefer to use bipolar instruments (current passes only between two closely placed elecshytrodes) or equipment employing only low voltage current both of which reduce the hazard Although laparoscopic fulgu ration is highly effective (01-20 percent failure rate) work is being done to eliminate failures and reduce morshybidity I n this respect practitioners using the laparoscopic approach to tubal occlusion have been most concerned with the number of times a tube must be burned and whether the tube should be transected andor a piece removed (see Table 2) The debate over which method is best still continues because the most effective procedures are often associated with high morbidity rates and the safest procedures with high failure rates In 1975 1000 physicians from around the world were asked by the American Association of Gynecological Laparoscopists to state the tubal procedures they preferred (108) Results follow

Number Percent Coagulation only 214 214 Coagulation and division 404 404 Coagulation and excision of

a segment 306 306 Other procedures 27 27 Not answered 6 06 No sterilization performed 43 43

1000 1000

The AAGL survey data must be interpreted cautiously since results of the different procedures chosen by the

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respondents are subject to varying interpretation Howshyever the survey did indicate that failure rates (in terms of pregnancy) are about the same for all three procedures but morbidity (eg mesosalpingeal tears with subsequent bleeding) was higher when a segment of tubewas excised (108) The survey also revealed that the percentage of laparoscopists performing coagulation alone increased from 153 in 1974 to 214 in 1975-an increase probably due to the lower morbidity associated with this technique Although early reports of coagulation alone revealed high failure rates some practitioners now claim that if a segshyment of tube is adequately fulgurated (ie blanching is visible on each side of the fulguration instrument) failure is unlikely and there is thus no advantage in dividing the tubes

Studies conducted in 1974 reveal that electrocoagulation without division using the new bipolar instruments may be as effective as dividing the tube Performing coagulation alone with a bipolar instrument Yuzpe encountered no pregnancies in 335 women many of whom had been fOllowed up for 10 months after sterilization (158) Broader experience is needed to determine the true efficacy of this technique

Wheeless (USA) tested the effectiveness of coagulation alone versus coagulation and division with conventional equipment Among 1000 women who were sterilized by coagulation alone there were 11 failures (11 percent) most of which were due to recanalization of the fallopian tube in the area of el ectrocoagulation (149) In contrast the three-burn technique-where a portion of tube is excised and the two remaining ends coag ulated-resulted in no recanalization failures (150) The failure rate reshymained low (025 percent) in Nepal where this technique was used in 2000 women but 35 patients (17 percent) experienced tubal hemorrhage All but two of the bleeding complications were controlled by recoagulation through the laparoscope the remaining two required laparotomy to control the bleeding (149)

Safer and equally effective sterilization by the coagulation and div ision technique has been achieved by a few practishytioners using low thermal current (74 129 137) Prior to insertion of the fulguration instrument which is heated from the inside by a wire the operator selects the amount of heat and length of time it is to be applied Because low voltage (6 volts) and low temperatures (usually under 140degC) are used the risk of burns to nearby structures such as the bowel during fulguration is reduced When the maximum temperature is reached and applied to the tube for the selected time the coagulating forceps cools automatically Thus there is also little danger of burns from inadvertent contact with nearby structures following fulguration One millimeter of the tube is burned on each side of the fulguration instrument then the tube is divided and hemostasis ascertained for the remaining ends Only those vessels in the mesosalpinx immediately adjacent to the segment of tube treated are coagulated Therefore the risk of bleeding is also minimized Using this technique Semm has performed over 270 sterilizations without accishydents (129) but the technique is still experimenta l and only limited experience with low thermal coagulation has been reported Because only a small section of tube is

Fig 3 During laparoscopic fulguration th operating lapE oscope (for single puncture laparoscopy) is inse ed thro IJgh lower rim of umbilicus The fallopian tube is grat ed by the fulgurating instrument inserted through a spemiddot ial channel in the scope

destre l ed potential exists for future reversal by surgi al reana tomosis of the remaining ends (137) The fact It at only I w voltage is required-the amount supplied by a car batter -suggests that this procedure might be used in areas where sophisticated electrical equipment is u navailshyable ( 29)

Becal e excision of a segment of tube is the most com plishycated of the fulguration procedures and associated with highel morbidity from mesosalpingeal tears which ca LI se bleed g Soderstrom (USA) indicates it should only be under aken by a surgeon experienced in operative lapashyroscopy (132) Most pract itioners who use this techni ue remo e a segment of tube to confirm histo logically t 1at they ave fulgurated the tube and not an adjacent str cshyture ~ g round ligament) However in n April 1)75 meet g in London the IPPF Panel of Experts on Sterilizashytion r ade the following statement regardi ng excision of a segrn lmt of tube

Tt ) panel does not recommend the removal of parts of thl ut rine tube for biopsy and histological examination as ct ck on the success of the operation Such a procedur m y add an otherwise avoidable risk of hemorrhage mak re ersibility more difficult burden the patho logical serv -Cf and increase the cost of the operation to the patie t c r th service Even when established practice in the comshym nity is to remove tissue for biopsy the panel doe~ not C( lsider this an essential part of female steri lization (68 1

OncE experience is gained in identifying the tube misshytakef rarely occur Thus most physicians now si mply coag late and divide the tube without obtain ing a spolcishymen tsee Fig 4)

Acce di ng to the 1975 AAGL su rvey over 40 percent of phys ians coagulate and divide the tu be while 306 perc7l t (down from 50 percent in 1971) excise a segment of tu e (108) The coagulation and division procedure is not ( I Iy less complicated to perform than excis ion but also rasults in a low failure rate if transection is complete and cludes a segment of the mesosalpinx In Sodershystror s opinion one adequate transection is superior to mult p ie partial or incomplete ones because it more fully prev nts recanalization (132)

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bull riighly effective (01-20 bull requires light source inshypercent failure rate) sufflation and fulgurashy

bull permits visualization of tion equipment the pelvic cavity for pashy bull equipment expensive thology at the same time and difficult to maintain sterilization is pershy bull successful reversal unshyformed likely

bull quick (requires 15-20 bull high risk of burn morbidshyminutes) ity (02-13 percent)

bull outpatient procedure requiresa high degreeof bull does not require an abshy physician skill

dominal incision

Hysteroscopic Fulguration

Although most physicians consider hysteroscopy easier to perform than laparoscopy because it requires less equipment tubal fulguration by hysteroscopy has been generally unsatisfactory because of the high incidence of failure and morbidity To occlude the tubes a hysteroshyscope (fiberoptic scope) is inserted via the cervix into the uterus and an electrode inserted through a channel in the hysteroscope is passed into the tubal orifices at the uterotubal junction An electrical coagulating current is then applied (see Fig 5)

Early attempts at cornual occlusion involved the blind insertion of a cautery sound into the upper angle of each uterine horn Although first attempted by Kocks (Gershymany) in 1878 it was not until 1929 that the first patient series of any size was reported At that time Dickinson stated he had performed cautery stricture of the uterine ends of the tubes in 65 women Current was passed for 10 to 30 seconds-the longer period of time used for women with more vascular uterine linings If the tubal vestibules were difficult to locate X-rays were used to visualize the cornua (25) Dickinson reported the new hysteroscopes would permit direct visualization of the uterotubal juncshytion and might improve the transcervical route to sterilizashytion (25) Gauss and Mikulica-Radecki (Germany) and Freund (Germany) in 1928 and Schroder (Germany) in 1 noted some difficulty in attempting tubal electroshy

I

Fig 4 Steps in laparoscopic fulguration of fallopian tube on a surgical specimen 1) approaching tube 2) grasping tube with coagulating forceps 3) fulguration and cutting and 4) final appearance of tube (whitened with chalk for clarity) (Courtesy of Dr William Brenner University of North Carolina Chapel Hill USA (9))

Fig5 A hysteroscope is introduced into the uterine cavity which has been distended by gas or liquid Under direct vision an electrode inserted through a channel in the scope is guided toward the uterotubal junction for subseshyquent electrocoagulation (Source Pauerstein CJ (106) p 166)

coagulation using a hysteroscope Subsequent improveshyment in instrumentation and experiments with media (eg nitrous oxide or dextran) to distend the uterus made it easier to locate and place an electrode directly into the tubal orifices under direct vision thus increasing the safety and effectiveness of fulguration

Failures may be caused by technical difficulties Uterine anomalies such as polyps deep uterine horns or a uterine septum can prevent passage of the electrode into the tubal orifices (114) Another technical difficulty occurs after cauterization of one tube if tissue adheres around the probe insulating it so that fulguration of the second tube is less effective To increase the effectiveness of the second fulguration Lindemann uses a different probe on the second tube (78)

In a review of 10 hysteroscopiC sterilization studies involvshying a total of 524 women Darabi reports a failure rate ranging from 125 to 828 percent I n the total series there were 186 fail ures (355 percent) 175 of which were discoshyvered during postoperative tubal occlusion tests Eleven pregnancies occurred following tests for tubal occlusion A 237 percent failure rate was noted among women who were not tested postoperatively (19)

Failures in the form of interstitial (within the interstitium of the tube) or cornual (withi n the myometrium of the uterine cornua) pregnancies have occurred following hysteroshyscopic fulguration Israngkun reported eight such pregshynancies (31 percent) among 251 women sterilized by this procedure (61) Because these pregnancies may rupture and lead to severe hemorrhage and are thus hazardous to the patients life he determined that hysteroscopic fulgushyration should not be done in rural areas of developing countries where backup medical facilities are not available (61)

Lindemann who discovered interstitial pregnancies in two patients two months after fulguration hypothesized that high frequency current does not destroy enough tube and its deep penetration into tissue causes necrosis and enlargement of the tubal openings which can lead to failure of the sterilization (79) Subsequently he used a

C-81

low-voltage-current thermoprobe (a sound heated from the inside) in which temperature can be predetermined and accurately controlled thus minimizing the risk of burns to other than tubal tissue No ectopic pregnancies resulted but the overall effectiveness rate (88 percent) in terms of tubal occlusion had not improved (79 129)

Most investigators now recognize that timing the passage of cu rrent and regulating voltage are important to provide sufficient damage to the tubal ostium without spreading current beyond the uterine muscles and tubes Nevertheshyless use of controlled temperatures and of time durations has not greatly improved the effectiveness of hysteroshyscopic fulguration (133 134) Although investigations are continuing in an effort to find the optimal procedure (see Table 3) many physicians have abandoned hysteroscopic fulguration in favor of introducing chemicals or trying different approaches to tubal occlusion


no incision required risk of uterine perforashybull quick outpatient proceshy tion and burns

dure high failure rate (11 shy 35 percent) risk of ectopic or cornual pregnancies

bull frequent technical diffishyculties in locating tubal orifices

bull may not be immediately effective

NTC thermoprobe FM W iest KG Rei chpietschufer 20 Berlin 30 Federal Republic of Germany

CLIPS

Since lips to occlude the fallopian tubes a e associated with Ie N morbidity are easy to apply by the bdominal r vagina l route and may result in a potentially reversib le tubal ( clusion their use in female sterilizat ion is gaini g wider ttention However clips are not use as often s ligatio or laparoscopic fulguration methods because of the PI walence of reported failures inclu ing ectopic pregn middotncies with some models

In 195 Evans (USA) suggested that clips were a simple safe c ld quick way to occlude the fallopian tubes (33) In the H Os when the use of cautery for tubal occlusi n becan 3 popular and reports of burns to structures near the tu e began appearing in the literature a number f physi( ans began experimenting with clips s a less hazshyardou method of tubal occlusion

Despi the simplicity of clip application a imal exper ishyments onducted in the 1960s showed that lips often are less e ective than conventional methods ei ther becau 3e they e pand after application renewing tu b I patency or becau e they become dislodged from the tube (83100) Despi- 1 failures researchers were encou raged by t il e minim I damage to the tissues which makes t e proced ure poten ally reversible In one of the first a imal experishyments reported by Neumann and Frick in 1961 paten y was ru tored in 50 percent of the fallopian tubes of bashyboom after clips were removed (96) However in 19 74 exper rnents by Ma and Wong (Hong Kong) only 2 (9

Table 3-Female Sterilization by Hysteroscopic Fulguri ion in Selected Studies 1974-1976

Author

amp Date

Refershyence

Number

Number of Patients

Kind of

Fulguration Current

Number Co ulashy

of t i n Seconds Terri era-

Applied t l e

Failures Indicated by

Tubal Patency

Failures Indicated by Pregnancy

Total Effect-Failures ivenelS

(Percent) (Percentl

Israngkun 1976

61 251 high frequency

30 watts at 2-3 volts

45-60 1 I NR 48 (8 ectopic or cornual pregs)

19 81

Lindemann 1976

79 48 low thermal

2 watts at 6 volts

60-90 95- 40degC 10 unilateral

12 bilateral 48 52

360(314) high frequency

25-30 watts 30-90 9( C 21 unilatera

13 bi lateral 9 (2 ectopic) 11 89


2-3 watts at 5 volts

60 9( C 17 unilatera

6 bilateral 7 (1 ectopic) 11 89

March 1975

87 27(23) high frequency

30 watts 12 1 I 2

Quinones 1976


27 8 watts 4 1 I 18 5 (3 cornual)

26 74

(179) high frequency

278 watts 6 1 I 30 17 83

Sugimoto 1974


30 watts or 40 watts

3-4 2

1 I 0 0 0 100

Number of patients followed up appears in parenthesis Of 16 patients 11 had sinus tracts which could lead to later recanalization fi lure

NR = Not Reported

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percent) of 22 rabbits became pregnant following clip removal and nine months of breeding (83) The investigashytors hypothesized that interruption of the blood supply to the tube may have caused permanent injury making revershysal impossible (83)

Realizing that tubal physiology and fertility rates in anishymals are different from those in humans several investigashytors began applying clips to human fallopian tubes Reshysearchers used the approach to the tubes most familiar to them-laparotomy laparoscopy colpotomy or culdoshyscopy Particular consideration was given to the number of clips applied to the tube where they were applied and the material used to make them (132) (see Table 4)

Tantalum Clips

Most of the clips used by investigators in the last two decades have been made of tantalum a non-tissueshyreactive metal The most frequently used model is simple in design with grooves on the inner surface to secure its grip on the tube It is applied to the tube via a specially designed pliers or applicator (see Fig 6)

Previously the clip was used to provide hemostasis (stop bleeding) during surgery and was highly effective when used for that purpose However the clip is less effective when used for tubal occlusion Failure rates of more than 10 percent particularly among puerperal patients have been recorded (49) Failures usually result when a clip

migrates off the tube bull opens slightly renewing tubal patency (may be

caused by normal buildup of intraluminal secretions) bull cuts through the tube leading to recanalization bull opens subsequent to the pressure produced by a

hysterosalpingogram or injection of dye used to test tubal occlusion

There is also danger of subsequent ectopic pregnancy when a clip opens wide enough to permit passage of sperm but not a fertilized ovum (49 97 106) ln an effort to reduce this hazard and increase effectiveness Wheeless and other investigators applied two clips to the tubes but the fai lure rate remained unacceptably high (112 percent) (148) The highest effectiveness rate (09 percent failure rate) was achieved by Gutierrez-Najar who applied two clips and then cut between them However as with all procedures where the tube is transected there is greater risk of bleeding from the cut ends of tube


bull simple in design and ap- bull high failure rate (00-11 plication percent potentially reversible bull risk of ectopic pregnancy inexpensive

bull application possible by a number of approaches

Reports of failure with tantalum hemoclips have led a few investigators to develop new designs to improve the efficacy of clips One of the most recent designs is being developed by Filshie (Great Britain) in cooperation with the Simon Population Trust The clip has an outer surface of tantalum and a soft-ridged inner core of Silastic It has been tested successfully in animals and human trials are to begin soon (11)

Spring-loaded Clips

In extensive clinical trials a spring-loaded clip designed in the 1970s by Hulka and Clemens (USA) has been judged more effective than the tantalum clip The clip has two plastic-toothed jaws which are hinged by a metal pin and are locked closed around the tubes by a stainless steel

Table 4-Tubal Occlusion by the Application of Clips in Selected Studies 1971-1975

l I

Author amp Oate Reference Number

Number of Patients

Kind of Clip Approach

Used

Number of Clips Applied to Each Tube

Part of Tube Treated

Failures Number Percent

Effectshyiveness

(Percent)

Davidson 20 9 tantalum laparoscopy 2 NR 2 22 78 1972 hemoclip

Gutierrez-Najar 47 1112 tantalum culdoscopy 2 isthmus (cut 9 99 1971 hemoclip between clips)

Haskins 49 100 tantalum laparotomy isthmus 11 11 89 1972 (puerperal) hemoclip

250 tantalum colpotomy isthmus 3 99 (nonpuerperal) hemoclip

Huang 52 64 tantalum culdoscopy isthmus 3 7 93 1975 hemoclip

Hulka 53 907 spring- laparoscopy isthmus 24 2 98 1975 loaded

Mroueh 94 150 tantalum culdoscopy isthmus 1(ectopic 18 82 1976 hemoclip preg)

600 tantalum culdoscopy 2 isthmus 3(1 ecto shy 5 95 hemoclip pic preg)

Wheeless 149 52 tantalum laparoscopy 2 1 amp 2 cm from 14 27 73 1976 hemoclip cornua

For recorded failures no differentiation is made between tubal patency and pregnancy NR = Not Reported

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spring (see Fig 7) Although the clip may be placed on the isthmus of the tube by any route its applicator was originally designed for laparoscopic use (see Population Reports Series C NUf11ber 4 March 1974)

As of March 1974 the spring clip had been applied in over 1000 women at nine different locations with a minimum one-year follow-up (56) The majority of clip applications was done as interval sterilization A few procedures were done following a first or second trimester abortion but because the tubes are edematous after second trimester abortion two clips were applied

In a follow-up study of 907 patients 24 failures occurred 11 were due to operator error 3 were luteal phase pregshynancies 3 occurred in early experiments using a protoshytype clip with incorrect spring tension and in 7 the cause of pregnancy was unknown On reexamination of 2 of these 7 patients clips had been properly applied (56) Hulka reports that if properly manufactured clips are correctly applied to the tube the pregnancy rate will be about 2 1000 or less (53) He suggests that the failure rate is likely to be slightly higher than that for fulguration because the tube must be caught properly in the jaws of the clip Thus there is greater chance of operator error

Only minor morbidity has occurred following spring-clip application Although a vagal reflex (nausea faintness bradycardia hypotension) occurred in 8 percent of Unishyversity of North Carolina patients the most often reported side effects during or following clip application were abdominal pain and cramps (26 percent of patients) In countries where more sedation and local anesthesia are used operative pain has not been a reported problem In other series the application of local anesthesia to the tube has eliminated operative pain Cramps lasting up to 48 hours following the procedure are thought due to the pressure of the clip on nerve endings in the tube and mesosalpinx and are treated with analgesics

To reverse occlusion produced by the spring-clip the section of tube under the clip which has undergone necrosis is cut out and the two remaining ends of tube

Fig 6 A tantalum Weck Hemoclipreg being applied to fallopian tube by means of a special laparoscopic clip applicator (Photo courtesy of Dr Hans Frangenheim Chief of the Womens Clinic Kostanz Federal Republic of Germany Weck Hemoclips are manufactured by Edward Weck amp Company Inc 49-33 31st Place Long Island City New York 11101 USA)

Fig 7 A spring-loaded clip in its laparoscopic applicator pri r to closing on fallopian tube (Courtesy of Dr Jaros lav Hu a University of North Carolina Chapel Hill USA)

joinec To date reversal by reanastomosis with Dexon ) sutUrE has only been attempted in 8 pigs six months folio ng clip application Six of the eight pigs became preg n nt Therefore a 75 percent restored fertility n te occur1ed which compares favorably to an 80 percent fertilil rate for pigs under normal husbandry condit ions (55)

~ ajor Advantages Major Disadvantages

bull

10 morbidity OL patient application pc sible pc entially reversible ef 1Jctive (02-15 pershyce t failure rate)

high cost of clip appl icator technically difficult

a d

Plastic Clip

Use 0 a plastic clip to occlude the fallopian 1ubes is bei lg invest i gated by Bleier in Germany The clip IS 10m IIO1g and 4 mm wide Between 1970 and 1973 the cli p vas appliE i to the fallopian tubes of 600 women via colpotomy lapan omy or minilaparotomy No mortality was reported and t e only morbidity was slight bleeding from t e fallop In tube and ovary It is possible that bleeding res Its from )ars of the vessels in the mesosalpinx which occur as thE clips latch snaps shut (53) No adh sions formed folioll ng clip application Technical diffi ulty was enshycount red in a few cases (number unreported) in which the cl ) broke at its joint during application In 1975 two failun 3 (pregnancies) were reported as resulting from opera lor error in which the clip was placed on to the meso alpinx instead of the fallopian tub Reversal of sterili ation following clip application has not yet been attem lted (8)

BANDS

The L e of bands is a recent addition to tubal oCcusiDn meth( Is To date they are utilized in only a few clini al cente 3 around the world The best known ~f the CJrrtmt

Davis Jnd Geck American Cyanamid Co Pearl River New YJrk 10965 JSA

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designs-the Falope Ringmiddot (also known as the Yoon band)-has been tested clinically only within the past three years Like clips bands may be applied by any approach except the transcervical to occlude the falloshypian tubes by the external application of pressure The amount of continuing pressure which will allow bands to adapt to tubal changes without expanding too widely or cutting through the tube is an important factor in detershymining their effectiveness

Falope Ringmiddot

Experiments using a silicone rubber band developed by Yoon (USA) began in 1973 The Falope Ring is a small (1 mm inner diameter) silicone circle which exerts 03-04 pounds per square inch It will revert to 90-100 percent its normal size and shape after application if not stretched beyond 6 mm (156)

The Ring can be applied to the tube by a variety of routes-laparotomy minilaparotomy culdoscopy colshypotomy or laparoscopy To date however most have been applied by one- or two-puncture laparoscopy (see Fig 8) The Ring was developed to eliminate the hazards of electrocautery during laparoscopy and at the same time provide a simple tubal occlusion method surpassing the effectiveness of tantalum hemoclips After the Ring is slipped onto the base of a loop of the tube via a special applicator the loop blanches white as the blood supply is cut off and eventually undergoes fi brosis (154 156)

When the Ring is applied via laparoscopy there is no danger of burns since electrocautery is not required In addition only a small amount of insufflation gas (15-2 liters) is needed

Nearly 4000 women have been sterilized by the Falope Ring since 1973 Over 900 procedures were performed at the Johns Hopkins University the rest were carried out in Seoul (Korea) and Manila (the Philippines) Whenever the Ring was properly applied there were no failures Of the 3 reported failures among the 500 cases evaluated 1 was caused by operator error when two Rings were applied to the same tube 1 resulted from an uncompleted procedure due to adhesions and the third was a luteal phase pregshynancy Tubal transection (10 in 370 cases) was most likely to occur when pelvic inflammatory disease or adhesions were present (156) Transection of the tube can also result from pulling it too strongly toward the applicator rather than lowering the tip of the instrument toward the tube to lessen tension If the tube is transected a Ring can be applied to the end of each segment or the ends can be electrocoagulated Lower abdominal cramping lasting up to 48 hours occurred in 32 of 567 cases and may be due to avascular ischemia of the treated knuckle of tube Applicashytion of an anesthetic jelly to the tube during the application procedure has eliminated pain In 8 cases the Ring was dropped into the abdomen by the operator Because the Ring is non-tissue-reactive it is not essential that it be retrieved (156)

In a comparison of the Falope Ring fulguration and the spring-loaded clip methods of tubal occlusion performed via laparoscopy Brenner reported no fai lures among

KL 65 Industrial Drive Ivyland Pennsylvania 18974 USA

Falope Ring cases and a lower failure rate for fulguration cases (04 percent) than for spring-loaded clip cases (1 5 percent) The incidence of technical difficulties was also lower for the Falope Ring but operative and postoperative complication rates were slightly higher than for the other two procedures

Falope Ring Fulguration Spring-Loaded Clip

(N=312) (N=967) (N=976) No No No

Technical Difficulties 9 29 34 35 66 68

Operative Complications 5 16 9 09 12 12

Postoperative Complications 10 32 18 18 15 15

The only operative complication reported for the Falope Ring was bleeding from the tube or mesosalpinx requiring cautery or the application of another Ring Early postopershyative complications were due to pelvic orwound infections (9)

Since doctors from the USA Korea the Philippines India Thailand Egypt Iran and Mexico are receiving training in the Falope Ring procedure data based upon broader experience are now being collected (165) For example the International Fertility Research Program (Research Triangle Park North Carolina) has analyzed data from Bangkok Singapore Seoul San Salvador and the USA Pregnancy failure rates using the life-table method were computed for those women who were not pregnant at the time of a completed sterilization that was successful according to the operator Pregnancy rates per 100 women followed up at 12 months wereO3 for the Ring (480 women followed up) 02 for fulguration (1576 women followed up) and 21 for spring-loaded clip (949 women followed up) (65) Although both operative and postoperashytive complications appeared lower for the Ring than for fulguration or spring-loaded clip a larger series of pashytients with Ring-occluded tubes is needed to provide an adequate basis for comparison with other methods

Fig 8 Steps in application of Falope Ringmiddot to tube of a surgical specimen 1) approaching tube with Ring resting at end of applicator 2) grasping tube with tongs 2-3 cm from uterine cornu 3) retracting loop of tube and 4) final appearance of tube with Ring applied (Courtesy of Dr William Brenner University of North Carolina Chapel Hill USA (9))

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Major Advantages

bull outpatient procedure (discharge in 3-6hours)

bull low morbidity bull low failure rate bull potentially reversible

(only a small segment of tube is damaged)

CHEMICALS

Several chemicals are now being used experimentally to occlude the fallopian tubes While many chemicals have been tested in animals only a few are being used in humans These chemicals either act by solidifying in the

Major Disadvantage

bull special applicator reshyquired

tube t us forming a plug (eg tissue adhesive) or by destro ng the inner lining of the tube with subseque t fibrosil (sclerosing agent) (see Table 5) I vestigat ions are un erway to determine which substances are mo t effectil l the proper dosage and the best inst rumentatio for de very Advantages and disadvantag ~ s of some chemic lis have not yet been fully determined

Chemi als may be introduced through the cervix and instiller into the tubes at the uterotubal junction und r direct sion via a hysteroscope or blindly VI a catheter They n ay also be introduced into the fimbri I end of t e tube u der direct vision via the abdominal or vaginal routes rhe transcervical route to the uterot bal junctio n is used most often because it is simplest to tJerform and requi rE no incision

Table 5-Tubal Occlusion by Chemicals in Selected E perimental Studies 1971-1976

Author amp Date

Refershyence Numshy

ber

Number of Subshy

jectsa Chemical Used

Formulation amp Dosage

ind of

emicalC

Agent Where Applied

Number of Failures

Indicated by Patency

Effectshyiveness

(Percent )

Alvarado 1974

3 30(16)b quinacrine NR 5 lerosing uterine cornua 10 (6 unilateral amp 4 bilateral)

37

Benoit 1975

6 30 quinacrine amp atropine

1 gm in 6 ml H2O 04 mg

5 lerosing uterus 17 11

43 77 83t

Dafoe 1976

18 8(4)b paraldehyde 05cc of 16 molar suspension of 48 gm paraldehyde in 10 ml ethanol

5 lerosing uterine cornua 1 (unilateral) 75

Davidson 1976

21 60(48)b quinacrine 5-6 ml suspension of 1 gm quinacrine in 7 ml H2O

s [erosing uterus 47 (of 96 tubes) (6 pregnancies)

0

50135)b quinacrine (same as above imshyproved instrumentashytion)

s lerosing uterine cornua 12 (1 pregnancy 76

Erb 1974 amp 1976

2931 19 silastic S-382

80 part medical tisshysue elastomer amp 20 parts 360 medical fluid + 1 stannous

t sue a hesive

95

octoate

Isranghkun 1976

62 60 quinacrine 60 gr in 7 ml H2O 5 lerosing uterine cornua 26 44

Lindemann 1976

79 50(16)b methyl-2-cyanoshyacrylate (MCA)

05 ml t a

sue hesive

interstitial 3 (unilateral) 81

Rakshit 1972


NR t a

sue hesive

uterus 6 0

21 silastic S-521

NR a

sue hesive

uterus 3 86

Richart 1971

121 14 silver nitrate 0 2 ml of 10 hydroshyphilic ointment

s erosing fimbria 0 100

Stevenson 1975

139 41 methyl-2-cyanoshyacrylate

1 ml t a

sue hesive

uterus 13 (11 unilateral amp 2 bilateral)

3 - shy

66

92 - shy

Zipper 1975

161 638 quinacrine amp potentiating agents

15 gr (various dosages)

s erosing uterus 241 (50 pregshynancies)

69

after one instillation after two instillations t after three i nsti lIat ions aA11 studies involved human subjects except Erb who used rabbits bNumber of cases followed up appears in parenthesis

NR = Not Reported

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Ideally chemicals should be

bull delivered by a single instillation bull 100 percent effective bull nontoxic bull inexpensive bull readily available bull confined to the tubes (no intraperitoneal spillage) bull painless to the patient bull stable with unlimited shelf-life

Chemicals which are toxic enough to cause tubal fibrosis may also damage peritoneum or viscera upon contact If they enter the vascular system they may end up in the lungs or elsewhere causing tissue damage Therefore toxic chemicals require a delivery system which prevents intraperitoneal spillage (134)

Major Advantages

bull simple to administer bull outpatient proced ure

Major Disadvantages

bull most are ineffective after a single administration requiring the women to return for further treatshyment

bull some are highly toxic to tissue thus carrying the risk of damage to nearby structures

bull many require special inshystruments for adminisshytration

bull the action of many chemicals is irreversible

bull dosage required is not always predictable

Quinacrine

Quinacrine is the chemical most often used to occlude human fallopian tubes It is a sclerosing agent which was first used by Zipper (Chile) in 1961 and is usually delivshyered to the tubes through the cervix via a catheter or cannula (see Fig 9)

In 1975 Zipper reported on studies conducted between August 1961 and September 1973 during which quinashycrine was instilled into the fallopian tubes of 800 women Of these women 638 were observed for a total of 14677 woman-months Five different dosages or combinations of quinacrine with other pharmacological agents were studied Considering all instillations tubal occlusion was observed in 437 (684 percent) of the 638 women The most effective combination for occluding the tubes was quinashycrine plus xylocaine with or without epinephrine instilled in two successive cycles of the menstrual cycle This combination of chemicals yielded a 94 percent tubal obstruction rate after two instillations (161) In the entire series 2 patients experienced excitation of the central nervous system and were treated with barbiturates given intravenously Sixteen other women experienced minor complications 7 women had amenorrhea lasting three months 4 intrauterine adhesions 4 chemical vaginitis and 1 a skin rash (161)

In a 1974 report Moulding (USA) suggested that failure of a quinacrine suspension to enter the oviducts may be the cause of the high failure rate He recommended additional experiments using a more viscous preparation and a cannula without an occlusive tip (93)

A number of investigators have attempted to improve the effectiveness of quinacrine by using instillation equipshyment which prevents reflux (drainage) of the chemical from the uterus Despite the use of an indwelling catheter to prevent reflux and the administration of atropi ne sulfate to prevent spasm of the uterotubal junction Benoit (Canshyada) achieved only a 77 percent tubal occlusion rate in 30 women after two instillations Davidson (USA) obtained bilateral occlusion in 6 women following only one instillashytion of 680 mg of quinacrine using a flexible polyethelene cannula to prevent reflux Only a 44 percent tubal closure rate tested by hysterosalpingogram was obtained by Israngkun and associates (Columbia University New York USA) who instilled 60 grof quinacrine hydrochloride in 7 ml of water into 60 women via a Kahn cannula fitted with a device to prevent influx (62)

While instruments are still being developed to refine the blind (not under direct vision) instillation of quinacrine Alvarado and Quinones (Mexico) tried instilling the chemshyical into 30 women under direct vision via hysteroscopy However the subsequent high failure rate (62 percent) caused the investigators to abandon th is route for delivery of the chemical (3 114)

Animal experiments to reverse the effects of quinacrine have been conducted by Zipper and his associates Tubal patency was restored in formerly obstructed tubes of rats by administration of an estrogen (estradiol benzoate) or progesterone between 1 and 28 days after instillation of quinacrine (159 160) Similar results in monkeys were obtained by Malaviya (India) who injected estrogen (estrashydiol dipropionate) from days 16 to 20 following instillashytion These investigators conclude that estrogen antagonshyizes the tubal occlusion action of quinacrine and is capable of reversing an already established occlusion (85)


inexpensive high failure rate (6-30 bull easily instilled by a sinshy percent)

gle instrument usually more than one bull outpatient procedure instillation required

requires little or no local bull needs improved instrushyanesthesia mentation for delivery

into the tubes

Silver Nitrate

Although si Iver nitrate was one of the fi rst chemicals investigated to achieve tubal occlusion it is seldom used today As early as 1849 silver nitrate was instilled into the uterine cornua of cesarean section patients via a sound (42) In 1971 more than a century later Richart (USA) instilled 02 ml of 10 percent silver nitrate in hydrophilic ointment into the isthmus via the fimbria of 12 women by culdoscopy Hysterography conducted 8 to 12 weeks following the procedure disclosed bilateral tubal occlushy

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- __---vaginal speculum

Fig 9 Quinacrine is delivered without direct vision high in uterine cavity near tubal ostium via a catheter or cannula

sion in all patients (121) Despite its effectiveness experishyments using silver nitrate were discontinued because the chemical was difficult to deliver into the tubes and it tended to spill out the ends of the tubes into the pelvis In addition all patients experienced abdominal pain for two to five days postoperatively (120)

Silasticmiddot

A number of adhesive substances-silastic (a silicone polymer) methyl-2-cyanoacrylate (MCA) and gelatinshyresorcinol-formaldehyde (GRF)-have been instilled experimentally into the uterotubal junction to form a plug These compounds are highly viscous (sticky) when inshystilled and polymerize (solidify) in place

Silastic first suggested in 1965 by Cortman and Taylor (USA) (1S) is one of the most promising tissue adhesives in terms of effectiveness and reversibi I ity In 1967 Hefnawi investigated its effectiveness in animals He instilled a highly diluted low viscosity silicone (SO parts medical grade elastomer SO parts medical fluid) into the oviducts of 37 rabbits When the plug was retained the procedure was 100 percent effective prod uced no inflammatory reaction and was reversible (SO) However many of the plugs did not remain in place but were ejected from the distal end of the tube into the peritoneal cavity

Rakshit in India was thefirst investigator to instill silastic in humans Blind transcervical instillation of the silicone polymer S-S21 into the uterine cavity of 30 women resulted in tubal occlusion in 21 (70 percent) doubtful occlusion in 6 and failure in 3 There was one failure among 10women in whom S-S21 was instilled transabdominally In no case did tissue reaction occur Rakshit observed that tubal peristalsis gave the silastic a segmented appearance as it solidified This suggested the need for a catalyst that would promote rapid solidification and prevent intraperishytoneal spillage of the silastic (116)

Erb (USA) found a means of preventing intraperitoneal spillage by mixing 1 percent stannous octoate with 80 parts medical elastomer (S-382) and 20 parts 360 medical fluid Stannous octoate a catalyst transforms the viscous silastic liquid to a rubbery solid in about four minutes

Dow-Corning Corporation Midland Michigan 48640 USA

Tests n animals have shown that while th silastic pi g confo TlS to the tubal lumen and resists defo rmation a d expul ~ on its high tensile strength permi t removal by pullin itoutofthetube(293031)Howeverbecauset e huma fallopian tube is more tortuous re lOval may e more ifficult if not impossible (120)

To de e Erb has conducted only animal experiments There was 1 failure (S3 percent) among 19 rabbits in which the silastic was instilled The failure Nas probat Iy due tl poor instillation since no plug was found in the uterin horn where two fetuses were discovered Fourte en of eig l teen plugs were successfully removed in 9 rabbi ts but fe tility was restored in only 29 percent fthe rabbi es Erb sl lggests that the low fertility rate after reversal W3S due te the tem porary loss of functioning by those ciliat-ed cells il the endosalpinx which came in contact w ith the plug Thirty days following instillation there was no e lishydencE )f tissue damage or alteration and no inflammati~ n of the ube (23) Tests conducted 56 days fo ll owing ins ilshylation -evealed that there was no expulsion of the pluGs An im rument to deliver the silastic plug in humans is n(lW being Jeveloped (31) (see Fig 10)

r ajor Advantages Major Disadvantages

bull po no (m no

~ntially reversible -tissue-reactive limal side effects) ncision required

bull effectiveness in huma not investi gated suffishyciently requires sophisticat equipment plug may reak d ri removal

s

~d

g

MeA

Resul from animal and human experimentation invo vshying IT lthyl-2-cyanoacrylate (MCA) monomer a ti ssJe adhes Ie indicate that it can be an effectiv but irrever ishyble m thod of tubal occlusion Experiments sing MCA to occluf e the fallopian tubes began in 1965 when Corfm iln instill j the chemical into the uterotubal junction 01 9 rabbit The resulting tubal occlusion was demons~ rat ld

by inj ~tion of saline containing methylene blue one to ~ ix

Fig 10 A Silaslic plug introduced into uterine cornua to bioI k tubal ostia (Courtesy of Dr Robert Erb Franklin Insl ute Research Laboratories Philadelphia Pennsylvashynia SA (29))

C-88

weeks after instillation and confirmed histologically By six weeks the tubal epithelium was destroyed and extenshysive fibrosis had taken place (16)

In 1975 Stevenson (USA) reported the results following transcervical instillation of MCA into the tubes of 41 women via an intrauterine catheter with a balloon (to prevent endometrial contact) on the seventh day following menstruation Ten to fourteen weeks following instillashytion the tubal lumen was obliterated by fibrosis and by 24 weeks no polymer was evident in the occluded tube On follow-up tests 27 (66 percent) of the 41 women had bilateral occlusion following one instillation of MCA The 14 other women who had one tube patent were given a second instillation and 10 of these had subsequent blockshying Two patients (5 percent) had bilateral tubal patency after the first attempt 1 withdrew from the study and in the other patient only one tube was blocked following a repeat instillation Therefore the effectiveness rate was 92 percent (38 patients) after the second instillation of MCA The women were followed-up from six months to one year with no subsequent pregnancies or major morbidity Six women experienced irregular blood loss for 48 hours and 3 complained of pelvic discomfort (1 was treated with antibiotics for pelvic sepsis) A transient gritty discharge appeared in 13 women (139)

According to Stevenson women with endometrial irregushylarities should not receive MCA because polyps and other anomalies will deflect the chemical and prevent it from entering both tubes In his study instillation was confined to times when the endometrium was thin and the tubal ostia were at their widest (ie days 6-10 of the menstrual cycle) Experiments are now underway involving the instil shylation of saline prior to MCA to further distend the tubal ostia but it is too soon to draw conclusions about this procedure (139)

Using a catheter filled with paraffin oil as a pushshytransport medium Lindemann and Mohr (West Gershymany) injected 005 ml MCA monomer into 50 women via hysteroscopy They suggested that carbon dioxide rather than dextran should be used as the uterine distention medium because contact with a liquid medium would result in polymerization of the MCA before it reached the tubes (77) The investigators observed that MCA desshytroyed 3-4 cm of epithelium It took 5-10 seconds to polymerize and no spilling occurred Of the 16 patients followed up for four to six weeks 9 had bilateral occlusion at four weeks while 4 additional patients showed bilateral occlusion at eight weeks By 1976 Lindemann had instilled MCA into the tubes of 150 women Bilateral tubal occlusion was achieved after 14 weeks in those cases where the solution was easily injected into the tubes without reflux into the uterus (77) Because tubal occlushysion may take eight or more weeks to occur following treatment patients must be maintained on contraceptives until occlusion is ascertained (79)


bull effective when reflux bull not immediately effecshyprevented tive

bull highly toxic (risk of inshyjury to nearby structures on contact)

bull irreversible

GRF

Animal experiments with gelatin-resorcinol-formaldeshyhyde (GRF) a biodegradeable tissue adhesive reveal that it may prove effective in blocking the fallopian tubes in humans Resorcinol promotes adhesive strength and preshyvents immediate breakdown while formaldehyde acts to solidify the gelatin-resorcinol solution and to promote adhesion between the glue and tissue

The route for delivery of GRF is still under investigation Although Falb (USA) acknowledged that GRF could be delivered by hysteroscopy he expected this approach to eliminate its simplicity and the possi bil ity of its delivery by nonphysicians Therefore investigations have begun to improve a cannulation device with a silicone tip for blind introduction of GRF (35)

Clinical trials of GRF in humans have not yet been conshyducted However use of the chemical to block the right fallopian tubes-the left tubes were untouched-and proshymote tissue ingrowth in rabbits was reported by Grode in 1971 None of the 4 animals subsequently bred became pregnant on the treated side (46)

Falb also conducted rabbit experiments using various adhesive formulas The most effective contained 54 pershycent gelatin solids and 37 percent formaldehyde concenshytration and resorcinol which after mixing form a water insoluble mass (Experiments adding quinacrine did not enhance the effectiveness of GRF) The formaldehyde and resorcinol dissipate so that they are of low concentration in the final product The compound was 100 percent effective in preventing pregnancy both initially and after subsequent breeding of the rabbits A few months after application GRF completely disappears from the tubes with no visual damage to the tubal lumen (34) Becausethe tubes are not occluded the action of GRF in preventing pregnancy is not understood Toxicity studies show that lesions form at the site of contact between GRF and various organs Therefore like MCA it must be confined to the tubes to prevent injury to other structures

SOLID PLUGS

Many investigators are optimistic about the potential of solid plugs for reversible sterilization The consistency of plugs varies from soft to hard but because they are SOlid they may be directly inserted into or removed from the uterine or fimbrial end of the tube (see Table 6) However instrumentation for their insertion needs to be simplified and reduced in cost Because there has been less extenshysive clinical experience with solid plugs than with most other tubal occlusion methods their advantages and disadvantages have not been fully ascertained

Aside from possessing the ideal properties common to all tubal occlusion agents plugs should

bull be compatible with tissue (nontoxic) bull possess properties for complete retention bull be removable for the restoration of fertility bull be inserted by a simple delivery system

Solid Silastic Intratubal Device

The only solid plug which has received clinical trials is a silastic device with a nylon thread core designed by

C-89

Table 6-Experimental Use of Solid Plugs for Tubal ( cclusion in Selected Studies 1976

r-------- - - - -------------- ----------- ----- - shy

Author Reference Point of Number of Numbet ofKind of Plug Approach

Be Date Number Insertion Subjects Failur~s

Craft 17 porous ceramic uterotubal hysteroscopy 15 NR 1976 iunction

Hosseinian 51 polyethylene uterotubal hysteroscopy 7 1976 iunction

Malinak 86 aloplastic mid-tube laparotomy 4 o 1976

Steptoe 138 silastic ampulla laparoscopy 40 1976 via fimbria

Craft and Steptoe used human subjects Hosseinian and Malinak used baboon NR = Not Reported

Steptoe (Great Britain) and intended for insertion into the ampulla of the tube via the fimbria The plug is available in either 4 or 6 cm lengths is 1 mm in diameter and has 15 mm protuberances located at 1 cm intervals Tantalum clips are applied between the protuberances to hold the device in place (see Fig 11)

A number of approaches-mini laparotomy laparotomy colpotomy culdoscopy or laparoscopy-may be used to insert the plug into the ampulla through the fimbrial end of the tube Steptoe has described a quick 15-minute lapashyroscopic approach for insertion of the device The major disadvantages of this approach are the need for a great deal of instrumentation (a special trocar and cannula to introduce the device and a special clip applicator with its own trocar and cannula) and for three punctures in the abdomen to insert these instruments

The Silastic device has been placed in 40 women The longest period of observation has been 2 years during which no pain or menstrual disturbances have been reshyported The device slipped out of one tube in one woman leading to failure (3 percent failure rate) as diagnosed by the presence of a normal intrauterine pregnancy The normal pregnancy indicates the device does not injure the tube Thus tubal occlusion is potentially reversible by removal of the device from the tube with a grasping forceps (137) To date no attempts have been made to reverse the procedure (136 138)

Major Advantages

bull potential reversibility bull application possible by

abdominal or vaginal routes

Major Disadvantages

bull specially designed instrumentation reshyquired

bull above average skill reshyquired for insertion via laparoscopy

Polyethylene Plug

Experiments are just beginning on a polyethylene plug which is inserted into the tube at the uterotubal junction The plug is 10 mm long and 1 mm in diameter Projecting from its base are spines made of elgiloy (a biocompatible metal) which penetrate the myometrium and fix the device in place The plug is placed in the tubal lumen with a stainless steel inserter having a 37deg angled flexible tip which fits through the operating channel of a speciallyshy

desiglled hysteroscope Hosseinian (USA) has tested t le plug i 7 baboons with one tubal patencyd l covered f( ur montl following insertion One device appeared out of posit i n although both uterotubal junctions in that animal were locked Although reversibility has not been testod investigators indicate that teeth on the end f the inser er can b used to grasp the base of the device and removn it from letube(51)

Ceramic and Proplastreg Plugs

Two lugs one made of ceramic and one made of Proshyplast lave been tested for their tubal occ sion prop rshyties raft (Great Britain) has inserted a ceramic plug made )f alpha alumina through the uterotubal junct ior of rabbi and hysterectomy patients This pl ug has a solid core nd porous head Technical proble s (eg misshyplace lent) were encountered in 5 of 15 women duri g insert l m of the plug making modification o f the insertigtn procE lure necessary To date only the insertion proceshydure as been tested Evaluation of the plugs fit or eff l1cshytiven 3S in preventing pregnancy will be ex p ored in future studil 3 (17)

The F oplast plug has only been investigated in animals The I lug is saturated with autogenous blood injected throu h a needle into the mid portion of the tube and secu r d by suturing it in place Follow-up tests on 4 babo IlS in which the plug had been introd ced via lapashyroto rTl l indicated that all oviducts were completly block d No adhesions or inflammatory reactions an d no effect on the fallopian tubes other than obamptruction wnre

Fig 11 Diagram 01 solid Silastic intratubal device in s itu De ce is held in place by application 01 8 clip placed bet een protuberances on the plug (Courtesy 01 Dr Patr ick C Steptoe Oldham Lancashire Great Britain)

Bitek nc PO Box 6893 Houston Texas 77025 USA

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observed Results have not yet been reported for animal studies in which the Proplast was inserted into the tube via the uterotubal junction (86)

Dacronreg and Teflon reg Plugs

Among the tubal occlusion methods tested by Hulka and Omran (USA) in 1970 was a Dacronreg plug which was inserted into the tubes of 17 pigs The plug was used alone or in combination with silver nitrate or electrocautery Although the Dacronreg plug was 100 percent effective in preventing pregnancies there were a high incidence of infection adhesions and the development of cystic ovarshyian structures (54)

More recently a notched Teflonreg plug developed by Meeker (USA) has produced minimal tissue reaction in baboons and rabbits and has been withdrawn from the tube to restore patency The plug is inserted through the fimbrial end of the tube and anchored in place by sutures Fertility was restored in 3 of 9 rabbits in which the plug was inserted for three months and then removed (89)

OTHER TUBAL OCCLUSION METHODS

Other tubal occlusion methods which do not fit into established categories are fimbriotexy and the use of the laser While fimbriotexy has been used in medical practice for more than a decade the use of a laser beam to occlude the fallopian tubes is a new method currently under invesshytigation

Fimbriotexy

Fimbriotexy-the placement of a cap or hood over the fimbrial end of the tube to prevent the ovum from gaining access-is a tubal occlusion method requiring additional research especially in humans In some cases reported the end of the tube has been buried in or attached to the broad ligament to prevent the cap from dislodging (74) However Clyman and Little (USA) have noted the presshyence of dense adhesions in some women in whom the caps were used Little suggests the use of sterile devices free from Ii nt to counteract the development of adhesions (74)

In animal experiments Laufe (USA) removed fimbrial caps in 5 rabbits to test reversibility Four subsequently conceived while the fifth rabbit did not conceive in any state and may have been infertile (74)


bull potential reversibility bull risk of postoperative adshyhesions

bull requires laparotomy bull may injure fimbria makshy

ing reversal difficult

Laser

Use of a carbon dioxide laser to provide concentrated heat to a point on the tube resulting in destruction is currently being investigated by Halbrecht (Israel) The laser beam would eliminate the need to touch the treated area

middotE I Dupont de Nemours amp Co 1007 Market Street Wilmington Delaware 19898 USA

Lopez-Escobar (Colombia) reported that application of a laser beam to the uterotubal junction in rabbits via laparotshyomy resulted in later recanal ization (142) Therefore effectiveness reversibility and standards for length of time the beam must be applied to obtain the desired result need to be determined (38 142) The use of smaller instruments and ways to reduce cost are also currently under study (104)


bull damage to tube re- bull requires cumbersome stricted and expensive equipshy

bull low morbidity ment bull may be applied via lapar- bull requires special trainshy

oscope hysteroscope ing or laparotomy bull no standards of treatshy

ment yet established bull potential for reversibility

unknown

BIBLIOGRAPHY

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2 ALEXANDER C Laparoscopic sterilization without electroshycautery Journal of ReProductive Medicine 14(4) 176-177 Ap ril 1975

3 ALVARADO A QUINONES R and AZNAR R Tubal instillashytion of quinacrine under hysteroscopic control In Sciarra JJ Butler J C and Speidel J J eds Hysteroscopic sterilization Proceedings of a workshop on hysteroscopic steril ization Minshyneapolis June 22-241973 New York Stratton Intercontinental 1974 p 85-94

4 ANDERSON ET Peritoneoscopy American Journal of Surgery 35 136-139 1937

5 ARANDA C PRADA C BROUTIN A MANGEL T EDELshyMAN D A and GOLDSMITH A Laparoscopic sterilization immediately after term delivery a preliminary report Journal of Reproductive Medicine 14(4) 171 -173 April 1975

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7 BISHOP E and NELMS WF A simple method of tubal sterilization New York State Journal of Medicine 39(4) 214-216 1930

8 BLEIER W [Transvaginal tubal ligation with polyethylene clips] [GEl [1975] 1 p

9 BRENNER W E EDELMAN D A BLACK J F and GOLDSMITH A Laparoscopic sterilization with electrocautery spring - loaded clips and silastic bands technical problems and early complications Fertility and Sterility 27(3) 256-266 March 1976

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11 CASEY D [Filshie Clip] Personal communication to J Wortman September 2919752 p

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13 CHENG M C E KHEW K S CHEN C RATNAM S S SENG K M and TAN W K CuldoscopiC ligation as an outpashytient procedure American Journal of Obstetrics and Gynecology 122(1) 109-112 May 1 1975

14 CLARK H C Laparoscopy- new instruments for suturing and ligation Fertility and Sterility 23(4) 274-277 April 1972

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15 CORFMAN P A and TAYLOR H C Jr An instrument for transcervical treatment of the oviducts and uterine cornua Obshystetrics and Gynecology 27(6) 880-884 June 1966

16 CORFMAN P A RICHART R M and TAYLOR H C Jr Response of the rabbit oviduct to a tissue adhesive Science 148(3775) 1348-1349 June 41965

17 CRAFT I Uterotubal ceramic plugs In SCiarra J J Droegemueller W and Speidel J J eds Advances in female sterilization technology Hagerstown Maryland Harper and Row 19764 p (In press)

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25 DICKINSON R L Sterilization without unsexing Journal of the American Medical Association 92(4) 373-379 January 29shy1929

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29 ERB R A Silastic A retrievable custom-molded oviductal plug In Sciarra J J Droegemueller W and Speidel J J eds Advances in female sterilization technology Hagerstown Maryshyland Harper and Row 1976 7 p (In press)

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31 ERB R A Davis R H BALIN H and KYRIAlIS G A Device and technique for blocking the fallopian tubes a method for reversible contraceptive sterilization In Schima M E Lushybell I Davis J E and Connell E Advances in voluntary sterilishyzation Amsterdam Excerpta Medica 1974 p 336-337

32 ERB R A DAVIS R H KYRIAlIS G A and BALIN H System and technique for blocking the fallopian tubes Advances in Planned Parenthood 9(2) 42-48 1975

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36 FA OOQUI M O and BAllOLl J M Complications ass)shyciated Nith laparoscopic tubal sterilization Contemporary ObGy 5(2) 57-61 February 1975

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38 FO )A M S New trends in sterilization In Fathalla M F and St laban M M eds Surgical methods of fertility cont rol (Proce dings of the First Egyptian Meeting Febr ary 7-81974) Cairo General Organization for Government PI inting Officl )S 1975 ~ 13-17

39 FR NGENHEIM H and KLEINDIENST W Tubal sterili ashytion Ul l der vision with the laparoscope new t chniques a d instru rJ2nts for tubal ligation and occlusion In Phillips J M a ld Keith eds Gynecological laparoscopy prine pies and techshyniques New York Stratton Intercontinental 1974 p 213-219

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41 FFi EE M J FILlPY R E ADEE R R and FISH T M Techn logy for mechanical fallopian tube-blockmg devices In Sciam J J Droegemueller W and Speidel J J eds Advi nshyces in iemale sterilization technology Hagerstown Maryla ld Harpe and Row 19765 p (In press)

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51 HOSSEINIAN A H bull LUCERO S bull and KIM M H Hysteroshyscopic implantation of uterotubal junctions blocking devices In Sciarra J J bull Droegemueller W and Speidel J J eds Advanshyces in female sterilization technology Hagerstown Maryland Harper and Row 19765 p (In press)

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61 ISRANGKUN C and PHAOSAVASDI S Hysteroscopic sterilization complications in 296 cases In Sciarra J J Droegemueller W and Speidel J J bull eds Advances in female sterilization technology Hagerstown Maryland Harper and Row 1976 5 p (In press)

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80 LITTLE W A Current aspects of sterilization the selection and application of various surgical methods of sterilization American Journal of Obstetrics and Gynecology 123(1) 12-18 September 1 1975

81 LOEFFLER F E Laparoscopic tubal ligation [Letter to the editor] British Medical Journal 2(5916) 444 May 25 1974

82 LOWER B R Critical assessment of sterilization proceshydures In Duncan G W Falb R D and Speidel J J eds Female Sterilization Proceedings of a Workshop on Female Sterilization Airlie Virginia December 2-3 1971 New York Academic Press 1972 p 151-158

83 MA H K and WONG V Is occlusion of the fallopian tubes with tantalum clips a reversible and reliable method of sterilizashytion Scottish Medical Journal 19 183-185 July 1974

84 MADLENER M Uber sterilisierende Operationen an den Tuben [About sterilization operations on the tubes] [GE] Zenshytralblatt fuer Gynaekologie 43(20) 380-384 May 17 1919

85 MALAVIYA B CHANDRA H and KAR A B Chemical occlusion of monkey oviducts with quinacrine antagonism and reversal with estrogen Contraception 12(1) 31-36 July 1975

86 MALINAK L R and HOMSY C A Oviduct occlusion followshying implantation of Proplas In Sciarra J J Droegemueller W and Speidel J J eds Advances in female sterilization technolshyogy Hagerstown Maryland Harper and Row 1976 2 p (In press)

87 MARCH C M and ISRAEL R A critical appraisal of hystershyoscopic tubal fulguration for sterilization Contraception 2(3) 261-267 March 1975

88 MARIK J J FRIEDMAN S bull and TYLER E T A simple technique of laparoscopic tubal sterilization Journal of Reproshyductive Medicine 15(3) 109-113 September 1975

89 MEEKER C I [Use of a Teflon plug to occlude the fallopian tubes ] Personal communication to J Wortman February 25 19761 p

90 MERZ W Sterilization In International Planned Parenthood Federation [IPPF] Preventive medicine and family planning

C-93

[Proceedings of the Sixth Conference of the Europe and Middle East Region of IPPF Copenhagen July 1966] London IPPF 1967 p 80-92

91 MIKULlCZ-RADECKI F and FREUND A Ein neues Hystershyoscop und seine Andwendung in der Gynakologie [A new hystershyoscope and its use in gynecology] [GE] Zeitschrift fuer Geburtshyshiite 92 13-15 1928

92 MOSS H C Vanadium clips for sterilization operations Journal of the American Medical Association 215(4) 639 Janushyary 25 1971

93 MOULDING T S and THOMPSON H Distribution of liqshyuids introduced into the uterus with a simple nonocclusive cannula Contraception 9(4) 369-377 April 1974

94 MROUEH A Culdoscopy Paper presented at the Third International Conference on Voluntary Sterilization Tunis Febshyruary 1-4 1976 1 p

95 MULLIGAN W J Results of salpingostomy International Journal of Obstetrics and Gynecology 11 242-244 1966

96 NEUMANN H H and FRICK H C 2nd Occlusion of the fallopian tubes with tantalum clips American Journal of Obstetshyrics and Gynecology 81 (4) 803-806 April 1961

97 NEUWIRTH R S CASTHELY S and KIM Y-H Tubal pregnancy following application of tantalum c lips at culdoscopy for sterilization American Journal of Obstetrics and Gynecology 114(8) 1066-1068 December 151972

98 NEUWIRTH R S LEVINE R U and RICHART R M Hysshyteroscopic tubal sterilization American Journal of Obstetrics and Gynecology 16(1) 82-85 May 1973

99 NEUWIRTH R S RICHART R M ISRANGKUN C LEshyVINE R U and PHAOSAVASDI S Hysteroscopic sterilization In Sciarra J J Butler J C and Speidel J J eds Hystershyoscopic sterilization New York Stratton Intercontinental 1974 p121-129

100 OMRAN K F and HULKA J F Tubal occlusion acomparshyative study International Journal of Fertility 15(4) 226-241 Ocshytober-December 1970

101 OU Y-Y A device of technique of vaginal tubal sterilization through posterior colpoceliotomy In Association for Voluntary Sterilization of the Republic of China Proceedings of the Asian Regional Conference on Voluntary Steri lization May 10-121975 Taipei Taiwan July 1975 p 139

102 OU Y-Y HSU C-T Onefingermethod-asimpleabdomshyinal tubal sterilization through a small incision I n Association for Voluntary Sterilization of the Republic of China Proceedings of the Asian Regional Conference on Voluntary Sterilization May 10-12 1975 Taipei Taiwan July 1975 p 138

103 OVERSTREET E W Techniques o f sterilization Obstetrics and Gynecology 7 109-125 March 1964

104 PALMER R and GOLD E M Female sterilization-clinical aspects In Schima M E Lubell I Davis J E and Conne E eds Advances in voluntary sterilization (Proceedings of the Second International Conference Geneva February 25-March 1 1973) Amsterdam Excerpta Medica 1974 p 249-254

105 PATEL D N PARIKH M N and SUNDARAM T A Lapashyroscopic sterilization In Talwalkar C V Medical termination of pregnancy and sterilization Bombay C V Talwalkar 1974 p 65-69

106 PAUERSTEIN C J Methods In Pauerstein C J The fallopian tube a reappraisal Philadelphia Leaand Febiger 1974 p159-187

107 PAUERSTEIN C J Tubal sterilization In Pauerstein C J The fallopian tube a reappra isal Philadelphia Lea and Febiger 1974 p 121 -140

108 PHILLIPS J KEITH D HULKA J HULKA B and KEITH L Gynecological laparoscopy in 1975 Paper presented at the Second International Congress of Gynecological Laparoscopy Las Vegas Nevada November 20-23 1975 29 p

109 PHILLIPS J KEITH D KEITH L HULKA J and HULKA B Survey of gynecologic laparoscopy for 1974 Journal of Reproshy

ductil Medicine 15(2) 45-50 August 1975

110 I OULSON A M Analysis of female sterilization techn iqles ObStE rics and Gynecology 42(1) 131-1 35 July 1973

111 r OWER F H and BARNES A C Sterilizalion by ffiear-s of peritcneoscopic tubal fulguration American Jo rnal of Ob~tetshyrics a d Gynecology 41 1038-1043 1941

11 2 I URANDARE B N The technique of female steriliza ion -tub I occlusion procedures In Talwalkar C V Medical te mishynatioll of pregnancy and sterilisation Bombay C V Talwal ~ ar 1974 ) 65-69

113 f UINONES R and ALVARADO A and LEY C H Hynershyoscor c sterilization follow-up of 800 cases I SCiarra J J Droe ~mueller W and Speidel J J eds Advances in fe lale steril i ation technology Hagerstown Maryland Harper lnd Row 1976 5 p (In press)

114 UINONES R ALVARADO A and LEY E Tubal electroshycoag l ation under hysteroscopic control (three hundred and i ifty case~ American Journal of Obstetrics and Gy ecology 12 (8) 1111- 113 April 15 1975

115 UINONES R RAMOS R A and DURAN A A T~lbal electl cauterization under hysteroscopic contro l Contracepl ion 7(3) 195-201 March 1973

116 AKSHIT B Attempts at chemical blockin of the fa llo Jian tube Ir female sterilization Journal of Obstetrics and Gyne ~ ol shyogy c India 20 618-624 1970

117 AKSHIT B Experiments on tubal blocki n for sten liza tion without laparotomy Journal of Obstetrics and Gyneco log y of India 8(2) 282-286 April 1968

118 AKSHIT B The scope of liquid plastics and other chmishycals f r blocking the fallopian tube In Richart RM and Prager D J luman sterilization Springfield Charles Thomas 1 H2 p 21 -221

119 ICCI J V One hundred years of gynaecology Ph ilcdelshyphia llakiston 1945 p 539-540

120 t lCHART R [Tubal occlusion ] Persona l communicction to J ortman April 8 1976 2 p

121 ICHART R M GUTIERREZ-NAJAR A J and fEUshyWI Rl ~ R S Transvaginal human sterilizati o a prel imi lary repol l Ameri can Journal of Obstetrics and Gynecology 11 ( 1) 108-1 O September 1 1971

122 lIMKUS V and SEMM K Sterilization by carbon dio( ide hyStE oscopy In Sciarra J J Butler J C and Speide l J eds ysteroscopic sterilization Proceedings o f a workshop on hYStE oscopic sterilization Minneapolis June 22-24 1973 ew York 3tratton Intercontinental 1974 p 75-84

123 I IiNGROSE C A D Office tubal steriliz tion Obsteu ics and ( ynecology 42(1) 151-155 July 1973

124 1I0UX J-E and YUZPE A A Electrosurgery untanj led Cont mporary Ob Gyn 4(3) 118-1 24 Septem r 1974

125 AMI G EL-SHAMMAH S S BADWAY S and LAUshyREN E K A An animal model for the development and ev luashytion f chemical tubal sterilization In Fathalla M F and S aashyban 1 M eds Surgical methods in fertility cont rol Proceea ings of th First Egyptian Meeting Assuit February 7-8 1974 C airo Gen al Organization for Government Printing Offi ces 1975 p 57-60

126 CHROEDER C Uber den Abbau und Leistungen der Hyst roskopie [Advantages and disadvantages of hystf rosshycopy [GE] Archives fuer Gynaekologie 156 407-419 1934

127 CHWIMMER W B Laparoscopy in famifv planning ou rshynal 01 Reproductive Medicine 13(6) 218-222 D cember 1974

128 CIARRA J J Jr Sterilization of women a review of new and I Jtentially reversible techniques In Schima M E l ubell I Davi J E and Connell E eds Advances in vo luntary ster lizashytion Proceedings of the Second International Conference 3enshyeva ebruary 25-March 1 1973) Amsterdam Excerpta MeJ ica 1974 p 62-69

C-94

129 SEMM K Tubal sterilization finally with cauterization or temporary with ligation via pelviscopy In Phillips J M and Keith L eds Gynecological laparoscopy principles and techshyniques New York Stratton Intercontinental 1974 p 337-359

130 SHAABAN M Reversibility of female sterilization In Fashythalia M F and Shaaban M M eds Surgical methods in fertility control Proceedings of the First Egyptian Meeting Assuit Februshyary 7-81974 Cairo General Organization for Government Printshying Offices 1975 p 128-133

131 SIVANESARATNAM V and NG K H Tubal pregnancies following postpartum sterilization Fertility and Sterility 26(9) 945-946 September 1975

132 SODERSTROM R M Laparoscopic sterilization a comshyprehensive review-1973 In Phillips J M and Keith L eds Gynecological laparoscopy principles and techniques New York Stratton Intercontinental 1974 p 209-212

133 SPEIDEL J J The future of female sterilization technology International Journal of Gynaecology and Obstetrics Spring 1976 16 p (In press)

134 SPEIDEL J J and PERRY M I Needed research to imshyprove female sterilization technology In Sciarra J J Droegeshymueller W and Speidel J J eds Advances in female sterilizashytion technology Hagerstown Maryland Harper and Row 19766 p (In press)

135 STEPTOE P C Assessment of the potential of hysterosshycopic sterilization In Sciarra J J Butler J C and Speidel J J eds Hysteroscopic sterilization (Proceedings of a workshyshop Minneapolis June 22-24 1975) New York Stratton Intershycontinental 1974 p 153-158

136 STEPTOE P C Intratubal devices for reversible sterilizashytion In Phillips J M and Keith L eds Gynecologicallaparosshycopy prinCiples and techniques New York Stratton Intercontinshyental 1974 p 309-314

137 STEPTOE P C [Intratubal silastic device and low current coagulationJ Personal communication to J Wortman April 5 1976 1 p

138 STEPTOE P C The potential uses of intratubal stents In Sciarra J J Droegemueller W and Speidel J J eds Advanshyces in female steril ization technology Hagerstown Maryland Harper and Row 1976 4 p (In press)

139 STEVENSON T C Methyl cyanoacrylate (MCA) for tubal occlusion In Sciarra J J Droegemueller W and Speidel J J eds Advances in female sterilization technology Hagerstown Maryland Harper and Row 1976 4 p (In press)

140 STOOT J E G M and UBACHS J M H Sterilization by salpingectomy through posterior colpotomy Contraception 8(6) 577-582 December 1973

141 SUGIMOTO O Hysteroscopic sterilization by electrocoagshyulation In Sciarra J J Butler J C and Speidel J J eds Hysteroscopic sterilization (Proceedings of a workshop Minshyneapolis June 22-24 1975) New York Stratton Intercontinental 1974 p 107-120

142 TATUM H and ANSBACHER R Female sterilization shybasic science aspects In Schima M E Lubell I Davis J E and Connell E eds Advances in voluntary sterilization (Proshyceedings of the Second International Conference Geneva Febshyruary 25-March 1 1973) Amsterdam Excerpta Medica 1974 p 260-266

143 THORSTEINSSON V T and PRATT J H Gynecologic operations for sterilization Minnesota Medicine 55 204-210 March 1972

144 TSUEI J J Female sterilization post-partum and interparshytum program-acceptability effectiveness technology and comshyplications In Thambu J A M ed Seminar on voluntary sterilishyzation and post-conceptive regulation Bangkok January 30shyFebruary 21974 Singapore Eurasia Press [1974J p 58-70

145 UCHIDA H Uchida tubal sterilization American Journal of Obstetrics and Gynecology 121 (2) 153-158 January 15 1975

146 UCHIDA H Uchida tubal sterilization Kanazawa Japan Hashimoto Kakubundo Co 1975 75 p

147 WHEELESS C R Jr An inexpensive system for female sterilization American Journal of Obstetrics and Gynecology 123(7) 727-733 December 1 1975

148 WHEELESS C R Jr Laparoscopically applied hemoclips for tubal sterilization Obstetrics and Gynecology 44(5) 752-756 November 1974

149 WHEELESS C R Jr Where weve been what weve tried and where we are going in the use of laparoscope in female sterilization In Sciarra J J Droegemueller W and Speidel J J eds Advances in female sterilization technology Hagershystown Maryland Harper and Row 19766 p (In press)

150 WHEELESS C R Jr and THOMPSON B H Laparoscopic sterilization-review of 3600 cases Obstetrics and Gynecology 42(5) 751-758 November 1973

151 WOOD C [TuballigationJ Personal communication to J Wortman March 20 1976 1 p

152 WORLD HEALTH ORGANIZATION [WHO) SCIENTIFIC GROUP Advances in methods of fertility regulation Geneva WHO 1974 (Technical Report Series No 527) p 30-34

153 YOON I B and KING T M A preliminary and intermediate report on a new laparoscopic tubal ring procedure Journal of Reproductive Medicine 15(2) 54-56 August 1975

154 YOON I B and KING T M [Falope RingmiddotJ Personal communication to J Wortman February 7 1975 1 p

155 YOON IB and KING TM The laparoscope falope ring technique Advances in Planned Parenthood 10(3) 154-159 1975

156 YOON I B and KING TM The laparoscopic FalopeshyRingmiddot procedure In Sciarra J J Droegemueller W and Speishydel J J eds Advances in female sterilization technology Hashygerstown Maryland Harper and Row 19764 p (In press)

157 YOON I B WHEELESS C R and KING T M A prelimishynary report on a new laparoscopic sterilization approach the silicone rubber band technique American Journal of Obstetrics and Gynecology 120(1) 132-136 September 1 1974

158 YUZPE A A ANDERSON R J COHEN N P and WEST J L A review of 1035 tubal sterilizations by posterior colpotomy under local anesthesia or by laparoscopy Journal of Reproductive Medicine 13(3) 106-109 September 1974

159 ZIPPER J MEDEL M and PRAGER R Alterations in fertility induced by unilateral intrauterine instillation of cytotoxic compounds in rats American Journal of Obstetrics and Gynecolshyogy 101 (7) 971 -978 August 1 1968

160 ZIPPER J PRAGER R and MEDEL M Biological changes induced by unilateral intrauterine instillation of quinashycrine in the rat reversion through use of estrogen and progesteshyrone Fertility and Sterility 24(1) 48-53 January 1973

161 ZIPPER J STACCHETTI E and MEDEL M Transvaginal chemical sterilization clinical use of quinacrine plus potentiating adjuvants Contraception 12(1) 11-21 July 1975

GWU-SCD-76-4P

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PUBLICATIONS OF THE POPULATION ilFORMATION PROGRAM (Copies are available to health personne in developing countries)

ORAL CONTRACEPTIVES - Series A __ A-1 Oral Contraceptives-50 Million Users (F S) _ _ G-3 A Review Modulation of Autonomic Transmis~ion Jy __A-2 Advantages of Orals Outweigh Oisadvantages (F) Prostaglandins (F S)

_ _ A-3 Minipill-A Limited Alternative for Certain Women __ _G-4 Prostaglandin Impact for Menstrual Induction V)

__ G-5 Physiology and Pharmacology of PG in Parturitio 1

INTRAUTERINE DEVICES - Series B ___G-6 Prostaglandins Promise More Effectill Fertilit Cc ntrol __ B-1 Copper IUOs- Performance to Oate (F S p)

__ B-2 IUOs Reassessed-A Oecade of Experience BAF RIER METHODS - Series H _ _H-1 Condom-An Old Method Meets a Ne ~ Social Jeee

STERILIZATION Female - Series C (F P S) __C-1 Laparoscopic Sterilization-A New Technique (F S P) __ H-2 The Modern Condom-A Quality ProDuct for __--C-2 Laparoscopic Sterilization II What Are the Problems Effective Contraception

(F S p) _ _H-3 Vag ina I Contraceptives-Reappraisal

__C-3 COlpotomy-The Vaginal Approach (F S p) __ H-4 Oiaphragm amp Other Intravaginal Barriers __C-4 Laparoscopic Sterilization with Clips (F)

__ C-5 Female Sterilization by Mini-Laparotomy (F) PEF ODIC ABSTINENCE - Series I __C-6 Female Sterilization Using the Culdoscope __1-1 Birth Control Without Contraceptives (F S) __C-7 Tubal Sterilization-Review of Methods __1-2 Sex Preselection-Not Yet Practical

STERILIZATION Male - Series D FA I ILY PLANNING PROGRAMS - Series J __0-1 Vasectomy-Old amp New Techniques (F S P) __J-1 Family Planning Programs amp Fertilit Patterns (F ) P) __0-2 Vasectomy-What Are the Problems (F) __J-2 World Fertility Trends 1974 (F S) _ _ 0-3 Vasectomy Reversibility-A Status Report _ _ _J-3 Advanced Training in Fertility Mana ement (F S P)

_ _J-4 Breast-feeding-Aid to Infant Health Fertili l Cmtrol LAW AND POLICY - Series E (F S p) ~E-1 Eighteen Months of Legal Change (F S) __ J-5 Contraceptive Oistribution-Taking SUPplies to __ E-2 World Plan of Action amp Health Strategy Approved Villages and Households (F S P) __ E-3 Abortion Law amp Pract ice A Status Report __ J-6 Training Nonphysicians in Family Planning Service _ _ E-4 Recent Law and Policy Changes in Fertility Control amp a Oirectory of Training Programs (F P SI

__ J-7 Pregnancy Tests The Current Status ( F P) PREGNANCY TERMINATION - Series F __J-B Effects of Childbearing on Maternal Health __ F-1 Five Largest Countries Allow Legal Abortion on __J-9 Postcoital Contracept ion An Appraisal

Broad Grounds (F S P)

__ F-2 Menstrual Regulation-What Is It (F S p) IN CTABLES AND IMPLANTS - Series K __ F-3 Uterine Aspiration Techniques (F S P) _ K-1 Injectable Progestogens-Officials Oehate but Use __- F-4 Menstrual Regu lation Update (F S) Increases (S)

PROSTAGLANDINS - Series G IN[ EXES __ G-l Clinical Use of PGs in Fertility Control (F S) _Index 1972-1973 __ G-2 Fertility Control Research Maps amp Oirectory (F S) __ Index 1974

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Population Informatio Program Department of Medical an Public Affairs

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Population Reports is published bi-monthly at 2001 S Street NW Washington DC 20009 USA by the Population Information Program Science Communication Division Department of Medical and Public Affairs of the George Washington University Medical Center and is supported by the United States Agency for International Developshyment Helen K Kolbe Project Director Second class postage paid at Washington DC

anastomose (join) the two remaining ends Ligation is the procedure most often reversed successfully but the same operative procedure for anastomosis is required The use of cautery makes reversibility virtually impossible to achieve because a large segment of tube is destroyed Likewise most chemical methods are not reversible beshycause the epithelium is permanently damaged

Comparisons of the effectiveness of the various tubal occlusion procedures are difficult to make In many cases there are insufficient data and investigators do not conshysider life tables or the Pearl Index in computing failure rates (see Population Reports Series H Number 4 Janushyary 1976) Thus there is no basis for comparison among studies and only estimates can be made from published information

While great strides in knowledge about tubal physiology and in biomedical engineering have been made more research is needed to determi ne the practical ity effectiveshyness and applicability of the newer methods of tubal occlusion such as use of chemicals Until then traditional methods (eg ligation) are likely to remain popular

LIGATION

Tubal ligation (tying the fallopian tubes) to prevent passhysage of sperm and ova is one of the oldest forms of tubal occlusion Nearly a century of experience with this meshythod has eliminated the least effective techniques and the outcome of most of those remaining is now predictable Traditionally performed through a large 10 cm (3-4 inches) abdominal incision (laparotomy) today the tubes are ligated through a 25 cm abdominal incision (minilapashyrotomy) or a 3-5 cm vaginal incision (colpotomy) The amount of skill required to perform ligation the approach used and effectiveness vary according to the type of ligatio1 procedure performed (see Table 1)

Major Advantages

bull only average skill is reshyquired for most proceshydures

bull only simple instrumenshytation is required

bull morbidity is usually low

Failure rates per 100 woman years are computed using the Pearl formula

No of pregnancies x 1200 No of months of exposure

Major Disadvantage

bull most effective proceshydures are usually irreshyversible

bull the procedures pershyformed via laparotomy require hospitalization

Ligatic 1 techniques can be classified into one or a comt i shynation Jf the following categories according to the exte 1t of acti n on the fallopian tubes

bull sim Ie ligation bull liga on and crushing bull liga on division and burial bull liga on and resection bull liga on resection and burial

SIMPL LIGATION Simple ligation is seldom performfd today lecause of the high failure rate asso iated w ith Its use F rst proposed by Lungren (USA) in 1880 (90) simple ligatio preceded other ligation methods by almost t 10

decad s In 1895 DLihrssen (The Netherl nds) used a doubl ligature on each tube in an effort to prevent t 1e failure associated with single ligatures (119) Howevlr subse uent investigations have shown that hydrosalpi r1x (colle ion of fluid) frequently develops between the ttlO

ligatul )S and as a result reports of double ligation have disapf eared from the literature In one of the few recent report on simple ligation Purandare (India) who p rshyforms colpotomy for interval sterilization and laparotor y for p erperal sterilization uses nonabsorbable lin n threac to tie the tubes at the junction of the lateral 0 eshyth ird 0 ld medial two-thirds of the tubes Purandare recogshynizes I Ie possibility of failu re with his tech nique and ac ks up tht procedure by abortion He has not r ecently p bshylished ailure rates orthe percentage of abor ions requir d amon the total number of procedures perf rmed

tv ljor Advantages

bull sirr )Ie to perform bull 1011 morbidity bull hig ll potential for revershy

sib l ity

Ligation and Crushing

MADl NER TECHNIQUE This technique first report ed in 19 ) is easier to perform and results in less bleedi 19 than I lore extensive ligation procedures (144) However like si 1ple ligation the failure rate is higher than forthc se technq ues in which tubal continuity is interrupted In the Madl~ 1er technique the midsection of the tube is picked up to )rm a loop and the base of the loop is crushed wit a clam~ and ligated with nonabsorbable suture matel ial (eg ilk cotton) (see Fig 2) In a modification of t lis techn Jue adopted by some practitioners ~ he top of he loop i cut off

ul us interstitial isthmic-ampullary

infundibLlum

Major Disadvantage

bull high failure rate (up to 20 percent)

Fig 1 Anatomy of fallopian tube in relation to the uterus an ovary

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C-75

I


o --J 0gt

Part of

Method Tube Treated



Uchida ampulla

Madlener isthmus

Wood ampulla

Irving ampulla



C_~ I l i-~~











laparotomy


laparotomy


-i i l ~f~Y


good

poor

good

moderate

very good

good

poor

poor poor

unr 00

laparoscopy

hysteroscopy


culdoscopy poor


very good


very Qood

Done with Standard

Equipment

yes yes yes no no

yes yes yes no

yes yes

yes yes yes no

no

yes yes

yes

yes yes

P

yes yes

no no no no

no

no

no no no no nCi


Degree of Skill

Required





above average

average

average

average average

Q r~np



high


Stage Rate

no no no no

yes

no no no no

no no

no no no no

yes

no no

no

no no

nn

no no

no no no

yes

no

high no


high no


low high high hight

low high


high

low high

high

low high

Inw

hIgh high

hight

hight

hight

hight

high t

high t


high t


nil


nil


nil

nil

28-3 2

0-19

20

1-2 01-2

0-D_6 10-25

30-40

02-D6

5-18

Incidence of

Morbidity

low low moderateb

low low

low low moderateb

low

low low

low low moderateb

low

low

low

moderate

moderate

low lOW

mOderateb


low

low

low

nil low

Possible as


yes no no

yes yes

yes no no

yes

yes no

yes no no

yes

NR

yes no

no

yes no

ves no no

yes yes yes yes

yes

yes

ves no no

yes ye

yes

-5

c o a J

al sect

c o

( tl J

shy ~ [ 0 on










on on

raquo

~ o

7 o N

on on

raquo

OlOl

OJ ~ ~ OJ

gt gt 88 OJ OJ

o 0 c c

en I c lt (JU OJ

E LII J to (J

lt u E

a 2

gt 0

J_

~ o 09 11jsect amp

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FULGURATION


C-78

--






















1000 1000


C-79











C-80






dominal incision




I








C-81









CLIPS





Author

amp Date

Refershyence

Number

Number of Patients

Kind of

Fulguration Current

Number Co ulashy


Applied t l e


Tubal Patency



(Percent) (Percentl

Israngkun 1976




19 81

Lindemann 1976

79 48 low thermal

2 watts at 6 volts


12 bilateral 48 52








March 1975


30 watts 12 1 I 2

Quinones 1976


27 8 watts 4 1 I 18 5 (3 cornual)

26 74


278 watts 6 1 I 30 17 83

Sugimoto 1974



3-4 2

1 I 0 0 0 100


NR = Not Reported

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Tantalum Clips











Spring-loaded Clips



l I


Number of Patients


Used




Effectshyiveness

(Percent)











C-83










bull



a d

Plastic Clip


BANDS



C-84


Falope Ringmiddot









(N=312) (N=967) (N=976) No No No







C-85

Major Advantages




CHEMICALS


Major Disadvantage





Author amp Date

Refershyence Numshy

ber

Number of Subshy



ind of

emicalC

Agent Where Applied

Number of Failures


Effectshyiveness

(Percent )

Alvarado 1974


37

Benoit 1975




43 77 83t

Dafoe 1976



Davidson 1976



0



Erb 1974 amp 1976



t sue a hesive

95

octoate

Isranghkun 1976


Lindemann 1976


05 ml t a

sue hesive


Rakshit 1972


NR t a

sue hesive

uterus 6 0

21 silastic S-521

NR a

sue hesive

uterus 3 86

Richart 1971



Stevenson 1975


1 ml t a

sue hesive


3 - shy

66

92 - shy

Zipper 1975




69


NR = Not Reported

C-86




Major Advantages


Major Disadvantages






Quinacrine











into the tubes

Silver Nitrate


C-87




Silasticmiddot









bull po no (m no



s

~d

g

MeA




C-88








bull irreversible

GRF





SOLID PLUGS






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r-------- - - - -------------- ----------- ----- - shy











Major Advantages



Major Disadvantages



Polyethylene Plug








C-90







Fimbriotexy







Laser









unknown

BIBLIOGRAPHY















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GWU-SCD-76-4P

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I


o --J 0gt

Part of

Method Tube Treated



Uchida ampulla

Madlener isthmus

Wood ampulla

Irving ampulla



C_~ I l i-~~











laparotomy


laparotomy


-i i l ~f~Y


good

poor

good

moderate

very good

good

poor

poor poor

unr 00

laparoscopy

hysteroscopy


culdoscopy poor


very good


very Qood

Done with Standard

Equipment

yes yes yes no no

yes yes yes no

yes yes

yes yes yes no

no

yes yes

yes

yes yes

P

yes yes

no no no no

no

no

no no no no nCi


Degree of Skill

Required





above average

average

average

average average

Q r~np



high


Stage Rate

no no no no

yes

no no no no

no no

no no no no

yes

no no

no

no no

nn

no no

no no no

yes

no

high no


high no


low high high hight

low high


high

low high

high

low high

Inw

hIgh high

hight

hight

hight

hight

high t

high t


high t


nil


nil


nil

nil

28-3 2

0-19

20

1-2 01-2

0-D_6 10-25

30-40

02-D6

5-18

Incidence of

Morbidity

low low moderateb

low low

low low moderateb

low

low low

low low moderateb

low

low

low

moderate

moderate

low lOW

mOderateb


low

low

low

nil low

Possible as


yes no no

yes yes

yes no no

yes

yes no

yes no no

yes

NR

yes no

no

yes no

ves no no

yes yes yes yes

yes

yes

ves no no

yes ye

yes

-5

c o a J

al sect

c o

( tl J

shy ~ [ 0 on










on on

raquo

~ o

7 o N

on on

raquo

OlOl

OJ ~ ~ OJ

gt gt 88 OJ OJ

o 0 c c

en I c lt (JU OJ

E LII J to (J

lt u E

a 2

gt 0

J_

~ o 09 11jsect amp

C-77


























FULGURATION


C-78

--






















1000 1000


C-79











C-80






dominal incision




I








C-81









CLIPS





Author

amp Date

Refershyence

Number

Number of Patients

Kind of

Fulguration Current

Number Co ulashy


Applied t l e


Tubal Patency



(Percent) (Percentl

Israngkun 1976




19 81

Lindemann 1976

79 48 low thermal

2 watts at 6 volts


12 bilateral 48 52








March 1975


30 watts 12 1 I 2

Quinones 1976


27 8 watts 4 1 I 18 5 (3 cornual)

26 74


278 watts 6 1 I 30 17 83

Sugimoto 1974



3-4 2

1 I 0 0 0 100


NR = Not Reported

C-82



Tantalum Clips











Spring-loaded Clips



l I


Number of Patients


Used




Effectshyiveness

(Percent)











C-83










bull



a d

Plastic Clip


BANDS



C-84


Falope Ringmiddot









(N=312) (N=967) (N=976) No No No







C-85

Major Advantages




CHEMICALS


Major Disadvantage





Author amp Date

Refershyence Numshy

ber

Number of Subshy



ind of

emicalC

Agent Where Applied

Number of Failures


Effectshyiveness

(Percent )

Alvarado 1974


37

Benoit 1975




43 77 83t

Dafoe 1976



Davidson 1976



0



Erb 1974 amp 1976



t sue a hesive

95

octoate

Isranghkun 1976


Lindemann 1976


05 ml t a

sue hesive


Rakshit 1972


NR t a

sue hesive

uterus 6 0

21 silastic S-521

NR a

sue hesive

uterus 3 86

Richart 1971



Stevenson 1975


1 ml t a

sue hesive


3 - shy

66

92 - shy

Zipper 1975




69


NR = Not Reported

C-86




Major Advantages


Major Disadvantages






Quinacrine











into the tubes

Silver Nitrate


C-87




Silasticmiddot









bull po no (m no



s

~d

g

MeA




C-88








bull irreversible

GRF





SOLID PLUGS






C-89


r-------- - - - -------------- ----------- ----- - shy











Major Advantages



Major Disadvantages



Polyethylene Plug








C-90







Fimbriotexy







Laser









unknown

BIBLIOGRAPHY















C-91





































C-92









































C-93









































C-94


































GWU-SCD-76-4P

C-95























C-96

I


o --J 0gt

Part of

Method Tube Treated



Uchida ampulla

Madlener isthmus

Wood ampulla

Irving ampulla



C_~ I l i-~~











laparotomy


laparotomy


-i i l ~f~Y


good

poor

good

moderate

very good

good

poor

poor poor

unr 00

laparoscopy

hysteroscopy


culdoscopy poor


very good


very Qood

Done with Standard

Equipment

yes yes yes no no

yes yes yes no

yes yes

yes yes yes no

no

yes yes

yes

yes yes

P

yes yes

no no no no

no

no

no no no no nCi


Degree of Skill

Required





above average

average

average

average average

Q r~np



high


Stage Rate

no no no no

yes

no no no no

no no

no no no no

yes

no no

no

no no

nn

no no

no no no

yes

no

high no


high no


low high high hight

low high


high

low high

high

low high

Inw

hIgh high

hight

hight

hight

hight

high t

high t


high t


nil


nil


nil

nil

28-3 2

0-19

20

1-2 01-2

0-D_6 10-25

30-40

02-D6

5-18

Incidence of

Morbidity

low low moderateb

low low

low low moderateb

low

low low

low low moderateb

low

low

low

moderate

moderate

low lOW

mOderateb


low

low

low

nil low

Possible as


yes no no

yes yes

yes no no

yes

yes no

yes no no

yes

NR

yes no

no

yes no

ves no no

yes yes yes yes

yes

yes

ves no no

yes ye

yes

-5

c o a J

al sect

c o

( tl J

shy ~ [ 0 on










on on

raquo

~ o

7 o N

on on

raquo

OlOl

OJ ~ ~ OJ

gt gt 88 OJ OJ

o 0 c c

en I c lt (JU OJ

E LII J to (J

lt u E

a 2

gt 0

J_

~ o 09 11jsect amp

C-77


























FULGURATION


C-78

--






















1000 1000


C-79











C-80






dominal incision




I








C-81









CLIPS





Author

amp Date

Refershyence

Number

Number of Patients

Kind of

Fulguration Current

Number Co ulashy


Applied t l e


Tubal Patency



(Percent) (Percentl

Israngkun 1976




19 81

Lindemann 1976

79 48 low thermal

2 watts at 6 volts


12 bilateral 48 52








March 1975


30 watts 12 1 I 2

Quinones 1976


27 8 watts 4 1 I 18 5 (3 cornual)

26 74


278 watts 6 1 I 30 17 83

Sugimoto 1974



3-4 2

1 I 0 0 0 100


NR = Not Reported

C-82



Tantalum Clips











Spring-loaded Clips



l I


Number of Patients


Used




Effectshyiveness

(Percent)











C-83










bull



a d

Plastic Clip


BANDS



C-84


Falope Ringmiddot









(N=312) (N=967) (N=976) No No No







C-85

Major Advantages




CHEMICALS


Major Disadvantage





Author amp Date

Refershyence Numshy

ber

Number of Subshy



ind of

emicalC

Agent Where Applied

Number of Failures


Effectshyiveness

(Percent )

Alvarado 1974


37

Benoit 1975




43 77 83t

Dafoe 1976



Davidson 1976



0



Erb 1974 amp 1976



t sue a hesive

95

octoate

Isranghkun 1976


Lindemann 1976


05 ml t a

sue hesive


Rakshit 1972


NR t a

sue hesive

uterus 6 0

21 silastic S-521

NR a

sue hesive

uterus 3 86

Richart 1971



Stevenson 1975


1 ml t a

sue hesive


3 - shy

66

92 - shy

Zipper 1975




69


NR = Not Reported

C-86




Major Advantages


Major Disadvantages






Quinacrine











into the tubes

Silver Nitrate


C-87




Silasticmiddot









bull po no (m no



s

~d

g

MeA




C-88








bull irreversible

GRF





SOLID PLUGS






C-89


r-------- - - - -------------- ----------- ----- - shy











Major Advantages



Major Disadvantages



Polyethylene Plug








C-90







Fimbriotexy







Laser









unknown

BIBLIOGRAPHY















C-91





































C-92









































C-93









































C-94


































GWU-SCD-76-4P

C-95























C-96

-5

c o a J

al sect

c o

( tl J

shy ~ [ 0 on










on on

raquo

~ o

7 o N

on on

raquo

OlOl

OJ ~ ~ OJ

gt gt 88 OJ OJ

o 0 c c

en I c lt (JU OJ

E LII J to (J

lt u E

a 2

gt 0

J_

~ o 09 11jsect amp

C-77


























FULGURATION


C-78

--






















1000 1000


C-79











C-80






dominal incision




I








C-81









CLIPS





Author

amp Date

Refershyence

Number

Number of Patients

Kind of

Fulguration Current

Number Co ulashy


Applied t l e


Tubal Patency



(Percent) (Percentl

Israngkun 1976




19 81

Lindemann 1976

79 48 low thermal

2 watts at 6 volts


12 bilateral 48 52








March 1975


30 watts 12 1 I 2

Quinones 1976


27 8 watts 4 1 I 18 5 (3 cornual)

26 74


278 watts 6 1 I 30 17 83

Sugimoto 1974



3-4 2

1 I 0 0 0 100


NR = Not Reported

C-82



Tantalum Clips











Spring-loaded Clips



l I


Number of Patients


Used




Effectshyiveness

(Percent)











C-83










bull



a d

Plastic Clip


BANDS



C-84


Falope Ringmiddot









(N=312) (N=967) (N=976) No No No







C-85

Major Advantages




CHEMICALS


Major Disadvantage





Author amp Date

Refershyence Numshy

ber

Number of Subshy



ind of

emicalC

Agent Where Applied

Number of Failures


Effectshyiveness

(Percent )

Alvarado 1974


37

Benoit 1975




43 77 83t

Dafoe 1976



Davidson 1976



0



Erb 1974 amp 1976



t sue a hesive

95

octoate

Isranghkun 1976


Lindemann 1976


05 ml t a

sue hesive


Rakshit 1972


NR t a

sue hesive

uterus 6 0

21 silastic S-521

NR a

sue hesive

uterus 3 86

Richart 1971



Stevenson 1975


1 ml t a

sue hesive


3 - shy

66

92 - shy

Zipper 1975




69


NR = Not Reported

C-86




Major Advantages


Major Disadvantages






Quinacrine











into the tubes

Silver Nitrate


C-87




Silasticmiddot









bull po no (m no



s

~d

g

MeA




C-88








bull irreversible

GRF





SOLID PLUGS






C-89


r-------- - - - -------------- ----------- ----- - shy











Major Advantages



Major Disadvantages



Polyethylene Plug








C-90







Fimbriotexy







Laser









unknown

BIBLIOGRAPHY















C-91





































C-92









































C-93









































C-94


































GWU-SCD-76-4P

C-95























C-96


























FULGURATION


C-78

--






















1000 1000


C-79











C-80






dominal incision




I








C-81









CLIPS





Author

amp Date

Refershyence

Number

Number of Patients

Kind of

Fulguration Current

Number Co ulashy


Applied t l e


Tubal Patency



(Percent) (Percentl

Israngkun 1976




19 81

Lindemann 1976

79 48 low thermal

2 watts at 6 volts


12 bilateral 48 52








March 1975


30 watts 12 1 I 2

Quinones 1976


27 8 watts 4 1 I 18 5 (3 cornual)

26 74


278 watts 6 1 I 30 17 83

Sugimoto 1974



3-4 2

1 I 0 0 0 100


NR = Not Reported

C-82



Tantalum Clips











Spring-loaded Clips



l I


Number of Patients


Used




Effectshyiveness

(Percent)











C-83










bull



a d

Plastic Clip


BANDS



C-84


Falope Ringmiddot









(N=312) (N=967) (N=976) No No No







C-85

Major Advantages




CHEMICALS


Major Disadvantage





Author amp Date

Refershyence Numshy

ber

Number of Subshy



ind of

emicalC

Agent Where Applied

Number of Failures


Effectshyiveness

(Percent )

Alvarado 1974


37

Benoit 1975




43 77 83t

Dafoe 1976



Davidson 1976



0



Erb 1974 amp 1976



t sue a hesive

95

octoate

Isranghkun 1976


Lindemann 1976


05 ml t a

sue hesive


Rakshit 1972


NR t a

sue hesive

uterus 6 0

21 silastic S-521

NR a

sue hesive

uterus 3 86

Richart 1971



Stevenson 1975


1 ml t a

sue hesive


3 - shy

66

92 - shy

Zipper 1975




69


NR = Not Reported

C-86




Major Advantages


Major Disadvantages






Quinacrine











into the tubes

Silver Nitrate


C-87




Silasticmiddot









bull po no (m no



s

~d

g

MeA




C-88








bull irreversible

GRF





SOLID PLUGS






C-89


r-------- - - - -------------- ----------- ----- - shy











Major Advantages



Major Disadvantages



Polyethylene Plug








C-90







Fimbriotexy







Laser









unknown

BIBLIOGRAPHY















C-91





































C-92









































C-93









































C-94


































GWU-SCD-76-4P

C-95























C-96

--






















1000 1000


C-79











C-80






dominal incision




I








C-81









CLIPS





Author

amp Date

Refershyence

Number

Number of Patients

Kind of

Fulguration Current

Number Co ulashy


Applied t l e


Tubal Patency



(Percent) (Percentl

Israngkun 1976




19 81

Lindemann 1976

79 48 low thermal

2 watts at 6 volts


12 bilateral 48 52








March 1975


30 watts 12 1 I 2

Quinones 1976


27 8 watts 4 1 I 18 5 (3 cornual)

26 74


278 watts 6 1 I 30 17 83

Sugimoto 1974



3-4 2

1 I 0 0 0 100


NR = Not Reported

C-82



Tantalum Clips











Spring-loaded Clips



l I


Number of Patients


Used




Effectshyiveness

(Percent)











C-83










bull



a d

Plastic Clip


BANDS



C-84


Falope Ringmiddot









(N=312) (N=967) (N=976) No No No







C-85

Major Advantages




CHEMICALS


Major Disadvantage





Author amp Date

Refershyence Numshy

ber

Number of Subshy



ind of

emicalC

Agent Where Applied

Number of Failures


Effectshyiveness

(Percent )

Alvarado 1974


37

Benoit 1975




43 77 83t

Dafoe 1976



Davidson 1976



0



Erb 1974 amp 1976



t sue a hesive

95

octoate

Isranghkun 1976


Lindemann 1976


05 ml t a

sue hesive


Rakshit 1972


NR t a

sue hesive

uterus 6 0

21 silastic S-521

NR a

sue hesive

uterus 3 86

Richart 1971



Stevenson 1975


1 ml t a

sue hesive


3 - shy

66

92 - shy

Zipper 1975




69


NR = Not Reported

C-86




Major Advantages


Major Disadvantages






Quinacrine











into the tubes

Silver Nitrate


C-87




Silasticmiddot









bull po no (m no



s

~d

g

MeA




C-88








bull irreversible

GRF





SOLID PLUGS






C-89


r-------- - - - -------------- ----------- ----- - shy











Major Advantages



Major Disadvantages



Polyethylene Plug








C-90







Fimbriotexy







Laser









unknown

BIBLIOGRAPHY















C-91





































C-92









































C-93









































C-94


































GWU-SCD-76-4P

C-95























C-96











C-80






dominal incision




I








C-81









CLIPS





Author

amp Date

Refershyence

Number

Number of Patients

Kind of

Fulguration Current

Number Co ulashy


Applied t l e


Tubal Patency



(Percent) (Percentl

Israngkun 1976




19 81

Lindemann 1976

79 48 low thermal

2 watts at 6 volts


12 bilateral 48 52








March 1975


30 watts 12 1 I 2

Quinones 1976


27 8 watts 4 1 I 18 5 (3 cornual)

26 74


278 watts 6 1 I 30 17 83

Sugimoto 1974



3-4 2

1 I 0 0 0 100


NR = Not Reported

C-82



Tantalum Clips











Spring-loaded Clips



l I


Number of Patients


Used




Effectshyiveness

(Percent)











C-83










bull



a d

Plastic Clip


BANDS



C-84


Falope Ringmiddot









(N=312) (N=967) (N=976) No No No







C-85

Major Advantages




CHEMICALS


Major Disadvantage





Author amp Date

Refershyence Numshy

ber

Number of Subshy



ind of

emicalC

Agent Where Applied

Number of Failures


Effectshyiveness

(Percent )

Alvarado 1974


37

Benoit 1975




43 77 83t

Dafoe 1976



Davidson 1976



0



Erb 1974 amp 1976



t sue a hesive

95

octoate

Isranghkun 1976


Lindemann 1976


05 ml t a

sue hesive


Rakshit 1972


NR t a

sue hesive

uterus 6 0

21 silastic S-521

NR a

sue hesive

uterus 3 86

Richart 1971



Stevenson 1975


1 ml t a

sue hesive


3 - shy

66

92 - shy

Zipper 1975




69


NR = Not Reported

C-86




Major Advantages


Major Disadvantages






Quinacrine











into the tubes

Silver Nitrate


C-87




Silasticmiddot









bull po no (m no



s

~d

g

MeA




C-88








bull irreversible

GRF





SOLID PLUGS






C-89


r-------- - - - -------------- ----------- ----- - shy











Major Advantages



Major Disadvantages



Polyethylene Plug








C-90







Fimbriotexy







Laser









unknown

BIBLIOGRAPHY















C-91





































C-92









































C-93









































C-94


































GWU-SCD-76-4P

C-95























C-96






dominal incision




I








C-81









CLIPS





Author

amp Date

Refershyence

Number

Number of Patients

Kind of

Fulguration Current

Number Co ulashy


Applied t l e


Tubal Patency



(Percent) (Percentl

Israngkun 1976




19 81

Lindemann 1976

79 48 low thermal

2 watts at 6 volts


12 bilateral 48 52








March 1975


30 watts 12 1 I 2

Quinones 1976


27 8 watts 4 1 I 18 5 (3 cornual)

26 74


278 watts 6 1 I 30 17 83

Sugimoto 1974



3-4 2

1 I 0 0 0 100


NR = Not Reported

C-82



Tantalum Clips











Spring-loaded Clips



l I


Number of Patients


Used




Effectshyiveness

(Percent)











C-83










bull



a d

Plastic Clip


BANDS



C-84


Falope Ringmiddot









(N=312) (N=967) (N=976) No No No







C-85

Major Advantages




CHEMICALS


Major Disadvantage





Author amp Date

Refershyence Numshy

ber

Number of Subshy



ind of

emicalC

Agent Where Applied

Number of Failures


Effectshyiveness

(Percent )

Alvarado 1974


37

Benoit 1975




43 77 83t

Dafoe 1976



Davidson 1976



0



Erb 1974 amp 1976



t sue a hesive

95

octoate

Isranghkun 1976


Lindemann 1976


05 ml t a

sue hesive


Rakshit 1972


NR t a

sue hesive

uterus 6 0

21 silastic S-521

NR a

sue hesive

uterus 3 86

Richart 1971



Stevenson 1975


1 ml t a

sue hesive


3 - shy

66

92 - shy

Zipper 1975




69


NR = Not Reported

C-86




Major Advantages


Major Disadvantages






Quinacrine











into the tubes

Silver Nitrate


C-87




Silasticmiddot









bull po no (m no



s

~d

g

MeA




C-88








bull irreversible

GRF





SOLID PLUGS






C-89


r-------- - - - -------------- ----------- ----- - shy











Major Advantages



Major Disadvantages



Polyethylene Plug








C-90







Fimbriotexy







Laser









unknown

BIBLIOGRAPHY















C-91





































C-92









































C-93









































C-94


































GWU-SCD-76-4P

C-95























C-96









CLIPS





Author

amp Date

Refershyence

Number

Number of Patients

Kind of

Fulguration Current

Number Co ulashy


Applied t l e


Tubal Patency



(Percent) (Percentl

Israngkun 1976




19 81

Lindemann 1976

79 48 low thermal

2 watts at 6 volts


12 bilateral 48 52








March 1975


30 watts 12 1 I 2

Quinones 1976


27 8 watts 4 1 I 18 5 (3 cornual)

26 74


278 watts 6 1 I 30 17 83

Sugimoto 1974



3-4 2

1 I 0 0 0 100


NR = Not Reported

C-82



Tantalum Clips











Spring-loaded Clips



l I


Number of Patients


Used




Effectshyiveness

(Percent)











C-83










bull



a d

Plastic Clip


BANDS



C-84


Falope Ringmiddot









(N=312) (N=967) (N=976) No No No







C-85

Major Advantages




CHEMICALS


Major Disadvantage





Author amp Date

Refershyence Numshy

ber

Number of Subshy



ind of

emicalC

Agent Where Applied

Number of Failures


Effectshyiveness

(Percent )

Alvarado 1974


37

Benoit 1975




43 77 83t

Dafoe 1976



Davidson 1976



0



Erb 1974 amp 1976



t sue a hesive

95

octoate

Isranghkun 1976


Lindemann 1976


05 ml t a

sue hesive


Rakshit 1972


NR t a

sue hesive

uterus 6 0

21 silastic S-521

NR a

sue hesive

uterus 3 86

Richart 1971



Stevenson 1975


1 ml t a

sue hesive


3 - shy

66

92 - shy

Zipper 1975




69


NR = Not Reported

C-86




Major Advantages


Major Disadvantages






Quinacrine











into the tubes

Silver Nitrate


C-87




Silasticmiddot









bull po no (m no



s

~d

g

MeA




C-88








bull irreversible

GRF





SOLID PLUGS






C-89


r-------- - - - -------------- ----------- ----- - shy











Major Advantages



Major Disadvantages



Polyethylene Plug








C-90







Fimbriotexy







Laser









unknown

BIBLIOGRAPHY















C-91





































C-92









































C-93









































C-94


































GWU-SCD-76-4P

C-95























C-96



Tantalum Clips











Spring-loaded Clips



l I


Number of Patients


Used




Effectshyiveness

(Percent)











C-83










bull



a d

Plastic Clip


BANDS



C-84


Falope Ringmiddot









(N=312) (N=967) (N=976) No No No







C-85

Major Advantages




CHEMICALS


Major Disadvantage





Author amp Date

Refershyence Numshy

ber

Number of Subshy



ind of

emicalC

Agent Where Applied

Number of Failures


Effectshyiveness

(Percent )

Alvarado 1974


37

Benoit 1975




43 77 83t

Dafoe 1976



Davidson 1976



0



Erb 1974 amp 1976



t sue a hesive

95

octoate

Isranghkun 1976


Lindemann 1976


05 ml t a

sue hesive


Rakshit 1972


NR t a

sue hesive

uterus 6 0

21 silastic S-521

NR a

sue hesive

uterus 3 86

Richart 1971



Stevenson 1975


1 ml t a

sue hesive


3 - shy

66

92 - shy

Zipper 1975




69


NR = Not Reported

C-86




Major Advantages


Major Disadvantages






Quinacrine











into the tubes

Silver Nitrate


C-87




Silasticmiddot









bull po no (m no



s

~d

g

MeA




C-88








bull irreversible

GRF





SOLID PLUGS






C-89


r-------- - - - -------------- ----------- ----- - shy











Major Advantages



Major Disadvantages



Polyethylene Plug








C-90







Fimbriotexy







Laser









unknown

BIBLIOGRAPHY















C-91





































C-92









































C-93









































C-94


































GWU-SCD-76-4P

C-95























C-96










bull



a d

Plastic Clip


BANDS



C-84


Falope Ringmiddot









(N=312) (N=967) (N=976) No No No







C-85

Major Advantages




CHEMICALS


Major Disadvantage





Author amp Date

Refershyence Numshy

ber

Number of Subshy



ind of

emicalC

Agent Where Applied

Number of Failures


Effectshyiveness

(Percent )

Alvarado 1974


37

Benoit 1975




43 77 83t

Dafoe 1976



Davidson 1976



0



Erb 1974 amp 1976



t sue a hesive

95

octoate

Isranghkun 1976


Lindemann 1976


05 ml t a

sue hesive


Rakshit 1972


NR t a

sue hesive

uterus 6 0

21 silastic S-521

NR a

sue hesive

uterus 3 86

Richart 1971



Stevenson 1975


1 ml t a

sue hesive


3 - shy

66

92 - shy

Zipper 1975




69


NR = Not Reported

C-86




Major Advantages


Major Disadvantages






Quinacrine











into the tubes

Silver Nitrate


C-87




Silasticmiddot









bull po no (m no



s

~d

g

MeA




C-88








bull irreversible

GRF





SOLID PLUGS






C-89


r-------- - - - -------------- ----------- ----- - shy











Major Advantages



Major Disadvantages



Polyethylene Plug








C-90







Fimbriotexy







Laser









unknown

BIBLIOGRAPHY















C-91





































C-92









































C-93









































C-94


































GWU-SCD-76-4P

C-95























C-96


Falope Ringmiddot









(N=312) (N=967) (N=976) No No No







C-85

Major Advantages




CHEMICALS


Major Disadvantage





Author amp Date

Refershyence Numshy

ber

Number of Subshy



ind of

emicalC

Agent Where Applied

Number of Failures


Effectshyiveness

(Percent )

Alvarado 1974


37

Benoit 1975




43 77 83t

Dafoe 1976



Davidson 1976



0



Erb 1974 amp 1976



t sue a hesive

95

octoate

Isranghkun 1976


Lindemann 1976


05 ml t a

sue hesive


Rakshit 1972


NR t a

sue hesive

uterus 6 0

21 silastic S-521

NR a

sue hesive

uterus 3 86

Richart 1971



Stevenson 1975


1 ml t a

sue hesive


3 - shy

66

92 - shy

Zipper 1975




69


NR = Not Reported

C-86




Major Advantages


Major Disadvantages






Quinacrine











into the tubes

Silver Nitrate


C-87




Silasticmiddot









bull po no (m no



s

~d

g

MeA




C-88








bull irreversible

GRF





SOLID PLUGS






C-89


r-------- - - - -------------- ----------- ----- - shy











Major Advantages



Major Disadvantages



Polyethylene Plug








C-90







Fimbriotexy







Laser









unknown

BIBLIOGRAPHY















C-91





































C-92









































C-93









































C-94


































GWU-SCD-76-4P

C-95























C-96

Major Advantages




CHEMICALS


Major Disadvantage





Author amp Date

Refershyence Numshy

ber

Number of Subshy



ind of

emicalC

Agent Where Applied

Number of Failures


Effectshyiveness

(Percent )

Alvarado 1974


37

Benoit 1975




43 77 83t

Dafoe 1976



Davidson 1976



0



Erb 1974 amp 1976



t sue a hesive

95

octoate

Isranghkun 1976


Lindemann 1976


05 ml t a

sue hesive


Rakshit 1972


NR t a

sue hesive

uterus 6 0

21 silastic S-521

NR a

sue hesive

uterus 3 86

Richart 1971



Stevenson 1975


1 ml t a

sue hesive


3 - shy

66

92 - shy

Zipper 1975




69


NR = Not Reported

C-86




Major Advantages


Major Disadvantages






Quinacrine











into the tubes

Silver Nitrate


C-87




Silasticmiddot









bull po no (m no



s

~d

g

MeA




C-88








bull irreversible

GRF





SOLID PLUGS






C-89


r-------- - - - -------------- ----------- ----- - shy











Major Advantages



Major Disadvantages



Polyethylene Plug








C-90







Fimbriotexy







Laser









unknown

BIBLIOGRAPHY















C-91





































C-92









































C-93









































C-94


































GWU-SCD-76-4P

C-95























C-96




Major Advantages


Major Disadvantages






Quinacrine











into the tubes

Silver Nitrate


C-87




Silasticmiddot









bull po no (m no



s

~d

g

MeA




C-88








bull irreversible

GRF





SOLID PLUGS






C-89


r-------- - - - -------------- ----------- ----- - shy











Major Advantages



Major Disadvantages



Polyethylene Plug








C-90







Fimbriotexy







Laser









unknown

BIBLIOGRAPHY















C-91





































C-92









































C-93









































C-94


































GWU-SCD-76-4P

C-95























C-96




Silasticmiddot









bull po no (m no



s

~d

g

MeA




C-88








bull irreversible

GRF





SOLID PLUGS






C-89


r-------- - - - -------------- ----------- ----- - shy











Major Advantages



Major Disadvantages



Polyethylene Plug








C-90







Fimbriotexy







Laser









unknown

BIBLIOGRAPHY















C-91





































C-92









































C-93









































C-94


































GWU-SCD-76-4P

C-95























C-96








bull irreversible

GRF





SOLID PLUGS






C-89


r-------- - - - -------------- ----------- ----- - shy











Major Advantages



Major Disadvantages



Polyethylene Plug








C-90







Fimbriotexy







Laser









unknown

BIBLIOGRAPHY















C-91





































C-92









































C-93









































C-94


































GWU-SCD-76-4P

C-95























C-96


r-------- - - - -------------- ----------- ----- - shy











Major Advantages



Major Disadvantages



Polyethylene Plug








C-90







Fimbriotexy







Laser









unknown

BIBLIOGRAPHY















C-91





































C-92









































C-93









































C-94


































GWU-SCD-76-4P

C-95























C-96







Fimbriotexy







Laser









unknown

BIBLIOGRAPHY















C-91





































C-92









































C-93









































C-94


































GWU-SCD-76-4P

C-95























C-96





































C-92









































C-93









































C-94


































GWU-SCD-76-4P

C-95























C-96









































C-93









































C-94


































GWU-SCD-76-4P

C-95























C-96









































C-94


































GWU-SCD-76-4P

C-95























C-96


































GWU-SCD-76-4P

C-95























C-96























C-96

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