Updates in Contraception From The XVI World Congress of the International Federation of Gynecology and Obstetrics

David A. Grimes, MD

Disclosures

September 20, 2000

In This Article

Transcervical Tubal Sterilization: Time for a Renaissance?

While tubal sterilization is the most widely used method of contraception around the world, current methods leave much to be desired. Anesthesia (local, general, or regional) requires skilled providers, and these anesthesia techniques carry their own risks of complications and death. Indeed, in the United States,[26] as well as in developing countries,[27] anesthesia remains an important cause of death from tubal sterilization. Moreover, an abdominal approach to the fallopian tubes carries risks of injury to bowel, bladder, and blood vessels, which can result in serious morbidity or death. Vaginal colpotomy for tubal sterilization has been popular in some countries, although postoperative infections have dampened enthusiasm for vaginal sterilization.

For these reasons, a transcervical approach to tubal sterilization has been an appealing -- though elusive -- goal for many years.[28] Approaches have included instillation of sclerosing solutions into the uterus or tubes. An example of the former is intrauterine placement of quinacrine pellets, which has moderate efficacy after 2 applications. However, the clinical use of quinacrine without the customary preclinical studies of safety led to criticism of this method. Alternative approaches have included silastic or methyl-2-cyanoacrylate (a glue) injected into the tubes under hysteroscopy.

At this meeting, Jay M. Cooper[29] of the University of Arizona, School of Medicine, Phoenix,presented preliminary studies of a novel approach to transcervical tubal sterilization: placing an occlusive device in the tube, which then incites an obstructive response. The procedure, termed "STOP" by its manufacturer (Conceptus, San Carlos, California) features a unique guidewire and catheter that enables cannulation of the proximal tube by hysteroscopy. The tiny coil expands on placement in the tube and obstructs the lumen through both expansion and a local reaction to the polyester fibers in the device. Dr. Cooper described the interim results for 207 women who had undergone this procedure. The most common anesthesia used for these procedures was intravenous sedation (around 51% of women). Average operating time was about 22 minutes. At 12-month follow-up, 96% of participants described their satisfaction as "excellent." At 3 months after the procedure, 140/143 participants evaluated had bilateral occlusion. At 6 months, all women had bilateral occlusion. Adverse events were uncommon: about 3% had problems related to the placement, while 1% had problems related to the device itself.

This approach is the first transcervical method of which I am aware that has achieved such high rates of tubal occlusion. If continuing studies confirm these high occlusion rates -- and high clinical efficacy -- this may be an appealing option for women where skilled operative endoscopy is available. Use of this approach could avoid the usual need for an operating room, anesthesia, and an intra-abdominal operation. However, its wider use in developing countries will be contingent on developing expertise in operative hysteroscopy and in maintaining this delicate equipment in often-challenging surroundings. Another drawback is the technical difficulty encountered in placing the device in both tubes. Bilateral device placement was accomplished in 88% of patients early in this series; this proportion may decline with increasing operator skill.

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