RHL Commentary by Suneeta Mittal
EVIDENCE SUMMARY
The review compares various techniques of tubal interruption, such as tubal rings, clips, electrocoagulation and the modified Pomeroy method for female sterilization. Nine randomized controlled trials conducted between 1976 and 1991 have been included. Clips were compared with tubal rings (three trials) and with the Pomeroy method (one trial). Electrocoagulation was compared with the Pomeroy method (two trials) and with tubal rings (two trials). In one trial, Filshie clips was compared with Hulka-Clemens clips.
Ring versus clips
There were no reported cases of operation-related mortality in any of the included studies. Major morbidity and method failure are rare with all current method of female sterilization. Minor morbidity and technical failures (failure to accomplish tubal occlusion with the intended method) were more likely to occur with tubal ring rather than with clips (Peto odds ratio [OR]: 2.15; 95% confidence interval [CI] 1.22-3.78). However, there was no statistical or clinical difference in pregnancy rate between these two methods.
Pomeroy versus electrocoagulation
Major morbidity (two studies, 2127 women, Peto OR 2.87; 95% CI 1.13-7.25) and postoperative pain (two studies, 2127 women Peto OR 3.85; 95 % CI 2.91-5.10)
were more frequent in the Pomeroy group compared with the electrocoagulation group. However, there was one case of bowel burn following electrocoagulation-an issue that cannot be overlooked in the case of electrocoagulation.
Ring versus electrocoagulation
Minor morbidity, technical failures and procedural difficulties were similar following tubal ring or electrocoagulation, though more women had postoperative pain following sterilization with tubal ring than electrocoagulation (Peto OR 3.28; 95% CI 2.31-4.66).
Pomeroy versus clips
The modified Pomeroy method did not differ from clips in terms of minor morbidities and menstrual irregularities. There were no discernible differences between the effectiveness of Filshie or Hulka-Clemens clips.
The authors searched the literature appropriately using the search strategy of the Cochrane Fertility Regulation Review Group to identify all randomized trials comparing various techniques of interruption of tubal patency for female sterilization. The inclusion criteria used in the review were appropriate.
Most of the trials included in the review were small and there were only one or two trials available for most comparisons, limiting the statistical strength of the findings. Over the years Filshie clip has evolved from mark I to mark VI with differing failure rates; the review does not specify the marks of the Filshie clip used in the trials.
The authors have rightly noted that in the trials that compared major morbidity, the number of subjects was too small to reach any reliable conclusions. The Cochrane review methodology required the inclusion of only randomized controlled trials. Nevertheless, the review discusses results from a prospective observational study of long-term pregnancy risk associated with female sterilization that provides useful information about failure rates of different methods (1).
The full RHL commentary also includes sections on: Relevance
- Magnitude of the problem
- Applicability of the results
- Implementation of intervention
Research
References
This document should be cited as: Suneeta Mittal. Techniques for the interruption of tubal patency for female sterilisation: RHL commentary (last revised: 21 June 2003). The WHO Reproductive Health Library, No 9, Update Software Ltd, Oxford, 2006. www.rhlibrary.com
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