Sterilization Failure, Regret and Future Fertility

Sterilisation failure is pregnancy after tubal occlusion, or persistence or return of sperm after vasectomy. Regret is later wish for fertility after a permanent procedure. Both are uncommon but important, and the clinician must handle ectopic pregnancy as an emergency, counsel regret without judgement and describe fertility options truthfully.

Rates. First-year pregnancies after tubal occlusion are 0.5 per 100 women, and after vasectomy 0.15 per 100 women with typical use and 0.1 per 100 women with perfect use. Failure after tubal occlusion continues for years, is higher in women sterilised under 30, and about one third of pregnancies after failure are ectopic.

Causes of failure in women. Luteal-phase pregnancy at the time of the procedure, tubal recanalisation or fistula, wrong structure occluded, clip or ring slippage.

Causes of failure in men. Incomplete occlusion or recanalisation, unrecognised duplicate vas, and unprotected sex before clearance.

Regret. Higher with age under 30 at the procedure, few or no living children, procedures done around childbirth or abortion, relationship change, loss of a child, and pressure from a partner or provider. Fewer patients seek reversal or assisted reproduction than express regret.

Return to fertility. The procedure is permanent. Reversal is not assured to succeed.

Assessment of a woman with pregnancy after tubal occlusion. Missed period, pain or bleeding needs urgent pregnancy testing. Ectopic pregnancy is presumed until a viable intrauterine pregnancy is proved. Do ultrasound and serial serum hCG.

Assessment of regret. Explore reasons, circumstances, relationship, age, the number of living children, the technique used and any records. Exclude depression or coercion.

Fertility options for a woman.

• Microsurgical tubal reversal when a healthy tube segment remains (best when over about 4 cm of tube remains), after clips and rings or limited partial salpingectomy. Outcome depends on age, technique, tubal length and other fertility factors. Ectopic pregnancy risk is increased.
• In vitro fertilisation bypasses the tubes and suits older women, women with short tubal remnants, after salpingectomy or coagulation, or with other fertility factors.

Fertility options for a man.

• Vasovasostomy, or vasoepididymostomy when there is epididymal obstruction. Patency is common but pregnancy rate falls as the interval since vasectomy increases and with partner age.
• Surgical sperm retrieval with intracytoplasmic sperm injection and in vitro fertilisation.

Suitability for reversal. Age and ovarian reserve in the woman, semen quality and interval in the man, partner fertility factors, surgical cost and access, and the patient’s own preferences.

Investigations before reversal. Women: ovarian reserve test, pelvic ultrasound, and tubal assessment at laparoscopy. Men: semen analysis, hormonal profile if indicated, scrotal examination. Both partners: HIV and syphilis testing.

Pregnancy after tubal occlusion.

1. Confirm pregnancy and haemodynamic state.
2. If unstable, resuscitate and go to surgery for a presumed ruptured ectopic pregnancy.
3. If stable, do transvaginal ultrasound and serum hCG, and repeat at 48 hours if the location is unknown.
4. If ectopic pregnancy is confirmed and the patient is stable, medical or surgical management.

Medical management regimen (single dose methotrexate). Methotrexate 50 mg/m2 intramuscularly on day 1. Check hCG on days 4 and 7. If the fall is under 15% between day 4 and day 7, give a second dose of 50 mg/m2. Follow hCG weekly until undetectable.

Contraindications are haemodynamic instability, a viable intrauterine pregnancy, renal or hepatic impairment, severe anaemia, leucopenia or thrombocytopenia, active peptic ulcer, breastfeeding, a gestational sac with foetal cardiac activity, and hCG over about 5,000 IU/L. Stop folate-containing supplements and avoid NSAIDs. Use effective contraception for at least 3 months after treatment.

Rhesus negative women. Give anti-D immunoglobulin 250 IU (50 micrograms) intramuscularly within 72 hours when not already sensitised.

Failed vasectomy. Repeat semen analysis, confirm persistent sperm, and repeat the vasectomy or refer. Continue backup until clearance.

Regret counselling steps.

1. Listen and acknowledge without judgement.
2. Confirm the procedure and technique from the records.
3. Present reversal and assisted reproduction with realistic outcomes and costs.
4. Check for coercion, depression or relationship distress.
5. Refer to a unit with microsurgical or assisted reproduction capacity.

Contraception in the meantime. A reversible method is needed until a pregnancy is planned.

Follow up after reversal. Test for pregnancy when menses are late. If no pregnancy occurs after 12 months, or after 6 months in a woman over 35, refer for assisted reproduction. After vasectomy reversal, repeat semen analysis at 3 months and then at intervals of 3 months until count stabilises.

Ectopic pregnancy. Rupture, haemorrhage and shock. Manage with resuscitation and urgent surgery. Salpingectomy is preferred when the other tube is healthy, and salpingotomy is considered when the other tube is damaged and future fertility is wanted.

Intrauterine pregnancy after failure. Confirm location, then offer options in line with the law, and counsel on the future need for reliable contraception.

Complications of reversal. Ectopic pregnancy, anastomotic stricture, infection, haematoma, failure and sperm antibodies.

Methotrexate toxicity. Stomatitis, gastrointestinal upset, hepatic and renal dysfunction, myelosuppression. Check full blood count, creatinine and liver enzymes before dosing and monitor after dosing.

Psychological effects. Regret, depression and relationship distress call for supportive counselling and referral where distress is significant.

Referral and escalation. Refer ruptured or large ectopic pregnancy for emergency surgery, persistent trophoblast after methotrexate, requests for reversal, and patients needing assisted reproduction.