Local Versus General Anesthesia

Local anesthesia for laparoscopic sterilization is effective in pre- venting pain. Local anesthesia is particularly appropriate for a minilaparotomy or a laparoscopy, because these procedures cause little trauma to the tissues and take a short time to execute. Short- term, general anesthesia, which means the patient sleeps, also is used.

Local anesthesia involves injecting a drug into the area being treated to interrupt the function of the pain-carrying nerves, making the area insensitive to pain. You are awake but usually given a sedative for relaxation and relief of anxiety. The use of local anes- thesia has several advantages: (1) it avoids risking the complications that can occur with general anesthesia; (2) for most patients it means a shorter recovery time and less time at the clinic or hospital; and (3) it may reduce the cost of the operation.

Using a local anesthetic means the gynecologist must make changes in how he or she executes the surgery. Having you awake but sedated makes it necessary to perform the surgery more gently.

Furthermore, the physician must be in continual communication with you, telling you what is being done and what sensations or discomfort to expect as the fallopian tubes and other organs are manipulated. Occasionally, you will have to be warned not to move.

A local anesthetic eliminates the pain, but you may still experience some discomfort.

General anesthesia, by contrast, induces a loss of consciousness and sensation, usually by injected or inhaled drugs. You feel noth- ing, which helps the surgeon carry out the procedure with dispatch.

Nevertheless, general anesthesia is associated with many possible complications: low blood pressure, irregular heartbeat, heart attack, airway obstruction, allergic reactions, brain damage, and death.

Although these reactions are rare, general anesthesia should be used only when necessary.

Epidural and spinal blocks are forms of regional anesthesia. With

these techniques, the nerves are anesthetized where they branch from

the spinal cord. These can be used for childbirth and abdominal

surgery, and some gynecologists now use them for sterilization.

Each type of anesthesia has its advantages and disadvantages.

Discuss them all with your gynecologist/surgeon. If you prefer a local, you may have to make some inquiries to find a clinic or hospi- tal that favors this method or offers a choice, although it is more widely used today because it is less expensive. In some communities, however, you may find that the only available gynecologist prefers using general anesthesia.

EFFECTIVENESS AND REVERSIBILITY

Sterilization is extremely effective and should be considered per- manent. It is possible to repair occluded fallopian tubes so that they can function again, but this is major surgery and does not always work.

Failure Rate

As we noted, female sterilization is more than 98 percent effec- tive over a 10-year period. Failures happen because an occluding device did not work properly, for example, a spring clip that does not exert sufficient pressure, or because electrocoagulation was not complete. A channel also can re-form in an incompletely sealed tube, allowing eggs or sperm to pass through and meet. Failure also can occur if the surgery is not performed carefully or a structure other than the tube was occluded.

Reversibility

Never contemplate having a tubal occlusion with the idea that

someday you might want to have it reversed. Life situations can

change unexpectedly and unpredictable events can lead to the desire

for a child. Divorce and remarriage, a change in career plans, an

alteration in your emotional or financial status, or the death of a

child can create a strong wish to reverse an occlusion. Women under

the age of 30, particularly, are advised against a tubal occlusion,

because younger women are more likely to experience life changes.

FEMALE STERILIZATION: TUBAL OCCLUSION

171 If there is even the slightest chance that you might want a child in the future, use a reversible type of contraception.

Because of the possibility of regret after an irreversible proce- dure, careful counseling is important before sterilization. Counsel- ing is available from physicians and family planning clinics, and no tubal occlusion should be performed without it.

Tubal occlusions can be reversed only under the best of circum- stances. Reversal does not always lead to pregnancy, because deli- cate microsurgery is necessary to reverse the blockage of the tubes.

Sterilization procedures that destroy too much of the tube or remove the fimbria, the part of the tube that collects the released egg cell, make a reversal impossible. And it is not unusual for a surgeon to start a reversal procedure only to find that, in addition to the deliberate scarring caused by the occlusion method, the woman’s tubes have been harmed by the adhesions and scarring of undiag- nosed pelvic inflammatory disease or endometriosis.

For a reversal to be successful, you need to have healthy fallo- pian tubes that were damaged minimally during sterilization. To become pregnant, you also need to be ovulating and have a fertile partner.

Chances for reversing a sterilization are best if a clip or silastic band was used to occlude the tubes. The most effective method, electrocautery, causes more extensive destruction, making it the most difficult to reverse. Some clinicians prefer to occlude the narrowest part of the tube whenever possible, in order to preserve the greatest amount of tissue—just in case the patient someday wants to have her sterilization reversed.

Although microsurgery techniques have increased the possiblity

of reversing a tubal occlusion, success rates for this surgery are

modest, and the expense is high. Because of age, irregular ovulation,

and other fertility problems, a high percentage of sterilized women

are not good candidates for a reversal attempt. Before having such

an operation, you and your partner should be tested for other fertil-

ity problems, and you should have an examination by laparoscopy

to determine the condition of your tubes and whether a reversal of

the occlusion is feasible.