REFERENTES NORMATIVOS DEL ECOTURISMO EN COLOMBIA

reversible methods of contraception, as some methods are as successful as

sterilisation at preventing conception. For instance, the TCu380A intrauterine

device, which has a 12-year cumulative pregnancy rate of 1.9/100 women

treated (Anonymous, 1997). This is similar to the success of laparoscopic

sterilisation (Peterson et al., 1996). It is imperative that couples are aware that male sterilisation is a local anaesthetic, outpatient procedure, which is

very successful at preventing conception and is safer. The failure rate of

vasectomy is approximately 1 in 1,000 in the first year (RCOG, 1999). The

surgeon should ensure that the medical records include a full gynaecological

and medical history, and the examination findings are recorded, along with

the preoperative counselling for sterilisation:

Out-patient consultation and counselling:

Parity and any complex obstetric history

Gynaecological history and current symptoms

Pelvic examination

Discussion of long-term contraceptive alternatives to tubal occlusion

Expected method of access to tubes and method of occlusion (and reason for

method of occlusion if not mechanical)

Risk of extended procedure, if non-life-threatening problems occur

Extent of consent to alternative methods of tubal occlusion if first intended

method not possible

Failure rate 1 in 200

Irreversibility, potential for reversibility with expected method and availability

of reversal locally on NHS

Information leaflet given

Immediate pre-procedure;

Date of last menstrual period

Pregnancy test result if performed

Confirm outpatient details and other preoperative discussions

Confirm valid consent form with the patient’s name, name of doctor obtaining

consent - to be countersigned by surgeon performing the procedure

(Fitness for day case surgery)

Operation notes:

Name of operating surgeon(s) including surgeon present in theatre taking

overall responsibility

Ease of access to the tubes

Clarity of identification of the tubes

Accurate placement of occlusive method

Post-procedure:

Method actually used

Discharge letter to GP

Patient informed of method used and any intra-operative findings / events

Whether further contraception advised eg. up to next period, or pending result

of tubal patency test.

Royal College of Obstetricians and Gynaecologists

Evidence Based Guidelines on Female Sterilisation, 1999

Prior to undergoing sterilisation of the female partner the surgeon should

establish the date of the last menstrual period to ensure she is not pregnant,

and perform a pregnancy test if indicated. It is imperative that the operating

surgeon ensures that the patient has been appropriately counselled, is aware

of the risks of the surgery and the failure rate of the procedure. The patient

should be warned that the risk of a laparotomy due to visceral injury is 1.9 per

1,000 and the mortality rate is 1 in 12,000 as described previously

(Chamberlain and Brown, 1978; Jansen et al 1997). The woman should be informed about the method of sterilisation performed prior to discharge, any

surgical difficulties encountered and if there was any difficulty in clip

application or if an extra clip was required. If there is any doubt as to the

success of the sterilisation then the woman should be informed

postoperatively, and advised to continue contraceptive precautions until a

patient should be warned prior to discharge to attend the emergency

department or her General Practitioner should she suffer abdominal pain or

begins to feel unwell due to the potential late presentation of bowel injury.

The woman should be informed both preoperatively and again prior to

discharge that the risk of sterilisation failure is 1 in 200 women overall lifetime

risk (RCOG, 1999). This figure is based on the CREST study (Peterson et al., 1996). This prospective study of 10,685 women, described earlier, derived a

ten-year life table probability of failure of 16.6 per 1,000 procedures. This

failure rate is substantially greater than the failure rates previously reported of

3-6 per 1,000 at up to one year (RCOG, 1999). After multivariate analysis the

spring clip (Hulka clip), bipolar coagulation, decreasing age and particularly

women less than 28 years of age were all associated with significantly

increased chances of sterilisation failure. However the Filshie clip was not

available in the USA at the time of the CREST study. The best available

evidence suggests that it has a failure rate of 2-3 per 1,000 at two years

(personal communication. Professor John Guillebaud). The RCOG guidelines

extrapolate this figure using the CREST model to derive a lifetime risk of

sterilisation failure of 1 in 200 for Filshie clip application and the chance of

failure does not diminish with time. With regard to the risk of an ectopic

pregnancy post laparoscopic sterilisation the RCOG Guidelines (1999)

suggest that women should be warned that the risk of an ectopic gestation is

greater if tubal diathermy has been used and less likely if mechanical

occlusion or tubal ligation has been performed. Whilst women who have been

women, if they conceive their chance of the pregnancy being ectopic is up to

nine times greater than a woman who has not been sterilised (RCOG, 1999).

The RCOG review provides reassurance that for women over thirty years of

age, tubal occlusion does not cause a significant change to the menstrual

cycle. All women should be informed that it is possible to reverse the

sterilisation if required, although it should be stressed that sterilisation is

intended to be permanent.

The guidelines state that culdoscopy should not be used as an approach to

sterilisation, and that laparoscopic mechanical occlusion of the fallopian tubes

by either clips or rings as a day case procedure should be is the method of

choice in the UK. The guidelines state that ‘transcervical application of

chemicals, adhesives or synthetic plugs are still under evaluation and have

not been considered for these recommendations on methods of tubal

occlusion’.

With regard to analgesia the RCOG guidelines state that it is probable that

pain after surgery is greatest after ring application, with diathermy being the

least painful and with clip application being intermediate. Of benefit at

alleviating pain is; instillation of a local anaesthetic agent over the fallopian

tubes, into the mesosalpinx or on the Filshie clip. With regard to sterilisation

under local anaesthesia, benefits were noted with regard to postoperative

pain and earlier return to normal activities post procedure. It is cheaper,

anaesthetic sterilisation reported that 91% of patients would recommend the

procedure to a friend (Mackenzie et al., 1987).