[Surgical sterilization in women].

Tubal ligation was initially proposed to prevent serious and foreseeable accidents related to pregnancy. The techniques and indications for tubal ligation have subsequently multiplied. Physicians must assess their own attitudes toward sterilization seekers, taking into account the moral and legal aspects, the risks of all surgery, and the uncertain prospects for reversal. Surgical sterilization should remain an exceptional procedure, reserved for women who have exhausted other medical resources. No law in France specifically addresses the legality of male or female sterilization, but physicians performing sterilizations have some risk of being charged with assault and battery. Laparotomy and minilaparotomy, except in postpartum sterilization, are usually done in France only when there are contraindications to laparoscopic sterilization. Among laparoscopic techniques, electrocoagulation and thermocoagulation are not often used because of the risk of serious complications. Yoon rings and Hulka-Clemens clips are preferred because of the lessened risk of accidents and improved potential reversibility. Laparoscopic sterilization is the technique of choice except during the postpartum or in very obese women, women who have undergone repeated abdominal surgery, or with cardiorespiratory complications. Vaginal techniques are another alternative in case of contraindications to laparoscopy, but they are contraindicated in case of a large uterus, infection, or endometriosis. The medical indications for surgical sterilization are becoming rare because of progress in preventive medicine, nutrition, and hygiene, and the appearance of new treatments and methods of prenatal surveillance. The principal indication at present is a scarred uterus following several cesareans. Other medical indications are neoplasia, severe cardiac insufficiency, and serious psychiatric disorders. Genetic indications are also exceptional. The greatest demand for sterilization is among women desiring contraceptive convenience, but some 10-20% of women sterilized in the absence of specific medical indications experience regret and 1-5% request reversal. Risk factors for reversal include young age of the woman, marital problems, sterilization during an obstetrical event, low parity, poor information on contraception, no previous contraceptive usage, incomplete information on sterilization and its consequences, and intrusion of the physician in the sterilization decision.