The decision to be sterilized can be the most important one in a woman’s life and should never be taken without very careful thought about all the possible implications. Counselling is designed to ensure that she and her partner have considered the full significance of the operation and realized the effect it will have on the rest of their lives.

Most couples are counselled first of all by their own family doctor although some family planning clinics and hospitals also offer a counselling service. He will stress the fact that sterilization is permanent and may try to make the woman aware of how she might feel once she is no longer able to become pregnant The couple are usually asked what types of contraception they have already used to make sure that there is not an alternative method they might use for a time before making a final decision.

The surgeon who is to perform the sterilization usually expects to talk the matter over with the couple beforehand. Typically, he will describe how the operation is carried out, explain its physical and possible emotional effects, dispel the myths surrounding sterilization and answer any additional questions which the couple may have about it.

Because of the irreversible nature of the operation, no one should opt for sterilization unless they are absolutely convinced they will never want to have more children. For instance, the couple should ask themselves if they might want another child if one of their existing children dies. Or the wife could change her mind if her husband dies or they get divorced and she remarries. Unfortunately, looking into the future is extremely hard to do but the couple have to think how they would feel if circumstances should change, and weigh this against the advantages of sterilization in their present situation. Generally speaking, though, it makes sense to wait until the youngest child is over a year old before going ahead with sterilization because, even nowadays, the first 12 months is the period when a child is most at risk from serious illness.

Whether or not you have children is only one of a number of important factors a doctor will take into account before agreeing to a sterilization.

There are no strict rules about what makes a woman a suitable candidate but doctors tend to keep to a set of guidelines which they apply to each couple’s individual circumstances. The doctor will weigh up a combination of factors 3 before coming to a decision.

A couple who already have a family of two or g more children are probably less likely to want to add to that number at a later date, but this does £ not mean that couples with one or even no | children – or single people – are regarded as £ unsuitable for sterilization.

Other considerations such as age and the stability of the marriage or partnership arejust as f important A young girl in a shaky marriage is g1 most likely to regret being sterilized as she has ‘” many years ahead of her in which to change her f mind and the greatest chance of getting divorced | and wanting children by a seconcf partner. In fact $ it is more likely that sterilization will hasten the end of an unhappy marriage than solve any problems and it should never be carried out in I these circumstances. For instance, a wife may blame an unsatisfactory sex life on her fear of | becoming pregnant When she becomes sterilized f and things don’t improve she loses her ‘excuse’ and finally has to face up to the fact that the | problem is much more fundamental.|

Sometimes sterilization is advisable because I the mother’s or any future baby’s health would | be in jeopardy, or because the woman is too “” mentally handicapped to be able to take contraceptive precautions and wouldn’t be able to look after the child. Other women are offered sterilization because they or their partners have a hereditary disease which they fear to pass on.

A woman’s personality and feelings about sex and her own fertility also have to be considered as part of the overall picture. Although the vast majority of women who have been sterilized say their sex lives have improved or not changed since the risk of pregnancy has been totally removed, some are emotionally affected by the final loss of their ability to have children.

The failure rate for sterilization is about the same as for the Pill – less than one per cent. For the very few women who do become pregnant after being sterilized the problem is usually that the clip or ring hasn’t blocked off the tube completely or that the surgeon did not identify the Fallopian tubes correctly and operated on a nearby fold of tissue. It is even possible for the tubes to heal together again naturally or to develop a small opening through which the egg can pass down in to the womb. To prevent this from happening, the surgeon often removes a small length of each Fallopian tube or buries the ends of the tubes in different layers of surrounding tissue.

Women waiting to be sterilized can be so relieved that they are finally going to have the operation that they become rather lax in using contraception. However, since they have made the decision that they definitely want any more children it is. Particularly important to ensure that they (or their partners) take proper precautions during this time.

Unlike male sterilization, a woman is ‘safe’ immediately she has had the operation. The only exception to this is if.she ovulates just before the operation and the egg has travelled down the tube before it is blocked. If the operation has been carried out mid cycle then it is advisable for her to use contraception until her next period.

In the first few months following sterilization women are recommended still to look out for signs of pregnancy. This is because some women are actually pregnant when the operation is done. Pregnane)’ is usually detectable during a laparotomy as a pregnant uterus looks different from a non-pregnant one. When a laparoscope is used, however, the gynaecologist doesn’t have a chance to see the uterus.

Either way, signs of pregnancy must not be ignored and the sooner the pregnancy is ter-minated the better, especially as there is a slightly increased chance that the pregnancy would be ectopic (contained within the Fallopian tubes).

A general anaesthetic is used in most female sterilizations. But in fact it’s a relatively minor operation, and almost all can be done under a local anaesthetic (where the woman remains conscious) if the doctor and patient are happy with this.

The operation itself entails cutting or blocking the Fallopian tubes- the two tubes through which the woman’s eggs pass from the ovaries to the womb. The conventional method is called ‘laparotomy5 or ‘tubal ligation’. The gynaecologist makes an incision a couple of inches long just above the pubic hair line and dien cuts each Fallopian tube and ties it with special thread. The woman can usually return home after a three-to-five day stay in hospital.

A ‘mini-laparotomy can be carried out on certain (usually slim) women which allows them to leave hospital sooner – often an overnight stay is all tiiat is necessary. A smaller cut is made below the pubic hairline and an instrument inserted through the vagina to push the Fallopian tubes into a visible position so that they can be operated on.

A newer but already widely used technique is the’laparoscopic’ method. The gynaecologist inserts a tube through a very small incision near the navel and gently pumps a harmless gas (nitrous dioxide or carbon dioxide) into the patient’s abdomen. This pushes away the intestines and gives better access to the tubes. He then replaces the tube with a long narrow optical instrument called a laparoscope. Through this he can see the womb, Fallopian tubes and ovaries and can also manipulate surgical instruments. A second ‘sterilizing5 instrument is then inserted through another small cut near the pubic hair line. Each tube is usually blocked either by using one or two special clips or by passing a small strong rubber band (a Falope ring) round a loop or ‘kink’ in the tube.

The Fallopian tubes can also be cauterized (sealed off) by using a high frequency electric current but this method is less common these days because, very occasionally, it has led to other organs becoming accidentally damaged.

Whichever method is used to block the tubes, the woman usually feels well as soon as she has recovered from the anaesthetic but she should be prepared to stay one or two nights in hospital to be on the safe side.

Is it true that the operation can sometimes be reversed? Once a woman has been sterilized she continues to produce an egg every month but because it never reaches the part of the womb where it might meet and be fertilized by a male sperm, it doesn’t develop and dies. Attempts can be made to unblock or rejoin the Fallopian tubes so that the eggs can once again reach the womb but the operation requires several hours of delicate, highly skilled surgery and even then success cannot be guaranteed.

A few doctors with a great deal of experience, and using a special operating microscope, have claimed mat up to 70 per cent of the sterilized women they ‘reverse’ nave become pregnant But nobody should consider sterilization as a reversible procedure or expect even a 5050 chance of success.

Doctors are reluctant to agree to reversal operations unless there are exceptional circum-stances and the woman is desperate to have another child. The sort of things they will take into account are the woman’s age, how long ago she was sterilized, the method used and how much of the Fallopian tubes were destroyed.

There are no precise figures on the number of sterilized women who request reversal but it is estimated that it runs at about one per cent Some unforseen change in circumstances- such as divorce and remarriage or the death of a child – is usually the reason for the request Unfortunately a large proportion of the women asking for a reversal did not fully understand what sterilization meant when they had it They continued to believe, despite counselling, that the operation could easily be reversed.

Women who have been sterilized at the same time as having an abortion or after childbirth may regret the sterilization once they are no longer pregnant A difficult or unwanted pregnancy is quite clearly not the ideal time to make this kind of decision. Although a woman may genuinely believe she knows her own mind at the time, it is easy to understand how she might come to regret her decision once the pregnancy is over.

How does a husband usually react to his wife’s sterilization? Since sterilization is usually a joint decision between a husband and wife it is fairly under-standable that once the operation is over the overwhelming reaction of most husbands is one of relief. And because they feel grateful to their wives for solving their birth control problems the relationships are often strengthened as a result If, on the other hand, despite counselling, a couple are not entirely honest with themselves or with each other about their reasons for wanting the sterilization the husband may come to resent the operation, which can lead to friction within the marriage. For instance where a husband is unnaturally-jealous or has reason to doubt his wife’s fidelity, the apparent sexual freedom steri-lization gives her can increase his suspicions and, even if they are totally unfounded, this can increase the rift between the couple. Such prob-lems are, however, unlikely to result from sterili-zation if the marriage is basically sound in the first place.