Sterilization for Both Sexes

One drastic way to practice birth control is by means of sterilization. The surgeon's knife is now being sought by increasing numbers of Americans, both men and women, who want to be sure that they will have no more babies. Few doctors or patients are willing to talk about it, but the Association for Voluntary Sterilization, Inc. estimates that such operations have been performed on at least 2,000,000 Americans.

The number of voluntary sterilizations was limited in the past by two ill-founded fears. One was that the operations were illegal. In fact, they are legal in every state although Utah still requires that they be done "for medical reasons only." The other deterrent to the operation -especially among males -was the popular confusion between sterilization and castration. Another reason for fresh male acceptance of sterilization is the spirited espousal of the practice by Stanford University Biologist Paul Ehrlich, who publicly called attention to his own vasectomy in 1964.

In the Pipeline. Sterilization operations for men and women are based on the same strategy: cutting the tubes that carry the sex cells on their paths toward junction and conception. In the woman, the Fallopian tubes -through which the egg cells travel from the ovaries toward the uterus -are hidden in the pelvic cavity of the lower abdomen. Before recent technical advances they were relatively difficult for the surgeon to reach. In the man, a tube called the vas deferens (literally, the "carrying-away vessel") arises from each testicle to carry the spermatozoa to the prostate gland where the seminal fluid is finally compounded for ejaculation through the urethra. Near its origin in the scrotum, the vas deferens is readily accessible to the surgeon's scalpel.

Because of these anatomical differences, the male operation is the simpler. After injecting a local anesthetic, the surgeon makes an incision about half an inch long on one side of the scrotum, draws out one vas, and cuts out a section up to an inch long. He usually cauterizes the remaining stumps of the vas and ties them shut with nonabsorbable thread. The surgeon then sutures the small wound and repeats the procedure on the other side.

Because patients have some discomfort for two or three days after a vasectomy, the Margaret Sanger Research Bureau in Manhattan schedules all such operations on Fridays; thus the patient will be able to return to work on Monday. The vasectomy patient undergoes no hormonal changes, and if he has fully understood the operation beforehand he should have no emotional problems. His capacity for sexual relations may even be increased, because he no longer fears conception. His sperm, trapped in the testicles, are reabsorbed, and eventually his body manufactures fewer of them. However, some sperm are left "in the pipeline" at the time of operation, so for the next six to twelve acts of coitus a contraceptive must be used. Most surgeons require that their patients return after four to twelve months and leave a semen sample for analysis to make sure that neither vas deferens has joined itself up again.

Tiny Incisions. For women there are a variety of surgical procedures. The most obvious is used on the woman who is having a baby by caesarean section, and has decided that this will be her last. Since her abdomen is already open, the obstetrician simply reaches in for the Fallopian tubes, ties them off and severs them -much as the urologist does in a vasectomy. Most surgeons also remove part of the tube. This procedure is called tubal ligation.

Equally common is the operation on a woman who has just given birth to a baby normally. Within 36 hours after the delivery, the surgeon makes a three-or four-inch incision in her lower abdomen to reach the tubes. The surgical wound is almost healed by the time the woman goes home with her baby.

In recent years, especially in Britain and Europe, gynecological surgeons have been seeking means of reaching and severing the Fallopian tubes without making a long pelvic incision. They have succeeded with the aid of the laparoscope, a tube containing a "light pipe," less than half an inch in diameter. The techniques vary in detail. At Johns Hopkins Hospital in Baltimore, Dr. Clifford R. Wheeless makes two incisions less than half an inch long just below the navel (see diagram). Through one, after blowing in carbon dioxide to separate the organs, he inserts the laparoscope to locate a tube. Through the second he inserts the electric cautery and a tiny surgical knife. The operation, under general anesthesia, takes about 30 minutes and allows the patient to leave the hospital the same day.

In a modified version of the operation, Dr. Alvin Siegler of New York's Downstate Medical Center makes his first incision for the laparoscope so close to the navel that no separate scar will be visible, then inserts the cautery and knife through two punctures not much bigger than those made by a heavy-gauge hypodermic needle.

The simplest development in sterilization of women, requiring only local anesthesia, is reported by Dr. Martin Clyman at Manhattan's Mount Sinai School of Medicine. He has designed special instruments that enable him to operate through an incision little more than an inch long in the vaginal wall, reaching and tying off both tubes in about ten minutes. This vaginal approach leaves the patient with no visible scars, and she can go home in 24 to 48 hours after the operation.

Although many hospitals still require that a staff committee give advance approval for a surgeon to sterilize a woman, the criteria for men are more subtle and largely psychological. The Margaret Sanger Research Bureau's clinic will not usually operate on men who are single, or in their twenties, or whose wives are not wholeheartedly in favor of the decision. Psychiatrist Helen Edey, who interviews the applicants, lists these requirements: 1) the man must be at least 25 years old and married, or in a "stable relationship," 2) if under 40 he must already have two children. For men over 40, each case is considered individually. Dr. Edey interviews man and wife together for 45 minutes to an hour, to make sure that they fully understand the predictable effects of the operation. "I look for signs of pressure by one spouse on the other," she says. "Both must want it sincerely, or there may be later regrets and resentment."

Why do couples prefer sterilization to the long-term use of contraceptives? "Because they know that failure rates from most forms of contraception are too high," Dr. Edey says. "Or they are afraid of side effects from the Pill, or they have aesthetic objections to having to remember to insert something at what is emotionally the wrong time."

Rates of Reversal. One nagging question that still deters many men from seeking sterilization: Is the operation reversible? The answer is that in some cases, after either male or female sterilization, fertility can be restored by a reverse operation to rejoin the severed tubes. The success rate of these procedures is disputed. Some physicians put it as high as 80%; most think 30% is more realistic. But the question seldom arises. Most urologists' records show that not more than 1% or 2% of their male patients have ever asked for a reverse operation.

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