3 Artificial contraception

3.3 Surgical methods of contraception

Surgical methods are by and large the most drastic and irreversible ones, ranging from castration to relatively untraumatic tube-tying. Because of the psychological and physiological side-effects, surgical removal of the testes or ovaries is not generally carried out for contraceptive reasons alone, although these operations may be carried out for other reasons, such as the presence of malignant tumours. Any kind of surgical sterilization can be physiologically traumatic for a woman, as it involves cutting or blocking the Fallopian tubes, leading from the ovaries to the uterus, to prevent the eggs from meeting any sperm (Figure 6a). The Fallopian tubes are located quite deep within the abdomen, so even ‘key-hole’ surgery is quite invasive. Surgical sterilization of men (vasectomy), on the other hand, is so straightforward that it can be done in 10 minutes under local anaesthetic, and is often referred to as ‘coffee-table’ surgery. Here, the tubes leading from the testes, where the sperm are produced, to the penis, are cut before they reach the glands which contribute other components, including fuid, to the ejaculate (Figure 6b). Thus, ejaculation takes place normally, but no sperm are released. No hormones are affected by the procedure, so sexual behaviour is unaltered.

You would probably predict that surgical contraceptive methods were very effective, and you would be correct. But once again, failure rates are not zero: occasionally, the operation is not performed correctly, the cut tubes will spontaneously repair themselves, and fertility will be restored. Reported failure rates are still low, however: about 0.1% is the norm (for both male and female sterilization). One side-effect of male sterilization seems to be an increased risk of developing kidney stones, or prostate or testicular cancer, although this has not been firmly shown. In general, female surgical sterilization seems relatively problem-free, although some women have reported having heavier periods.

Another method of contraception which we shall consider here is surgical abortion. This is, apart from coitus interruptus (withdrawal), probably the earliest form of ‘contraception’, and it is only within the last few decades that it has become a proper surgical process: prior to this time, and in many countries even today, abortion was frequently a ‘self-help’ method of contraception, and at best was the province of well-intentioned amateurs. Surgical (as opposed to spontaneous) abortion consists of a physical, or occasionally chemical, intervention which causes the growing fetus to detach from the uterus and pass out, with the placenta (afterbirth), through the vagina. (Fetus is the term used to describe the developing human after the eighth week of gestation, when all the systems of the body have formed.) Surgical abortion can be carried out at any time during pregnancy, but the current legal limit for a surgical abortion in the UK is at 24 weeks of gestation. (This is the term used to describe the progress of a pregnancy; babies are generally born after 38 weeks of gestation.) Because modern medical practices can allow some fetuses as young as 22 weeks to survive with intensive care, the ‘social’ limit, i.e. what is generally considered acceptable, is closer to 18 or 20 weeks. Surgical abortion is carried out by inserting instruments into the uterus via the cervix, and either sucking or scraping out the contents. This ensures that all the placenta is removed as well as the fetus: if any part of the placenta is left in the uterus, it may give rise to a serious infection. In times past, it was often sufficient to rupture the membranes surrounding the fetus (hence the popularity of the ‘knitting needle’ method, in which a knitting needle or other similar object was inserted through the cervix to induce an abortion). Once the membranes are ruptured, the fetus is very prone to infection, which is likely to kill it. A dead fetus is generally rejected by the uterus, which expels it. The success rate of an abortion is very high, although it depends on the precise method used.

Figure 6, Diagram to show where sterilization cuts are made (a) for women and (b) for men. Notice that in (a) the tubes may be blocked rather than cut, using rings or clips.

Although the majority of abortions are carried out by physical removal of the fetus and placenta, chemical abortifacients are becoming more widely used. These are commonly referred to as ‘morning after’ pills, and, although there are several kinds, generally act by administering a cocktail of hormones whose effect is to alter the environment of the uterus so that implantation of the embryo is impossible. These pills can be used for only the first few days after unprotected intercourse, as they will generally not produce an abortion if implantation has already occurred. However, a different hormone, the most widely used form of which is known as RU486, can be used at rather later stages. RU486 is a type of prostaglandin. Prostaglandins are a family of hormones made in the body from fats, and are unusual in that they do not need to be transported by the blood to their target organs, but are produced nearby. The effects of prostaglandins are diverse, and some of them are believed to be involved in labour. RU486 acts by inducing delivery of the recently implanted embryo. One drawback of chemical abortifacients is that they need to be administered before a pregnancy has been confirmed, so are probably less suitable for regular use than as an emergency measure, because of the acute side-effects (headaches and nausea) experienced by many women taking them.

Even in the cleanest of modern hospitals, abortion presents a significant risk to the mother. The forcible detachment of a healthy placenta from the wall of the uterus leaves a large number of ‘open’ blood vessels, and there is a considerable likelihood that haemorrhage (bleeding) will occur, possibly resulting in the mother's death. Although nowadays death from this cause is extremely rare, subsequent infection can render the woman sterile. The introduction of legal abortion in the UK following the 1967 Abortion Act, which allowed abortions to be carried out under cleaner conditions, made a significant difference to the maternal death rate, and this has provided a strong argument for legalizing abortion elsewhere. The argument is as follows: if it is accepted that abortion is going to happen regardless of the law, might it not be better to minimize the risk associated with the operation by allowing it to be carried out properly, rather than under unsanitary, back-street conditions?

The adverse effects of undergoing an abortion are not all physical. Although a woman's initial reaction is often one of relief that she is no longer pregnant, there are often severe long-term emotional effects of the loss of a baby – for, almost always, by the time the abortion is carried out, the woman is all too aware that what is growing inside her is a baby, and not just a lump of tissue. This emotional reaction is sometimes overlooked both by the woman herself and by medical staff with whom she comes into contact, and sympathetic counselling should be offered to anyone in this situation. The emotional impact is, of course, particularly severe if the woman actually wanted the baby, but underwent an abortion because the fetus was abnormal. There is a large body of literature on the subject of abortion, but space constraints prevent further discussion here.

As mentioned above, abortion is one of the oldest methods of limiting family size. It is believed that in this country one of the major roles of the wise women and healers of olden times was as practitioners of abortion. This is thought to be an important cause of their persecution as witches: the largely male establishment resented anybody who could empower women, particularly in the matter of their own fertility, and they perceived this question of a woman's choice as a threat to their sovereignty. The objection to abortion on the grounds that it takes the fetus’ life is a relatively recent development. Even the Roman Catholic Church, until 1869, found early abortion acceptable. This was because of an ongoing debate about when the soul enters the body: if it was not until ‘quickening’ (that is, when fetal movements can be felt), then abortion before this time did not result in taking a life, and so was permissible. However, in 1869, Pope Pius VI decreed that the soul enters the body at the moment of conception, so abortion at any time is wrong. Whatever the ethical, legal and political debates surrounding abortion, the fact remains that it is a widely used and effective means of limiting family sizes throughout the world.