Female sterilisation A Family Planning & Gynecology topic for MBBS

1. FEMALE STERILISATION
Labeeb Pc

2. Topics discussed
• Timing of sterilisation
• Guidelines
• Surgical -
• Minilaparotomy
• Laparoscopic Sterilisation
• Vaginal tubal ligation
• Hysteroscopic sterilisation
• Complications
• Failure
• Reversal

3. TIMING OF STERILISATION
1. Postpartum sterilisation
• After 24 hrs to 7 days of delivery
2. Interval sterilisation
• Non preg , >6 weeks, within 7 days of menses
3. Postabortal sterilisation
4. Caesarean sterilisation
• Laparoscopic tubal ligation –not recommended? when?
*tubes are vascular & oedematous , may get torn easily

4. CASE SELECTION
• Females – 22 to 45 yrs (male – below 60y)
• Married
• Atleast one child , above one yr
• Sound state of mind
• Mentally ill patients - psychiatrist & legal guardian

5. Delay procedure….
• Suspected pregnancy
• 7-42 days postpartum
• Active pelvic infection/ peritonitis
• PID within 3M
• STD
• Active liver/gall b disease
• Cerebrovascular/ CAD
• Complicated heart diseases
• Severe anemia
• Psychiatric disorder
• Multiple scars of prev laporotomies

6. • Pregnancy conditions-
• Puerperial sepsis
• PROM >24 hrs
• Postpartum Psychosis
• Severe trauma to genital tract
• Recent septic abortion
• Severe post abortal hemorrhage
• Pre ecclampsia/ ecclampsia

7. Special precautions..
• Past Cardiovascular disease
• c/c resp disease
• Hyperthyroidism
• Diabetes with vascular disease
• c/c liver disease
• Pelvic TB, endometriosis
• Obesity
• Coagulation disorders

8. COUNSELLING
1. Permanency
2. Surgical procedure
3. Possible failure
4. Complications
5. Not protect against STD or HIV
6. Reversal is available ??

9. CONSENT
• Not under coercion, sedation
• Signed berfore surgery
• Consent of spouse not required

10. Minilaparotomy
Laparoscopic sterilisation
Vaginal tubal ligation
Hysteroscopic sterilisation
SURGICAL APPROACH

11. MINI LAPAROTOMY
• Post partum, post abortal, or interval period.
• Interval sterilisation –
• Empty stomach , void urine
• Local anaesthesia
• Premedication – meperidine, promethazine
• Uterine manipulator
• 2-3cm transverse suprapubic incision, 2.5cm above.

12. Post partum sterilisation
• local anaesthesia
• 2-3 cm subumbilical incision, 2cm below the fundus
• Tube identified by the fimbrial end
• Tubal ligation done using modified Pomeroy’s method /
clips or rings
• Kept for observation for 4 hrs,discharged
• Antibiotics & analgesics are given

13. 1. Pomeroy method
2. Parkland procedure
3. Madlener procedure
4. Fimbriectomy
5. Irwing technique
6. Uchida technique
7. Aldridge method
8. Shirodkar’s method

14. POMEROY METHOD
• Babcock’s forceps
• Catgut suture
• Difficult in tubal adhesion

15. • Babcock’s forceps

16. PARKLAND PROCEDURE

17. MADLENER PROCEDURE
• Crushed at base
• Ligated with silk
• Failure rate high

18. FIMBRIECTOMY ( Kroener )
Failure rate high

19. IRWING TECHNIQUE
• Catgut
• Proximal tube buried within
substance of myometrium.
• Distal end buried in
mesosalpinx
• Very low failure rate

20. UCHIDA TECHNIQUE
• Saline with epinephrine
injected into subserosal
area of tube
• Medial stump buried in
mesosalpinx
• Lateral stump ligated , kept
outside mesosalpinx –
purse string suture
• Failure rate very low.

21. ALDRIDGE METHOD
• Hole in ant leaf of broad ligament
• Fimbrial end buried into this.
• High failure rate

22. SHIRODKAR’S METHOD
• Cut ends are turned in opposite directions,
so that spontaneous recanalisation does not occur

23. COMPLICATIONS
• Anaesthetic hazards
• Bowel & bladder injury
• Broad ligament hematomas
• Infection
• Wound sepsis
• Peritonitis

24. LAPAROSCOPIC STERILISATION
Advantages
• Direct visualisation & manipulation
• Associated pelvic & abdominal abnormality detected
• Hospitalisation not needed
• Cosmetic advantage
• Min postop pain & discomfort
• Reversibility more after clip application.

25. Veress needle
Trocar & canula

26. • Lithotomy position
• Local anaesthesia
• Bladder catheterised, uterine manipulator applied
• Trendendeleburg position ( head down 15o ) after placing
first trocar
• Entering abdominal cavity –
1. Veress needle
2. Direct trocar
3. Open laparoscopy

27. VERESS NEEDLE

28. OPEN LAPAROSCOPY

29. METHODS
1. Rings
2. Clips
3. Electrocoagulation

30. RINGS
• Falope ring – silicone
rubber with barium
sulphate

33. CLIPS
• Filshie clip
• Silicone
• Better
• Hulka Clemens clip
• Spring loaded

36. ELECTRO COAGULATION
• Unipolar& Bipolar cautery
• Reversal difficult

37. COMPLICATIONS
• Anaesthetic complications
• Injury of large vessels
• Bleeding from epigastric vessels – trocar
• Tearing of mesosalpinx & hemorrhage
• Bowel injury
• Thermal burns
• Surgical & Mediastinal emphysema

38. CONTRA INDICATIONS
• Severe cardio pulmonary disease
• Prior abdominal surgery
• Postpartum sterilisation
• Extreme obesity, umbilical hernia
Laparoscopy best used for interval sterilisation or
following abortion of less than 12 weeks.

39. VAGINAL TUBAL LIGATION
• Colpotomy performed
• Complications – bowel injury, pelvic abscess

40. HYSTEROSCOPIC STERILISATION
• Essure
• Buscopan & NSAID to
prevent tubal spasm
• Fibrotic tissue reaction
• Backup contraception – 3M
• Then hysterosalpingogram to
confirm occlusion

41. SEQUELAE OF STERILISATION
1. Ectopic pregnancy
• Partial recanalisation, tuboperitoneal fistula
• More likely after 3 yrs
2. Post tubal ligation syndrome
• Abnormal bleeding, isolated ovarian syndrome
• Pain, cystic ovaries
3. Regret & Depression

42. FAILURE
• Typical failure rate – 0.3%
Procedure Failure rate %
Irwing 0.1
Parkland 0.25
Laparoscopic rings & clips 0.2 - 0.3
Pomeroy’s 0.3
Madlener’s 2
Fimbriectomy 2 - 3

43. • Due to –
• Recanalisation
• Incomplete division
• Incomplete occlusion
• Ligation of round ligaments in place of tubes
• Presence of early pregnancy

44. REVERSAL
• Micro surgical anastomosis
• Depends upon –
• Type of procedure
• Length of tube remaining
• Associated conditions like endometriosis, post op adhesions
affecting infertility