Female SterilisationDepartment of Obstetrics and Gynaecology

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INDIA

Normal Anatomy:

Anatomy:

• Length- 10-14cm• Diameter- 2-6mm• Lat-Med- Infundibulum with fimbriae, Ampullary,

Isthmus, interstitial.• Blood Supply-Br. of uterine and ovarian artery• Nerve Supply-Sympathetic and Parasym. T11-12 & L1• Lymphatic drainage- iliac & lateral aortic nodes

Fallopian tube :

• Interstitial-narrowest 1mm• Ampulla

– longest and widest– Fertilization

• Junction of ampulla & isthmus • Histology 3layers

– Serosa primarily visceral peritoneum– Sub-serosa – Muscularis– Mucosa 3different cell types

Physiological function:

• Ovum pick-up• Capacitation of spermatozoa• Acrosomal reaction • Facilitation of fertilization• Transfer of zygote to uterus for implantation

Human Ovum :

Human Spermatozoa :

Fertilizatin :

Case Selection(Self-declaration by the client will be the basis for compiling this information.)

• Patients should be married.• Female Patients age ˂ 49 years and ˃ 22 years.• The couple should have at least one child whose age

is above one year.• Patients or their spouses/partners must not have

undergone sterilization in the past.• Patients must be in a sound state of mind.• Mentally ill clients must be certified.

Counselling:

• Patients must be informed of – all the available methods of family planning – made aware that this operation is a permanent one.

• Clients must make an informed decision for sterilization voluntarily.

• Patients counseled in their language.• Patients should be informed about the surgery

and its complications.

Features of Female Sterilization:

• Permanent procedure.

• Surgical complications &failures &further management.

• No effect on couple life.

• No effect daily activity.

• No protection to STD or HIV.

• Reversal possible but a major surgery and less success rate.

Women Experiencing an Unintended Pregnancy Within the First year of Use (%)

Method Typical Use Perfect Use Women Continuing Use at 1 Year (%)

No method 85 85

Spermicides 29 18 42

Withdrawal 27 4 43

Periodic abstinence 25 51

Calendar 9

Diaphragm 16 6 57

Female (Reality) 21 5 49

Male 15 2 53

Combined pill and minipill 8 0.3 68

Female sterilization 0.5 0.5 100

Male sterilization 0.15 0.10 100

Clinical Selection of a Case:

• Demographic information• Medical History• Physical examination• Laboratory examination

Timing of Sterilization:

• Interval sterilization should be performed in the follicular phase of the menstrual cycle).

• Post-partum sterilization should be done after 24 hours up to 7 days of delivery.

• Sterilization with medical termination of pregnancy (MTP) can be performed concurrently.

• Sterilization following spontaneous abortion provided the client fulfils the medical eligibility criteria.

Pre-operative Care:

• Pre-medication• Analgesia or Anaesthesia- – Local Anaesthesia Anaesthesia of Choice.– General Anestheisa rare but • In case of a non-cooperative patient• In case of excessive obesity• In case of a history of allergy to local anaesthetic drugs

• Monitoring– Pre-operatively– Intra-operatively– Post-operatively

Surgery:

General Requirements

• Bladder empty

• Surgeon to identify both fallopian tube up to fimbria

• Occlusion should be 2-3cm from cornu & in isthmus

• Excision of 1cm of tube

• No crushing or use of cautery

• Incision closure by either absorbable or non-absorbale

suture.

Surgical Techniques:

Tubectomy

Abdominal

ConventionalP

omeroy’s

Uchida’s

Irving’s

Madlener

Kroener

Oxford

Aldridge

Minilaparoto

myLaparoscopy

Vaginal

Pomeroy:

Loop is made consisting major part of isthmus &

ampulla

Avascular mesosalphix needle 0 chr. Catgut is passed and tied firmly

About 1-1.5cm of segment of loop

distal to ligature is excised .

About 1.5cm intact tube adjacent to uterus left. Specimen sent for histology.

UchidaIsthmus portion grasped and subserosa infiltrated

and incised

Muscular portion identified and divided

Serosa dissected bluntly and exposed

muscular portion ligated and resected

Proximal portion buried in

mesosalhinx and distal one kept open

to peritoneal

Irving

Parkland

Points

• Modified pomeroy is most common method

• Uchida has least chance of failure among all

• Irving & Parkland method are rare in use

• Suture used is 1chromic catgut

• Absorbable suture used to prevent

recananlization

Laparocopic Sterilization:• Requirements– Trendelenberg position ˃15˚– Uterine elevator used– Pneumoperitoneum– Insufflation with CO2

• Falope ring used. Other methods spring clip Hulka & Titanium clip

• After application abdomen should carefully inspected• Expel gas before removing the port

Post-operative Care• Post-operative BP, pulse & respiration/15min• Patient can be discharged– Stable for 4hours– Passed urine, walk, drink & talk.– Evaluated by doctor

• Patient accompanied by responsible adult• Antibiotics, analgesics, etc provided or

prescribed.

Electrocoagulation:• Unipolar was first to be used • Least chance of failure • Causes most thermal injury to adjacent organs• Bipolar is more safe but with higher ligation

failure• Central Govt. policy is no use of cautery

Complications :

• Nausea and vomiting• Vasovagal attack• Respiratory depression• Cardiorespiratory arrest• Uterine perforation • Bleeding from mesosalpinx• Injury to urinary bladder• Injury to bowel or vessel• Convulsion and toxic reaction to anaesthetic drugs

Post-operative Care:

• Wound sepsis

• Haematoma in the abdominal wall

• Intestinal obstruction, paralytic ileus and

peritonitis

• Tetanus

• Incisional hernia

Conditions Unrelated to Ligations:• Menstrual irregularities– Scanty periods– Menorrhagia

• Chronic pelvic inflammatory disease• Psychological problems• Sexual function

Hysteroscopic Ligation

1. Essure :– The Essure system is a type of permanent birth

control for women. The Essure system includes two small metal and fiber coils that are placed in the fallopian tubes. They're inserted through the vagina, so no incision is required.• 3months other contraceptive use is necessary• HSG to be done to ensure the tubal block• Does not prevent STI

– Benefits• Permanence• Effectiveness• Lack of significant long-term side effects• No need to buy contraception, interrupt sex for

contraception or seek partner compliance• No incision• Convenience — the Essure system can be

implanted at your health care provider's office• No effect on your menstrual cycle

– Discourage if• Are sensitive to nickel or allergic to the contrast

agent used to confirm tubal blockage• Have a uterine or tubal condition that prevents

access to one or both tubal openings• Might want to become pregnant• Previously had a tubal ligation• Recently gave birth or had an abortion• Recently had a pelvic infection

– Risks• Infection• Pelvic pain• Perforation of the uterus or fallopian tubes• Tubal blockage occurring on only one side• No ablative surgery of uterus

If client conceieves with essure then more chances of ectopic pregnancy.