STERILIZATION
Chronography
Year / Scientist / Event /1834 / Blundell / First recommendation in the US for incision and removal of a portion of fallopian tube for sterilization
1881 / Lundgren / First report of tubal sterilization by simple ligation at time of cesarean delivery described by Samuel Smith Lungren of Toledo, Ohio in 1880
1910 / Madlener / Technique for crushing and ligation of fallopian tube; 89 procedures, 3 deaths, 0 pregnancies by 1919
1924 / Irving / Procedure of ligation, division, and burial of proximal stump in myometrium; modified techniquedescribed; 814 procedures, 0 failures by 1950
1930 / Bishop and Nelms / Procedure for ligation and resection devised by their late associate, Pomeroy; 60 sterilizations
1934 / Aldridge / Technique for temporary sterilization; 1 successful reversal and pregnancy
1935 / Kroener / Fimbriectomy procedure; 200 fimbriectomies, 0 failures by 1969
1946 / Uchida / Technique for tubal ligation, resection, and burial; 5000 sterilizations, 0 failures by 1961; 20,000 sterilizations, 0 failures by 1975
1960s / Parkland / Method popularized at Parkland Memorial Hospital
ELIGIBILITY:
1. Married clients
2. Female clients should be below the age of 49 years and above the age of 22 years
3. The couple should have atleast one child above the age of 1 year unless the sterilization is medically indicated
4. Clients or their spouses/ partners must not have undergone sterilization in the past unless failure
5. Sound state of mind
6. Mentally ill patients must be certified by a psychiatrist and consent by legal guardian or spouse.
COUNSELLING:
1. Permanent method
2. all other available methods
3. voluntary consent
4. side effects and complications
5. no protection against STDs and HIV
6. reversal of procedure
TIMING:
1. Interval
2. Postpartum
3. Concurrent with MTP
4. Following spontaneous abortion
SURGICAL TECHNIQUES:
1. Minilaparotomy
2. Laparoscopic tubal occlusion
3. Concurrent with Caesarean delivery
REQUIREMENTS FOR MINILAPAROTOMY:
· Empty bladder
· Identify the tube by fimbrial ends
· Site of occlusion within 2-3 cm from the uterine cornu in the isthmic portion
· Excision of 1 cm
· Modified Pomeroy method
COMPLICATIONS:
Intra- operative complications
1. Nausea and vomiting
2. Vasovagal attack
3. Respiratory depression
4. Cardiorespiratory arrest
5. Bleeding from mesosalpinx
6. Uterine perforation
7. Injury to urinary bladder
8. Injury to intra abdominal viscera
9. Toxicity to drugs
Post- operative complications
1. Wound sepsis
2. Hematoma
3. Intestinal obstruction, paralytic ileus, peritonitis
4. Incisional hernia
5. Ectopic pregnancy
ADVANTAGES:
There appears to be a protective effect with regards to a reduced risk of ovarian cancer and need for hospitalization due to pelvic inflammatory disease.
Failure of surgery leading to pregnancy
· Counsel to report immediately if missed periods
· Rule out ectopic pregnancy
· Offer MTP and repeat sterilization
· If wishes to continue, then medically support
· Intimate district quality assurance committee
TYPES:
1. THE POMEROY TECHNIQUE
· Common, inherent simplicity and its long-established efficacy
· Partial salpingectomy
Following accurate identification of the fallopian tube, a Babcock clamp is placed around the proximal portion of the tubal ampulla and the tube is elevated to reveal the vascular supply of the mesosalpinx. It is important to follow the tube distally to its fimbriated end to ensure that it is the fallopian tube and not the round ligament. A single strand of rapidly absorbable suture material (1-0 or 0 plain catgut) is placed around the elevated loop of tube and firmly tied. The fallopian tube is thus ligated and the blood supply is occluded simultaneously. A hemostat may now be placed on the suture strands immediately distal to the knot, and the excess suture may be excised. The hemostat now becomes a useful holder for the next step in the procedure. At this point, a second tie of the same suture material may be applied at the discretion of the surgeon, but this is not usually necessary. While gentle traction is maintained on the elevated section of tube, the open blade of the Metzenbaum scissors is used to pierce the mesosalpinx and approximately 1 cm of tube is excised. The excised tube should be appropriately labeled and sent to the pathology laboratory for documentation. With the contraction of the muscularis, the white avascular endosalpinx appears as an elevated area in the center of each cut segment. The proximal and distal ends of the divided and ligated oviduct are now examined for bleeding and then the tube is returned to the abdominal cavity and the procedure is repeated on the opposite tube.
· The major advantages of the Pomeroy technique are that it is easily taught, is simple to perform, and is highly-effective.
· Difficult to perform in the setting of tubal adhesive disease due to the inability to elevate a knuckle of tube.
· The reported pregnancy rate is less than 1 per 1000 procedures in the first year, but up to 7.5 per 1000 procedures 10 years since sterilization.
2. THE PARKLAND PROCEDURE
· Rather than ligation of a knuckle of tube followed by creation of a window in the mesosalpinx, the window is created first.
· provides for immediate anatomic separation of the disconnected tubal segments unlike the Pomeroy technique.
Fig. 2.A.Identification of avascular region of mid-portion of tube.
B.Windowthrough mesosalpinxis created below the tube.
C.Rapidly absorbable (0 chromic or plain gut) sutures placed proximally and distally.
D.Ligated portion of tube excised.
3. THE MADLENER TECHNIQUE
A. A loop of the ampullary portion of the tube is elevated and then both segments are crushed with a hemostat.B.A strand of nonabsorbable suture material is used to ligate the tube over the crushed area. No tissue is excised. The devascularized loop of tube undergoes aseptic necrosis. High failure rates
4. THE IRVING PROCEDURE
A.The tube is divided in the region of the ampullary–isthmic junction, and the ends of the suture are kept long for traction and for use in the subsequent steps of the procedure.B.Using blunt dissection, a tunnel is made within the substance of the uterine myometrium and the proximal tube is pulled into this chamber and sutured in place.C.The distal tube is then buried within the substance of the broad ligament. Additional sutures may be necessary to close the defect within the mesosalpinx and adjacent broad ligament as a result of the previous dissection.
5. THE UCHIDA TECHNIQUE
A.A subserosal injection of a saline-epinephrine solution is made in the region of the tubal ampulla.B.The serosa is then incised with the scissors, exposing the muscular layer of the tube. A segment of the muscular layer is elevated while the serosa is simultaneously stripped back over the proximal and distal segments.C.The proximal portion of the muscular tube is ligated and excised. The proximal ligated segment then drops back beneath the serosa.D.A purse-string suture is placed around the distal tube and tied. Additional sutures may be needed to close the defect in the mesosalpinx and adjacent broad ligament involved in the earlier dissection.
6. Kroener fimbriectomy
Top.A suture is anchored in the mesosalpinx and placed around the tube in the distal ampulla. A second suture may be placed adjacent to the first, and the infundibulum of the tube is excised.Bottom.The tube as it appears following excision of the distal segment.
7. THE ALDRIDGE PROCEDURE
Top.By blunt dissection, a pocket is developed within the substance of the broad ligament. Traction sutures are placed within the muscular layer of the distal tube and are used to draw the infundibulum into the peritoneal pocket.Bottom.Several sutures of nonabsorbable suture material are then used to anchor the infundibulum of the tube into the new anatomic subperitoneal location. Care must be taken to ensure that the entire fimbriated portion of the tube is firmly held beneath the peritoneum.
Technique / Popularity* / TubalDestruction / Failure and/orPregnancy Rate / ReversalPotential /Uchida / 1+ / 50% / Rare / Very poor
Fimbriectomy / 1–2+ / 40% / Poor
Irving / 1+ / 30% / Poor
Pomeroy / 5+ / 3–4 cm / 2–4:1000 women / Good
Aldridge / Rarely done / None / Significant / Excellent
ESSURE STERILIZATION PROCEDURE
Essure sterilization is a new hysteroscopic tubal occlusion method that became approved for use in the United States in November 2002.
Essure is a coiled spring device that is inserted through the uterine cavity into the tubal openings using a hysteroscope. This can be done as an office procedure. The Essure micro-insert consists of a stainless steel inner coil, a super-elastic outer coil, and polyethylene fibers wound in and around the inner coil. When released, the outer coil expands to anchor the micro-insert in the fallopian tube. As the device expands to fill the tubal opening, it gradually becomes scarred in place and forms a barrier so that sperm cannot reach the egg. The device extends from the uterine cavity, through the interstitial segment of the tube within the uterine muscle, and into the isthmic segment of the fallopian tube outside of the uterus. A hysterosalpingogram (HSG) is performed three months later to ensure the fallopian tubes are completely blocked and that the woman can begin relying on Essure to prevent pregnancy. Because of the scar formation, reversal of Essure can not be achieved by simply removing the coils. Toreverse the Essure method of tubal sterilization, the fallopian tube must be cut beyond the reach of the Essure device and then implanted into a new opening in the uterus.
ADIANA STERILIZATION PROCEDURE
Adiana is another new hysteroscopic sterilization procedure. It was approved for use in the US by the FDA in July 2009. Adiana uses radio frequency energy and a polymer microsinsert that together result in tubal blockage in the interstitial segment of the fallopian tube that is within the uterine muscle.
With the Adiana procedure, a catheter is positioned immediately inside the opening of the patient’s fallopian tube using a hysteroscope. The catheter applies low-level radiofrequency (RF) energy to remove the thin layer of cells that line a 1 cm section of the inside of the fallopian tube. A soft polymer matrix implant, that is smaller than a grain of rice, is then inserted into the tubal opening. As scar tissue grows into the inplant, tubal blockage occurs. The area of the tube that is affected is smaller than with the Essure device. The portion of the tube outside the uterus is not affected. Similar to Essure, a confirmatory hysterosalpingogram (HSG) is performed three months later to ensure the fallopian tubes are completely blocked and that the woman can begin relying on Adiana for permanent contraception.Adiana reversalis also performed by the technique oftubouterine implantation.
Medical Eligibility Criteria for Female Surgical Sterilization (Source: Medical Eligibility Criteria for Contraceptive Use, Third Edition, WHO, 2004)
There are no absolute contraindications for performing a sterilization operation. However, there are certain relative contraindications where one needs to apply the criteria of “C”, “D”, and “S” as stated below.
A- Accept- There is no medical reason to deny sterilization to a person with this condition.
C Caution The procedure is normally conducted in a routine setting, but with extra preparation and precautions.
D Delay The procedure is delayed until the condition is evaluated and/or corrected. Alternative temporary methods of contraception should be provided.
S Special The procedure should be undertaken in a setting with an experienced surgeon and staff, the equipment needed for providing general anaesthesia, and other back-up medical support. To meet these conditions, the capacity to decide on the most appropriate anaesthesia regimen is also needed. Alternative temporary methods of contraception should be provided if referral is required or if there is otherwise any delay.
1. Pregnancy D
2. Young age* C Clarification: Young women, like all women, should be counselled about the permanency of sterilization and the availability of alternative, long-term, highly effective methods. Evidence: Studies show that up to 20% of women sterilized at a young age later regret this decision, and that young age is one of the strongest predictors of regret (including requests for reversal information and obtaining reversal) that can be identified before sterilization.
3. Parity* a) Nulliparous A b) Parous A c) Breastfeeding A
4. Post-partum* < 7 days A
7 to < 42 days D
≥ 42 days A
5. Pre-eclampsia/ eclampsia: mild preeclampsia A
severe preeclampsia/ eclampsia D
6. Prolonged rupture of membranes: 24 hours or more D
7. Puerperal sepsis, intrapartum or puerperal fever D
8. Severe antepartum or post-partum haemorrhage D
9. Severe trauma to the genital tract: cervical or vaginal tear at time of delivery D
10. Uterine rupture or perforation S Clarification: If exploratory surgery or laparoscopy is conducted and the patient is stable, repair and tubal sterilization may be performed concurrently if no additional risk is involved.
11. Post-abortion* Uncomplicated A
Post-abortal sepsis or fever D
Severe post abortal haemorrhage D
12. Severe trauma to the genital tract: cervical or vaginal tear at time of abortion D
13. Uterine perforation
14. Past ectopic pregnancy A
15. Smoking A
16. Obesity ≥ 30 kg/m2 body mass index (BMI) C Clarification: The procedure may be more difficult. There is an increased risk of wound infection and disruption. Obese women may have limited respiratory function and may be more likely to require general anaesthesia. Evidence: Women who are obese are more likely to have complications when undergoing sterilization.
17. Cardiovascular disease: Multiple risk factors for arterial cardiovascular disease* (Such as older age, smoking, diabetes, and hypertension) S
18. Hypertension, adequately controlled C
19. Elevated blood pressure levels (properly taken measurements)
Systolic 140–159 or diastolic 90–99 C
Systolic ≥ 160 or diastolic ≥ 100 S
20. Valvular heart disease: Uncomplicated C
21. Complicated (pulmonary hypertension, atrial fibrillation, history of subacute bacterial endocarditis)
22. Epilepsy C
23. Depressive disorders C
24. Heavy or prolonged bleeding (includes regular and irregular patterns) A