Female sterilisation

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 Postpartum sterilisation After 24 hrs to 7 days of delivery Interval sterilisation Non preg , >6 weeks, within 7 days of menses Postabortal sterilisation 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 Permanency Surgical procedure Possible failure Complications Not protect against STD or HIV 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. Pomeroy method Parkland procedure Madlener procedure Fimbriectomy Irwing technique Uchida technique Aldridge method 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 ( K roener ) 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 15 o ) after placing first trocar Entering abdominal cavity – Veress needle Direct trocar Open laparoscopy

27. Veress needle

28. Open laparoscopy

29. Methods Rings Clips Electrocoagulation

30. Rings Falope ring – silicone rubber with barium sulphate

31. Clips Filshie clip Silicone Better Hulka Clemens clip Spring loaded

32. Electro coagulation Unipolar& Bipolar cautery Reversal difficult

33. Complications Anaesthetic complications Injury of large vessels Bleeding from epigastric vessels – trocar Tearing of mesosalpinx & hemorrhage Bowel injury Thermal burns Surgical & M ediastinal emphysema

34. 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.

35. Vaginal tubal ligation Colpotomy performed Complications – bowel injury, pelvic abscess

36. Hysteroscopic sterilisation Essure Buscopan & NSAID to prevent tubal spasm Fibrotic tissue reaction Backup contraception – 3M Then hysterosalpingogram to confirm occlusion

37. sequelae of sterilisation Ectopic pregnancy Partial recanalisation , tuboperitoneal fistula More likely after 3 yrs Post tubal ligation syndrome Abnormal bleeding, isolated ovarian syndrome Pain, cystic ovaries Regret & Depression

38. 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

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

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