Female Sterilization

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<p>.By: Dr. shirisha P.G</p> <p>1</p> <p>Anatomy of fallopian tubeampulla Isthmus Infundibulum Fimbria Interstitial portion</p> <p> Fimbrial segment - faces the ovary Infundibular segment - funnel shaped segment behind the fimbria Ampullary segment - wide middle segment Isthmic segment - narrow muscular segment near the uterus Interstitial segment - passes through the uterine muscle into the uterine cavity2</p> <p>The History of Female Sterilization1823 First proposed by James Brundell in London 1880 First published report of procedure by Lungren in Toledo, Ohio 1930 First publication of the Pomeroy Technique, Pomeroy, New York State Journal of Medicine 1936 Bosch performed the first laparoscopic tubal occlusion in Switzerland3</p> <p>Female sterilization: Sterilization is the most widely used means of permanent contraception in the world. Female sterilization is the surgical procedure which is used to end a woman's ability to become pregnant Procedure involves : - ligation with or without resection - or blocking of both fallopian tubes So that the egg &amp; sperm cannot meet4</p> <p> Explanation of procedure, including anaesthesia Benefits Highly effective Reduction in risk of ovarian cancer (OR 0.3-0.9) and PID No change in sexual desire or pleasure Alternatives Other forms of contraception Vasectomy Potential risks Operative Failure Ectopic pregnancy5</p> <p>Informed consent</p> <p>Methods of Female SterilizationInterval Laparoscopic Falope Ring (most commonly used) Hulka Clip Filshie Tubal Ligation System Electrocoagulation (Mono and Bi -Polar) Post Partum/ Labor &amp; Delivery</p> <p> Pomeroy(most commonly used) Parkland Irving Uchida Filshie Tubal Ligation System</p> <p> Hysteroscopy Essure Adiana (Not commonly used.)</p> <p>6</p> <p>.</p> <p>Methods of Female Sterilization1ProcedureMinilaparotomy</p> <p>Timing Post Partum Post Abortion</p> <p>Technique Mechanical Devices (Clips, Rings) Tubal Ligation or Excision Electrocoagulation (Unipolar, Bipolar) Mechanical Devices (Clips, Rings)</p> <p> IntervalLaparoscopy Interval Only</p> <p>Laparotomy</p> <p>In conjunction with other surgery (Cesarean section, salpingectomy, ovarian cystectomy, etc.)</p> <p> Mechanical Devices (Clips, Rings) Tubal Ligation or Excision</p> <p>1</p> <p>Female Sterilization In: Landry E, ed. Contraceptive Sterilization: Global Issues and Trends. New York: Engender Health; 2002: 139-160</p> <p>Since 2002, hysteroscopic methods are available and can be performed interval-only (Essure and Adiana).7</p> <p>Mini-laparotomy Advantages Postpartum Local anaesthesia Partial salpingectomy -lower failure rate - tissue to pathology Dis advantages: More post op pain Longer recovery Wound healing is delayed.8</p> <p>methods: pomeory parkland irving uchida kroeners madlener</p> <p>Pomeroy Technique Developed in 1930 by Ralph Hayword Pomeroy Operation done under GA or LA or I.v sedation Procedure: Abdominal draping &amp; cleaning Sterile dressing Incision9</p> <p>Identifying tubeFallopian tubes brought out through incision ,clamps placed 4cm lateral to the fundus and tube is pulled up so as to form loop Avoiding the blood vessel by observation base of the loop is doubly ligated with chromic catgut no.0,keeping 2cm of loop above the tie Stump ligature is held with an artery forceps</p> <p>Cut the loop of about 1.5cm ,margins should not be very close to knots10</p> <p>10</p> <p>The stumps of tubal ends are cleaned with mop and inspected carefully to make sure that the tube is cut completely Same procedure should be followed at the opposite side Check hemostasis &amp; close the abdomen layer by layer</p> <p>tied</p> <p>cut</p> <p>final result</p> <p>Failure rate 7.5/100011</p> <p>11</p> <p>12</p> <p>12</p> <p>Modified pomeroys technique By placing silk suture of moderate thickness near and medial to stump ligature following pomeroys technique This causes necrosis of intervening portion of tube to lessen the chance of failure By placing more than one knot around the loop</p> <p>13</p> <p>13</p> <p>Methods of Female SterilizationIrving Technique</p> <p>Method published in 1924 Was developed for sterilization at C/S Bury the proximal tubal stump within the myometrium Original description distal tube buried in the broad ligament Benefits Used in conjunction with cesarean delivery Complications Moderate level of difficulty to perform Pomeroy and Parkland are quicker1 Up to Date Sept 2010, Stovall T. et al. Surgical Sterilization of Women1. Sterilization. The University of Kentucky Department of OB-GYN Womens Health Curriculum.</p> <p>Failure rate: 1/10001</p> <p>14</p> <p>Methods of Female SterilizationUchida TechniqueIntroduced by Hajime Uchida in the 1940s Most complex method Inject saline into the subserosal layer 2 cm distal to the cornua Incise serosa to free a 2 to 3 cm segment Ligate proximal and distal end of freed tube Proximal tube dunked, distal is exteriorized and serosa is then closed Benefits Can be performed immediately postpartum Complications Moderate level of difficulty to perform Pomeroy and Parkland are quicker</p> <p>Failure rate: more than 20,000 cases performed by Uchida personally without a failure 1</p> <p>1 Sklar AJ. Tubal Sterilization. eMedicine. November 15 2002. Available at http://www.emedicine.com/med/topic3313.htm15</p> <p>Methods of Female SterilizationParkland Technique</p> <p>Introduced in the 1900s Isthmic portion of tube is segmented and ligated at two points An avascular area in the mesosalpinx is opened 0 or 2-0 plain catgut passed through the opening Proximal and distal ligated and segment excisedFailure rate not reported1</p> <p>16</p> <p>Methods of Female SterilizationParkland Technique (continued)</p> <p>Benefits Designed to reduces natural tube reattachment Good success rates Few complications Inexpensive to perform (if no pathology) Complications Ectopic pregnancies, infection, bleeding Time required to perform procedure properly17</p> <p>Failure rate not reported1</p> <p>Fimbriectomy : Fimbrial end of tube is doubly ligated with silk sutures and then removed. Can be used in vaginal sterilizations Reversal is extremely poor High failure rate ( 2-3%) So, this technique is abonded madleners technique: a loop of tube in the middle third position is crushed at the base and ligated with silk Procedure is simple But high failure rate so practically abonded18</p> <p>Laproscopic procedures Falope Ring (most commonly used) Hulka Clip Filshie Tubal Ligation System Electrocoagulation (Mono and Bi -Polar)</p> <p>19</p> <p>19</p> <p>Falope Ring (Yoon band) Introduced by yoon in 1974 In India silastic band technique is more popular Under GA or LA Made up of silicon rubber with 5% barium sulphate Outer diameter 3.6mm Inner diameter-1mm Thickness-2.2 mm20</p> <p>Silastic ring applicators</p> <p>21</p> <p>21</p> <p>Falope Ring application Mostly done by double puncture laparoscopy After identification of tube, the tube is grasped about 3 cm from uterus And than the tube is brought up into the applicator The rings are pushed over the knuckle of the tube At last the applicator is released.22</p> <p>22</p> <p>Methods of Female Sterilization</p> <p>Falope Ring/Yoon Band23</p> <p>Methods of Female SterilizationHulka ClipLaparoscopic Tubal occlusion is accomplished by placing a spring clip (plastic and gold plate) across the fallopian tube Hulka clip has limited tubal capacity Not magnetically inert Potential patient allergy due to gold plate</p> <p>Failure rates 36.5/1000 (3.7%) (Ectopic 8.5/1000)1</p> <p>1</p> <p>Pregnancy After Tubal Sterilization with Bi-Polar Electrocoagulation. Obstetrics and GYN. August 1999 Volume 94. Herbert B Petterson et al for the CREST Working Group 24</p> <p>Methods of Female Sterilization</p> <p>Hulka Clip25</p> <p>Methods of Female Sterilization</p> <p>Hulka Clip26</p> <p>Methods of Female SterilizationFilshie Tubal Ligation System Laparoscopic and Minilapararotomy</p> <p>,</p> <p> FDA approved in 1996 (post CREST study) Tubal occlusion accomplished by placing a titanium hinge clip lined with silicone rubber across the fallopian tube Large tubal capacity Magnetically inert (okay for MRI) Minimal post operative pain Designed for use interval and post partum (post vaginal birth and at the time of Csection) Clip migration rare but possibleFailure rate of 2.7/1,000 (.27%)1,2</p> <p>1 A Penfield, MD. The Filshie Clip for Female Sterilization: A Review of World Experience. American Journal of Obstetrics and Gynecology, March 2000 2 Failure Rates from Family Health International, used in the initial FDA PMA Submission for the Filshie Clip 27</p> <p>Methods of Female Sterilization</p> <p>Filshie Clip Laparoscopy28</p> <p>Methods of Female Sterilization</p> <p>Filshie Clip Laparoscopy29</p> <p>Methods of Female SterilizationMonopolar CoagulationLaparoscopic Proposed in 1937 by Anderson Complications Bowel Burn Bleeding Longer portion of tube is damaged Failures and ectopic pregnancy Transection is frequent</p> <p>Failure Rate: 7.5/1000 (.07-.75%)1</p> <p>1</p> <p>Peterson LS Contraceptive use in the United States: 1982 -90. Advance Data: From Vital Health Statistics February 1995; 260 1-8 30</p> <p>Methods of Female SterilizationBipolar CoagulationLaparoscopic Introduced in 1973 by Jacques Rioux Benefits Most common method of laparoscopic sterilization Burn several locations along the tube Complications Formation of uteroperitoneal fistulas High rate of ectopic pregnancy Potential for bowel burns Reversals are potentially more difficult due to the extent of tube damage1 Peterson HB, et al. The risk of pregnancy after tubal sterilization: Findings from the U.S. Collaborative Review of Sterilization. Am J obstet. Gynecol. 1996; 174 (4):1161-1170 31</p> <p>Failure Rate: 24.8/10001 (.2-2.5%)</p> <p>Minilaparotomy Instruments and equipment Surgical skills and expertise Requires a few inexpensive, standard surgical instruments. Can be performed by health workers with basic surgical ability and skills, after training in the technique. Suitable for postpartum, postabortion and interval periods. May be performed in maternity centres and basic health facilities with surgical capacity.</p> <p>Laparoscopy Requires sophisticated, and expensive endoscopic equipment, that is difficult to maintain. Restricted to specially trained surgeons, usually obstetricians and gynaecologists. Requires regular practice to maintain skills. Most suitable for interval period and following first trimester abortion. Fully equiped operating room and anaesthetist required.</p> <p>Timing</p> <p>Setting</p> <p>Time necessary for the operation.</p> <p>Depending on the experience of Depending on the experience of the operator, takes on average 10- the operator, takes on average 5 20 minutes. 15 minutes and so most appropriate for services with large daily case-loads.32</p> <p>32</p> <p>Minilaparotomy Precautions Difficult to use for obese women (especially for interval procedures) and those with pelvic scarring and adhesions. Complications are rare. Slight risk of bowel and bladder injuries, uterine perforation and wound infection. Recommended local anaesthesia. Short-term abdominal pain may occur. Highly effective; failure rates less than 1% after 12 months.</p> <p>Laparoscopy Not recommended for postpartum women or for women with previous lower abdominal surgery or pelvic infections. Complications are rare. Slight risk of vascular injury, bowel injury and insufflation accidents. Some complications may require use of general anaesthesia. Local, spinal or general anaesthesia. Postoperative chest and shoulder pain resulting from abdominal insufflation may occur. Highly effective; failure rates less than 1% after 12 months.</p> <p>Complications</p> <p>Anaesthesia Side-effects</p> <p>Effectiveness</p> <p>3333</p> <p>Essure</p> <p>Methods of Female Sterilization Approved in 2002 Micro-insert placed into each tube, PET fibers stimulate in-growth over several weeks 86% Success Rate for 1st time placements of microinserts 3 months of alternative contraception until HSG procedure confirms occlusion Not suitable for patients with known allergies to contrast media or hypersensitivity to nickel Irreversible May limit a patients ability to have in vitro fertilization, should patient change her mind May limit the ability to perform endometrial ablation in the future</p> <p>Hysteroscopic (Hospital and Office-based procedure)</p> <p> ACOG does not recommend concomitant endometrial ablationFDA. Essure System: Summary of Safety and Effectiveness. November 4, 2002 available at http://www.fda.gov/cdrh/pdf2/p020014b.pdf 1UpToDate Hysteroscopic Sterilization; Jan 2010 34</p> <p>Failure rate .26%1(5 year rate)</p> <p>Methods of Female SterilizationAdiana</p> <p>Hysteroscopic (Hospital and Officebased procedure) Approved in 2009 Catheter delivers low RF energy for one minute then a 3.5 mm nonabsorbable silicone elastomer matrix is placed in each tubal lumen 3 months of alternative contraception until HSG procedure confirms occlusionFailure rate 1.8%1(2 year rate)</p> <p>Photograph from Adiana website 1Adiana Transcervical Sterilization System PMA P070022 Draft Panel Discussion Questions, p.2, December 14, 2007.</p> <p>35</p> <p>Studies and FindingsMost Common Methods Failure Rates and Ectopic Pregnancy</p> <p>Method</p> <p>Failure rate</p> <p>Ectopic Preg</p> <p>Pomeroy (PP)</p> <p>0.75%*</p> <p>1.5/1000* procedures</p> <p>Bipolar Cautery</p> <p>2.4%*</p> <p>17.1/1000* procedures</p> <p>Filshie Clip</p> <p>0.22%**</p> <p>0/30,000** procedures</p> <p>* The Risk of ectopic Pregnancy after tubal sterilization, Peterson H. NEJM March 13, 1997 ** Kovacs et al. Female Sterilization with Filshie clips: What is the risk of failure? A retrospective survey of 30,000 applications. J. of Family Planning and Reproductive Health Care. 2002: 28(1): 34-35</p> <p>36</p> <p>Other ConsiderationsRegret:</p> <p>Women may experience regret post-procedure 2-26% of women express regret post-sterilization 1-2% will seek reversal Sterilization is permanent Association with age at time of sterilization, change in marital status and future regret</p> <p> Requests for reversals and/or IVF possible* Chi, I.C., Jones D.B. Incidence, risk factors, and prevention of poststerilization regret: an updated international review from an epidemiological perspective. Obstet Gynecol Surv 1994;49:722-32 * Van Voorhis BJ. Comparison of tubal ligation reversal procedures. Clin Obstet Gynecol 2000;43:641-9 Curtis, K., Mohllajee, A.P., and Peterson, H.B. Regret Following Female Sterilization at a Young Age: A Systematic Review. Contracep 2006;73:2. P 205-210 37</p> <p>Other Considerations Reversibility All surgical tubal occlusion procedures are considered to be permanent female sterilization methods. Changes in lifestyles and life situations among some women has led to instances of regret after sterilization regardless of the method used.</p> <p> The application of the Filshie clip in tubal ligation results in an avascular necrotic segment of the fallopian tube of about 4 mm. The result is complete tubal occlusion with minimal tubal damage.</p> <p>38</p> <p>Summary of Female Sterilization Tubal occlusion is an effective&amp; permanent method of female sterilization most commonly used techniques are pomeroys &amp; Laproscopic falope ring with less failure rates</p> <p>39</p> <p>Thank you</p> <p>40</p>