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1 . By: Dr. shirisha P.G

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Page 1: Female Sterilization

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.

By: Dr. shirisha P.G

Page 2: Female Sterilization

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Anatomy of fallopian tube

• 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 cavity

ampullaIsthmus

Infundibulum

Fimbria

Interstitialportion

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The History of Female Sterilization

1823 – 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 Switzerland

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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 & sperm cannot meet

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Informed consent• 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 pregnancy

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Methods of Female Sterilization

Interval• Laparoscopic

– Falope Ring (most commonly used)

– Hulka Clip– Filshie Tubal Ligation System – Electrocoagulation (Mono

and Bi -Polar)

• Hysteroscopy– Essure – Adiana

(Not commonly used.)

Post Partum/ Labor & Delivery

• Pomeroy(most commonly used)

• Parkland• Irving• Uchida• Filshie Tubal Ligation

System

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. Procedure Timing TechniqueMinilaparotomy • Post Partum

• Post Abortion• Interval

• Mechanical Devices (Clips, Rings)

• Tubal Ligation or Excision

Laparoscopy • Interval Only • Electrocoagulation (Unipolar, Bipolar)

• Mechanical Devices (Clips, Rings)

Laparotomy In conjunction with other surgery (Cesarean section, salpingectomy, ovarian cystectomy, etc.)

• Mechanical Devices (Clips, Rings)

• Tubal Ligation or Excision

1 Female Sterilization In: Landry E, ed. Contraceptive Sterilization: Global Issues and Trends. New York: Engender Health; 2002: 139-160

Methods of Female Sterilization1

Since 2002, hysteroscopic methods are available and can be performed interval-only (Essure and Adiana).

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Mini-laparotomy

• Advantages methods:• Postpartum pomeory• Local anaesthesia parkland• Partial salpingectomy irving -lower failure rate uchida - tissue to pathology kroeners• Dis advantages: madlener• More post op – pain• Longer recovery• Wound healing is delayed.

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Pomeroy Technique

• Developed in 1930 by Ralph Hayword Pomeroy

• Operation done under GA or LA or I.v sedation

• Procedure:• Abdominal draping & cleaning • Sterile dressing• Incision

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Identifying tube

Fallopian 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

Cut the loop of about 1.5cm ,margins should not be very close to knots

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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 & close the abdomen layer by layer

tied

cut

final result

Failure rate 7.5/1000

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Modified pomeroy’s technique

• By placing silk suture of moderate thickness near and medial to stump ligature following pomeroy’s technique

• This causes necrosis of intervening portion of tube to lessen the chance of failure

• By placing more than one knot around the loop

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Methods of Female Sterilization

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 deliveryComplications• Moderate level of difficulty to

perform• Pomeroy and Parkland are

quicker

1. Sterilization. The University of Kentucky Department of OB-GYN Women’s Health Curriculum.

Irving Technique

Failure rate: 1/10001

1 Up to Date – Sept 2010, Stovall T. et al. Surgical Sterilization of Women

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Methods of Female Sterilization

Introduced 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

postpartumComplications• Moderate level of difficulty to

perform• Pomeroy and Parkland are quicker

1 Sklar AJ. Tubal Sterilization. eMedicine. November 15 2002. Available at http://www.emedicine.com/med/topic3313.htm

Failure rate: more than 20,000 cases performed by Uchida personally without a failure 1

Uchida Technique

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Methods of Female Sterilization

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 excised

Parkland Technique

Failure rate not reported1

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Methods of Female Sterilization

Benefits• Designed to reduces

natural tube re-attachment

• Good success rates• Few complications• Inexpensive to perform (if

no pathology)Complications• Ectopic pregnancies,

infection, bleeding• Time required to perform

procedure properly

Parkland Technique (continued)

Failure rate not reported1

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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 madlener’s 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 abonded

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Laproscopic procedures

– Falope Ring (most commonly used)

– Hulka Clip

– Filshie Tubal Ligation System

– Electrocoagulation (Mono and Bi -Polar)

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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 mm

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Silastic ring applicators

21

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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

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Methods of Female Sterilization

Falope Ring/Yoon Band

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Methods of Female Sterilization

Laparoscopic• 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

1 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

Failure rates 36.5/1000 (3.7%) (Ectopic 8.5/1000)1

Hulka Clip

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Methods of Female Sterilization

Hulka Clip

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Methods of Female Sterilization

Hulka Clip

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Laparoscopic and Minilapararotomy

• 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 C-section)

• Clip migration rare but possible

Methods of Female Sterilization

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

,Filshie® Tubal Ligation System

Failure rate of 2.7/1,000 (.27%)1,2

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Methods of Female Sterilization

Filshie® Clip – Laparoscopy

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Methods of Female Sterilization

Filshie® Clip – Laparoscopy

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Methods of Female Sterilization

Laparoscopic• Proposed in 1937 by

Anderson• Complications• Bowel Burn• Bleeding• Longer portion of tube is

damaged• Failures and ectopic

pregnancy• Transection is frequent

1 Peterson LS Contraceptive use in the United States: 1982 -90. Advance Data: From Vital Health Statistics February 1995; 260 1-8

Failure Rate: 7.5/1000 (.07-.75%)1

Monopolar Coagulation

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Methods of Female Sterilization

Laparoscopic• Introduced in 1973 by

Jacques RiouxBenefits• Most common method of

laparoscopic sterilization• Burn several locations

along the tubeComplications• 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

Failure Rate: 24.8/10001 (.2-2.5%)

Bipolar Coagulation

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Minilaparotomy Laparoscopy

Instruments and equipment

Requires a few inexpensive, standard surgical instruments.

Requires sophisticated, and expensive endoscopic equipment, that is difficult to maintain.

Surgical skills and expertise

Can be performed by health workers with basic surgical ability and skills, after training in the technique.

Restricted to specially trained surgeons, usually obstetricians and gynaecologists. Requires regular practice to maintain skills.

Timing Suitable for postpartum, post-abortion and interval periods.

Most suitable for interval period and following first trimester abortion.

Setting May be performed in maternity centres and basic health facilities with surgical capacity.

Fully equiped operating room and anaesthetist required.

Time necessary for the operation.

Depending on the experience of the operator, takes on average 10-20 minutes.

Depending on the experience of the operator, takes on average 5 -15 minutes and so most appropriate for services with large daily case-loads.

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Minilaparotomy Laparoscopy

Precautions Difficult to use for obese women (especially for interval procedures) and those with pelvic scarring and adhesions.

Not recommended for postpartum women or for women with previous lower abdominal surgery or pelvic infections.

Complications Complications are rare. Slight risk of bowel and bladder injuries, uterine perforation and wound infection.

Complications are rare. Slight risk of vascular injury, bowel injury and insufflation accidents. Some complications may require use of general anaesthesia.

Anaesthesia Recommended local anaesthesia. Local, spinal or general anaesthesia.

Side-effects Short-term abdominal pain may occur.

Postoperative chest and shoulder pain resulting from abdominal insufflation may occur.

Effectiveness Highly effective; failure rates less than 1% after 12 months.

Highly effective; failure rates less than 1% after 12 months.

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Methods of Female Sterilization

Hysteroscopic (Hospital and Office-based procedure)

– 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 micro-

inserts– 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

• ACOG does not recommend concomitant endometrial ablation

FDA. 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

Essure®

Failure rate .26%1

(5 year rate)

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Methods of Female Sterilization

Hysteroscopic (Hospital and Office-based procedure)– Approved in 2009– Catheter delivers low RF energy for

one minute then a 3.5 mm non-absorbable silicone elastomer matrix is placed in each tubal lumen

– 3 months of alternative contraception until HSG procedure confirms occlusion

Photograph from Adiana website1Adiana Transcervical Sterilization System PMA P070022 Draft Panel Discussion Questions, p.2, December 14, 2007.

Adiana®

Failure rate 1.8%1

(2 year rate)

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Studies and Findings

0/30,000** procedures

0.22%**Filshie® Clip

17.1/1000* procedures

2.4%*Bipolar Cautery

1.5/1000* procedures

0.75%*Pomeroy (PP)

Ectopic PregFailure rateMethod

* 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

Most Common Methods Failure Rates and Ectopic Pregnancy

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Other Considerations

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• Requests for reversals and/or IVF possible

Regret:

* 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

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Other Considerations

• 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.

• 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.

Reversibility

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Summary of Female Sterilization

• Tubal occlusion is an effective& permanent method of female sterilization

• most commonly used techniques are pomeroy’s & Laproscopic falope ring with less failure rates

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Thank you