Wednesday, 21 March 2012

Permanent family planning methods for women


Female sterilization is the most commonly used permanent method of family planning.
According to WHO survey in 1994, among 202 million married couples who have been sterilized worldwide, 163 million are women. In this 161 million are in developing countries.
Though vasectomy, the permanent sterilization method of men is safe,  more reliable and easier method, female sterilization is four times commonly performed throughout the world.
The reasons behind increase in female sterilization rates are:
1. Relaxation in the age, parity and other requirements for sterilization.
2. Interest shown by doctors and health care providers.
3. Development of new techniques.
4. Increased awareness among people about small family and its benefits.
5. Government encouragement.

Requirements of a safe procedure:
Patient should be counseled properly regarding the need for sterilization, the options available and have to specify that this is permanent procedure and also tell about the complications that may occur.
Have to assess the woman according to her obstetrical history, general condition systemic and local examination.
We have to do basic laboratory tests like hemoglobin percentage, blood grouping   to the patients and also more specific investigations if needed.
We have to take informed and written consent from the patient and her husband.
Infection prevention measures to be taken like starting antibiotics pre-operatively and to be continued post-operatively also if needed.
Proper  type of anesthesia to be selected depending on the procedure want to perform and patient fitness for anesthesia to be noted.
Instructions to be given to the accompanying persons, regarding procedure and the care they have to take after the procedure.
Before procedure the  instructions  patient has to follow:
 The woman should not eat or drink anything for 8 hours before surgery, she should not take any medication for 24 hours before surgery.
She has to bathe thoroughly the night before the procedure and wear clean, loose fitting clothing.
She has to bring a relative to help her after procedure and to go home.

Types of female sterilization:
There are three broad categories in female sterilization depending on the procedures used to reach   the fallopian tubes.
 Primarily abdominal procedures  are,
1. Laparotomy : in conventional laparotomy which is done under general anesthesia or under local anesthesia the techniques used are,
Pomeroy technique

In this a loop formed by pulling the   fallopian tube and the base of loop is ligated with chromic catgut. The top of the loop is cut off.
In modified Pomeroy technique, a silk stitch is applied medial to the tubal stump.
Most simple and safe procedure of tubal ligation also used in mininlaparotomy.

Irving technique:
In it the tube is cut in between two ligatures and the medial stump is buried into a hole made in the uterine wall and the lateral stump is peritonealized.

It requires considerable exposure, larger incision, more time and is more hemorrhagic.

Uchida technique:
In this method saline and epinephrine is injected into the mesosalpinx then it is cut upon, by pulling the muscular tube out apportion of the tube to be removed then two ends are ligated and medial stump buried in the mesosalpinx.

More extensive and more hemorrhagic. Fimbriectomy may be performed along with this.

Kroener’s technique:

 Fimbriectomy  is done in this method. The fimbrial end of the tube is doubly ligated with silk sutures and removed.

Madlener technique:

The middle third portion of the tube in the loop is crushed at the base and ligated with silk.
It is very simple procedure but with high failure rates. And not done nowadays.

Parkland technique:

In this procedure an avasular site near mesosalpinx is perforated to separate the tube for about 2.5 cms. The freed tube is ligated at both ends and the intervening 2cm segment is excised.

Nowadays Pomeroy technique is mostly used next Parkland technique is used. Other techniques are almost abandoned.
As minilaparotomy has become popular, conventional laparotomy is being done in conjunction with other surgeries like cesarean section, salpingectomy, ovarian cystectomy etc.

2. Minilaparotomy:
The minilaparotomy procedure, which is a  new and very popular sterilization technique.
In it proper infection prevention procedures to be used.
Case history to be taken, physical and pelvic examination to be conducted.
The woman will be given light sedation, local anesthetic injected just above pubic hair line.
A small 2.5 to 3 cm of transverse incision is made above the symphysis pubis.
Uterus to be raised and turned anteriorly to bring the 2 fallopian tubes under the incision.
Each tube is tied and cut, or else closed with clip or ring. Tubal ligation is mostly performed by Pomeroy’s technique or Parkland technique can be used.
Incision is closed with stitches and covered with adhesive bandages.
The woman receives instructions on what to do after she leaves the clinic or hospital. She usually can leave in few hours.
minilaparotomy can be done during postpartum, post-abortion, or in interval period.

Above two, laparotomy and minilaparotomy are loosely called as tubectomies.

3. Laparoscopy:
laparoscopic sterilization is becoming more popular nowadays.
In the laparoscopy procedure,proper infection prevention procedures  to be used.
Case history taken, physical and pelvic examination to be conducted
Woman will be given light sedation, local anesthetic injected just under woman’s navel.
Abdomen is inflated with gas or air.
Small incision  of about 2 cm is  made and laparoscope  is inserted.

Each tube is closed with either a clip or a ring or by electro coagulation.
Then the gas or air is let out of woman’s abdomen
 And the incision is closed and covered with adhesive bandages.
The woman receives instructions on what to do after  she leaves the clinic or hospital. She usually can leave in few hours.

It is safe simple and effective procedure which could be performed through one or two very small incisions in the abdomen either under sedation or local anesthesia on an outpatient basis.
But this procedure needs special training and special instruments   for laparoscopy.
Laparoscopy should be done during interval only, and contraindicated in postpartum period.

Transvaginal procedures  are:
These are done by colpotomy or by culdoscopy.

Nowadays these are no longer recommended.

Transcervical procedures  are:
These procedures are still in experimental level.
They can be done during interval period only by using hysteroscopy.

In all the above methods the basic step is occluding the fallopian tubes either by ligation and excision or with mechanical devices such as clips or rings or with electro coagulation. This works in preventing fertilization as the both fallopian tubes are blocked or cut off,  the woman’s eggs cannot meet the man’s sperm.
But the woman will not have any problem in menstruation she will continues to have menstrual periods .

After the procedure  the  instructions  patient has to follow:
 The woman should take rest for 2 or 3 days and avoid heavy lifting for a week.
She has to keep the incision clean and dry for 2-3 days and not to rub or irritate the incision for 1 week.
She can take paracetamol or another safe pain killer if needed.  She should not take aspirin or ibuprofen which will slow blood clotting.
She should not  have sex for at least one week, or until all pain is gone.

The  woman should return to the clinic:
For a follow-up, if possible, within 7 days or at least within 2 weeks and to have the stitches removed, if necessary.
If she is having questions or problems of any kind she can return to clinic.
We have to encourage the patient during the follow up to ask any doubts if she is havingand have to verify if she is satisfied or not. And have to tell she can  return any time if she has questions or concerns.


She must return to clinic immediately in case of:
Having high fever, more than 380c  especially in first week.
If she presents with pus or bleeding from the wound
Having signs of infection like pain, heat, swelling, or redness of the wound that becomes worse or
does not stop.
Presenting with abdominal pain, cramping, or tenderness that becomes worse or does not stop.
If she presents with diarrhoea  or fainting or extreme dizziness etc.
All these problems to be appropriately treated, if needed the patient has to be hospitalized.

The success rate of female sterilization:
Female sterilization is having high success rate when properly performed.
In the first year after the procedure,  0.5 pregnancies per 100 women are reported.
And within 10 years of the procedure,  1.8 pregnancies per 100 women are reported.
Effectiveness depends partly on how the tubes are blocked, but overall pregnancy rates are very low.
Especially during  postpatum tubal ligation,
In the first year after the procedure , 0.05 pregnancies per 100 women are noted
And within 10 years after the procedure, 0.75 pregnancies per 100 women are noted.

The  common causes of female sterilization failure:
At the time of sterilization the patient may be having  an undetected luteal-phase pregnancy.
Instead of fallopian tube, some other structure may be occluded during surgery, most often the round ligament.
Incomplete or inadequate occlusion of the fallopian tube.
During procedure the mechanical device may be misplaced.
There may occur development of tuboperitonoal fistula leading to escape of ovum or sperm and failure of procedure.

The methods used to prevent failure of female sterilization:
 We have to schedule the procedure within the first 7-10 days of the start of a menstrual cycle.
Have to identify fallopian tubes properly by tracing them to the fimbrial end prior to occlusion.


Advantages of female sterilization:
It is a very effective method of contraception compared with many other methods.
It is the permanent method of sterilization, once the woman undergone the procedure she is once for all free from the fear of getting pregnant.
Unlike temporary procedures there is no need to remember taking of pill or changing of intra uterine device etc.
In case of mechanical barriers and usage of intra uterine devices  repeated clinic visits may be required when problems arise during their usage or to change to new one but in permanent sterilization  no repeated clinical visits are required.
There will be no interference with sex as in case of mechanical barriers. So it will increase sexual enjoyment.
It is not having any  effect on breast feeding unlike oral contraceptive pills.
No known side effects or health risks are noted unlike oral pills and intra uterine devices.
As minilaparotomy can be performed just after a woman gives birth, she can complete her delivery and sterilization in one hospital stay.
Female sterilization is known to help in  protecting  against ovarian cancer.

Disadvantages of female sterilization:
It is usually painful at first, though anesthesia is given patient has to bear somewhat pain.
Uncommon complications of surgery: can occur during or after the procedure like:
Infection or bleeding at the incision site,
Internal infection or bleeding,
Injury to internal organs while performing the procedure.
Anesthesia risk also is there whether general or in local anesthesia.
Normally it is very effective in preventing pregnancy but if pregnancy occurs, it is likely to be ectopic pregnancy, which is a dangerous situation.
Unlike oral pills or mechanical barriers which can be advised by health workers permanent sterilization requires a specially trained provider.
Compare with male sterilization it is slightly more risky and often more expensive.
In some cases when the woman wants reversal surgery for some reasons it  is difficult and expensive.
Unlike barrier methods it will not give  protection against STIs and HIV/AIDS.

Medical eligibility for female sterilization:
Most women who have completed their family can have sterilization including those who :
The woman who have just given birth, within 7 days of delivery they can go for minilaparotomy.
As it is not having any effect on breastfeeding, the lactating woman can also go for sterilization.
Also, women with the below conditions can have sterilization,
Like woman with mild pre-eclampsia with controlled blood pressure with medication.
Women with the history of past ectopic pregnancy.
Women having benign ovarian tumors.
Woman with irregular or heavy vaginal bleeding patterns, painful menstruation can also undergo as sterilization is not having effect on menstruation.
Woman with vaginitis without purulent cervicitis can undergo.
Woman with varicose veins can also undergo.
Women who are HIV positive or high-risk of HIV or with other STIs also can undergo, though sterilization cannot prevent them by stopping fertilization it can prevent vertical transmission.
Uncomplicated schistosomiasis
Women with malaria, non-pelvic tuberculosis can also undergo if the general condition of the patient is stable.
Women with cesarean delivery can undergo sterilization during the surgery itself.

Conditions in which female sterilization to be delayed :
 If the woman is pregnant we should not perform sterilization procedures.
In case of postpartum or second trimester abortion, in between  7-42 days female sterilization should not be performed as at that time as per the size of the uterus the fallopian tubes are difficult accessible for minilaparotomy and laparoscopy should not be done.
In case of unexplained vaginal bleeding the cause should be identified and  treated , pregnancy to be ruled out then only have to proceed for sterilization.
In case of severe pre-eclampsia and  eclampsia  better to wait till the control of blood pressure and patient’s general condition improves.
In case of pelvic inflammatory disease within past 3 months, history of  therapy should be taken  and possibility of recurrence or adhesions to be ruled out.
In case of patient suffering from  sexually transmitted infections appropriate therapy should be given till the infection subsides as performing surgery in these patient may lead to flaring of infection and failure of procedure.
In case of patients suffering from pelvic cancers the type and extent of the cancer to be ruled out before proceeding for sterilization, have to rule out the extent of involvement of fallopian tubes and the chances of success of sterilization.
In case of malignant trophoblast disease, the disease to be treated first before sterilization.
In case of gall bladder disease with symptoms, active viral hepatitis the procedure to be delayed until these diseases get treated.
One of the most common causes leading to delaying the procedure is severe iron deficiency anemia with hemoglobin below 7g/dl, in this case first patient hemoglobin to be improved before the procedure. As anemic people may not with stand the blood loss during procedure, though minimal. And also healing of wound will be delayed, they are also prone for post-operative infections.
In cases like of acute lung disease as bronchitis or pneumonia, systemic infection or severe gastroenteritis also the procedure to be delayed until the infectious state to be treated.
In women with abdominal skin infection, it should be treated before procedure as it may hamper the healing of skin incision.
In patients undergoing emergency abdominal surgery, better to delay the sterilization procedure, as there may be conditions like intra abdominal infection with peritonitis which will affect the success of sterilization.
Cardiovascular conditions of women in which  female sterilization to be delayed:
Women with acute heart disease due to blocked arteries may not sustain the strain of surgery.
In case of deep vein thrombosis or pulmonary embolism, spread of embolus can occur especially during laparoscopy procedure.


Cases that have to refer to higher centers  with experienced staff and equipment :
Where patient presents with fixed uterus either due to previous surgery or infection, the procedure of sterilization may become difficult and sometimes perforation of surrounding structures can occur in these cases experienced staff with proper emergency setup are needed.
In case of woman presenting with endometriosis, may have adhesions inside, fallopian tubes, ovaries may be involved making the procedure difficult.  And also endometriosis may spread because of the procedure. So we have to be careful while doing.
In case of woman with hernia either umbilical or any abdominal wall hernias, these should be operated simultaneously with the sterilization procedure.
In rare cases like postpartum uterine rupture or perforation, these should be repaired first followed by sterilization procedure.
In case of post-abortion uterine perforation, decision to be taken appropriately whether to open the abdomen or conservative procedure to be adopted, depending on it sterilization procedure should be  choosed.
Also women with moderate or severe  blood pressure i.e., 160/100 or higher,  vascular disease including diabetes-related, and with complicated valvular disease to be referred  to higher centers.
The women with severe cirrhosis of liver, diabetes for more than 20 years, hyperthyroidism, coagulation disorders, chronic lung disease, pelvic tuberculosis and schistosomiasis with severe liver disease are to be referred to higher centers.



Have to be cautious while performing sterilization procedure in case of:
Patient having pelvic inflammatory disease since last pregnancy, may present with extensive adhesions.
Women with current breast cancer, may have secondaries in the abdomen, which may spread or adhesions may present.
In case of woman with uterine fibroid, it may obstruct the access to fallopian tube. Injury to fibroid can occur during procedure.
In women with mild high blood pressure, i.e.140/90 to 155/99 mm of hg or with history of  high blood pressure.
In dealing with women having past history of  stroke or heart disease or valvular heart disease without complications, surgeon to be cautious.
We have to cautious in dealing with women with epilepsy or taking medicines for seizure, taking antibiotics or griseofulvin.
In case of women with diabetes with vascular disease, proper care to be taken during the surgery as thrombosis or embolism like complications can occur.
In women with thyroid disorders, proper treatment history, and present hormonal values  to be taken.  Strain of the surgery  may lead to thyroid storm in uncontrolled cases.
In cases of women with mild cirrhosis of liver, liver tumors or schistosomiasis with liver fibrosis also proper care to be taken while proceeding  for sterilization procedure.
In case of moderate iron deficiency anemia with hemoglobin between  7-10 g/dl, have to be cautious regarding blood loss and healing of wound etc.
In patients with sickle cell disease, inherited anaemia, kidney disease, diaphragmatic hernia, severe malnutrition also proper care to be taken during and after the procedure.
In case of obese women the accessibility to the tubes may become difficult, so have to cautious during procedure.
In case patient wants sterilization procedure at the time of some elective abdominal surgery, surgeon has to be careful while performing it, as the original procedure and its consequences may lead to some problems in sterilization.
In dealing with women of young age, proper history of completion of family has to be taken. As 20% of women sterilized in young age later regret the decision and come for reversal.


 The  long term effects of Female Sterilization:
Chances of having ectopic pregnancy: absolute risk of ectopic pregnancy is lower among sterilized women, but when a pregnancy occurs, it is likely to be ectopic.
Post sterilization syndrome:  this includes abnormal menstrual bleeding, dysmenorrhoea and premenstrual stress. The latest evidence questions the existence of post-sterilization syndrome. Studies show no association between sterilization and menstrual disturbances. Hormonal changes after sterilization are inconsistent and having no significant changes.
The likelihood that the woman will have a hysterectomy at some time following sterilization cannot be explained based on biological facts.
Female sterilization has been shown to have a protective effect against ovarian cancer
However female sterilization does not protect users against STIs or HIV infections, women has to use barrier methods of contraception for protection against them.

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