Tools
Tubal Sterilization
Introduction
Tubal Sterilization is performed at the request of women who have completed childbearing and desire an effective and irreversible form of birth control.[1] It can be performed at any time during a woman's cycle and in the immediate postpartum or postabortal period.[2] It may be performed via laparoscopy, mini-laparotomy, or hysteroscopy.[2] Apart from contraceptive benefits, there are some studies that show that tubal ligation procedures are associated with decreased risk of epithelial ovarian cancers as well as an observed reduced risk of pelvic inflammatory disease.[3]
Informed consent is very important.[4] It should be stressed that this procedure is permanent and not meant for reversal.[5] The risk of regret and risk factors for regret including young age at sterilization (less than 30 years), lower parity, sterilization performed in the immediate postpartum period, divorce or remarriage following sterilization, being poor or being of Hispanic origin should be discussed.[6] Young age at the time of sterilization seems to be the strongest predictor of regret.[7] It is important to discuss that it does not provide 100% protection.[8] According to the CREST study, the 10-year failure rate is 18.5 per 1000 procedures (all procedures aggregated).[9] The pregnancy rates were highest following laparoscopic Hulka clip sterilization and lowest following monopolar coagulation and postpartum salpingectomy.[10] Even bilateral salpingectomy is associated with a risk of failure.[11] If tubal sterilization does fail, there is an increased risk of ectopic pregnancy with a ten-year probability of 7.3 ectopic pregnancies per 1000 procedures.[12] The rates of ectopic pregnancies also vary by procedure, with the highest rates following laparoscopic sterilization using bipolar coagulation.[13] Patients should, therefore, be counseled to present early if they suspect pregnancy. Serious complications following tubal sterilization are rare, which demonstrates its safety.[1] As with any procedure, informed consent should be obtained.[14] Therefore the risks associated with the procedure such as bleeding, infection, injury to nearby organs, wound complications, among others, should be discussed.[14] The alternatives such as vasectomy, long-acting reversible contraceptives (Long-acting reversible contraceptives [LARCs] like intrauterine devices [IUD]), injection, ring, patch, pills, barrier methods, and abstinence should also be reviewed with the patient.[15]
Anatomy and Physiology
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Anatomy and Physiology
The fallopian tubes lie on either side of the uterus and are divided into four segments which include:
- Infundibulum or fimbriated end overlying the ovary
- The thin-walled and wide ampulla, which varies in length and shape
- The narrow, straight and thin isthmus
- The intramural portion of the tube pierces the uterine wall and usually located on the superolateral segment of the uterine cavity.
Indications
- For women wanting a permanent method of contraception.
- For women in whom a future pregnancy could pose a significant risk of medical harm.
Contraindications
Contraindications include ambivalent patients, lack of finances,very young age, incapable of making a medical decision, the presence of gynecological malignancy, and morbidly obese patients.
Preparation
Follow the following steps:
- Perform pregnancy test
- Pap smear
- Urinalysis
- Screening for STD
- Ultrasound of the pelvis if there is suspicion of any pelvic mass on physical exam
Technique or Treatment
Approaches
Hysteroscopy offers the advantage of the ability to perform in the office setting with minimal to no sedation with a paracervical block and avoidance of incisions and intra-abdominal entry with its attendant risks.[16] It involves hysteroscopic placement of nickel-titanium coils into the tubal ostia.[17] Occlusion of the tubes occurs with tissue growth and scarring from inflammation induced by the coils.[17] Three months following the procedure, a hysterosalpingogram is performed to confirm tubal blockage.[18] Staying on a reliable contraceptive before documenting tubal occlusion is important. The Food and Drug Administration has recommended that the patient is counseled on risks such as possible pelvic pain, possible perforation, migration, inability to complete the procedure, a possible reaction to nickel. Removal of the coils may be necessary should the patient have these complications.[19]
Laparoscopy offers the advantage of immediate efficacy and ability to evaluate the pelvis.[20] It is safe and associated with low complication rates, estimated at 0.9 to 1.6 per 100 procedures.[21] Because it involves entry into the peritoneal cavity, it does have a risk of injury to intra-abdominal organs including the bowel, major vessels, and nerves. The rate of conversion to laparotomy is estimated to be 0.9 per 100 cases. Other complications associated with this procedure include unplanned major surgery needed due to a problem related to the tubal surgery, transfusion, febrile morbidity, wound complications, readmission, or a life-threatening event. To perform laparoscopic sterilization, the fallopian tubes are located and followed out to the fimbriated end. Occlusion of the tubes may be accomplished with the use of electrocoagulation (typically bipolar energy), mechanical devices such as the Filshie clip/Hulka clip or Falope ring or via salpingectomy. The mid-isthmic portion of the fallopian tube should be chosen when the whole tube is not removed. If bipolar energy is chosen, it is important to place three burns over a total of 3 cm segment of the isthmic portion of the fallopian tube is performed using a cutting waveform at 25-35 watts. To confirm complete desiccation of the fallopian tube, an ammeter or current flow meter can be used. Complete or partial salpingectomy may be performed and may be preferable in the setting of an abnormal appearing fallopian tube. Transection of the tube may be accomplished using bipolar or monopolar energy and cutting devices. It is associated with increased operating time and is technically more difficult than the use of electrocoagulation or mechanical devices. Complication rates do not vary significantly according to the procedure performed. As expected, diabetes, obesity, prior abdominal or pelvic surgery, general anesthesia are independent predictors for complications.
Minilaparotomy is used for postpartum sterilizations, in patients who have significant risks with laparoscopy, or as an interval procedure in low-resource settings.[22] A 2 cm to 3 cm incision is made in the area of the uterine fundus, which is typically in the umbilical region in a postpartum patient. Commonly used methods for sterilization via mini-laparotomy include partial salpingectomy via the Parkland or modified Pomeroy methods, or via mechanical devices such as Hulka clip or Filshie clip. Salpingectomy may also be performed. When an excision procedure is performed, the excised tubal segments should be sent for pathologic examination. With the Parkland method, the mid-isthmic portion of the fallopian tube is grasped with a Babcock clamp. A window is created in the avascular plane of the mesosalpinx. Two pieces of the 0-chromic suture are passed through this window, and a 2 cm to 3 cm segment of fallopian tube is ligated. With the Pomeroy method, the mid-isthmic portion of the tube is grasped, and a knuckle of the fallopian tube is ligated with a single strand of a rapidly absorbable suture such as 1-0 or 0 plain catgut suture. A second suture may be placed under the first suture if desired.
Complications
Some complications include:
- Mortality is low and about 0.01% to 0.02% and mostly related to general anesthesia.
- Conversion to open laparotomy
- Bowel injury from trocar, electrocautery
- Vascular injury from trocar
- Ectopic pregnancy
- Failure to sterile
- Vascular injury
- Failure to sterile because of lack of anatomical knowledge, failure to identify oviduct, poor technique
- Ectopic pregnancy
- Pain
- Infection
- Patient regret [23]
Clinical Significance
Patients should be warned about the possibility of post-tubal ligation syndrome. There is some controversy whether post tubal ligation syndrome is a real entity. For many decades patients undergoing tubal ligation have presented with menorrhagia, pelvic discomfort, and ovarian cystic changes. It is not known whether these symptoms are due to damage to the blood supply or a result of oral contraceptives that the women were taking prior to the procedure. Fortunately, the number of cases are few, and the pattern of symptoms is not always consistent.
Enhancing Healthcare Team Outcomes
Tubal ligation is usually done by the obstetrician but initially most women come for advice on the topic to their primary care provider or nurse practitioner. The key about tubal ligation is that the patient must be informed that it is a permanent procedure and should never be done as an emergency. While the mortality of the procedure is low, a number of serious complication may ocur. The patient should be counseled with the spouse before a decision is made to undertake the procedure. The outcomes for most patients who undergo tubal ligation are good.[24] (Level V)
References
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Danis RB, Della Badia CR, Richard SD. Postpartum Permanent Sterilization: Could Bilateral Salpingectomy Replace Bilateral Tubal Ligation? Journal of minimally invasive gynecology. 2016 Sep-Oct:23(6):928-32. doi: 10.1016/j.jmig.2016.05.006. Epub 2016 May 24 [PubMed PMID: 27234430]
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