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Simulation

Laparoscopic Sterilization

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Female Sterilization

  • Highly utilized method
    • ~11 million women in United States undergo female sterilization
    • 30% of all contraceptive users undergo female sterilization •
  • Mortality rate is:
    • 1-4 per 100,000 procedures
    • Less than the rate related to pregnancy and childbirth
    • Mostly related to anesthesia
  • Complication rate is from 0.4 to 1%
    • Wound infection, bleeding, or perforation of internal organs
    • Obesity, diabetes, or previous abdominal or pelvic surgery are risk factors

Indications

  • Desire for and understanding of permanent sterilization
  • Contraindication to nonpermanent options in a woman done who has completed childbearing, i.e., uterine anomalies that prohibit use of intrauterine contraception

Contraindications and Cautions

  • Absolute contraindication: Desire for more children
  • Cautions: Conditions that increase risk
    • Multiple previous abdominal surgeries
    • Morbid obesity o Medical co-morbidities

**Must counsel that there are nonpermanent options that work as well for contraception without surgery and nonabdominal permanent surgical options (hysteroscopic), as well as male vasectomy

Benefits of Laparoscopic Sterilization

  • Opportunity to inspect abdominal and pelvic organs
  • Small incisions
  • Immediately effective
  • Enables rapid return to full activity

Equipment Needed for Laparoscopic Sterilization

  • Stirrups
  • Speculum/tenaculum/uterine manipulator (or sponge stick)
  • Urinary catheter (for either pre-op drainage or to be left in through the procedure)
  • Laparoscope
  • Light source
  • Monitor(s)
  • Trocars
  • Basic L/S instruments
    • Most hospitals and surgery centers have a minor L/S “tray” with all necessary equipment
    • Become familiar with your center’s equipment

Preevaluation

  • Informed consent
    • Inform patient regarding risks, benefits, and alternatives
    • Medicaid 30-day consent form for any woman with government-funded coverage
  • Anesthesia pre-op consult if indicated
    • Medical co-morbidities
    • Per your hospital or clinic policy

Early Steps of Laparoscopic Sterilization

  • Confirm all necessary equipment is present
  • Conduct a “time-out” per institution protocol
  • Once patient is under anesthesia and asleep, place her in stirrups and perform an exam
  • Prep and place a uterine manipulator through the cervix
  • Place and leave a catheter in the bladder **there is some variation to this by institution and program**

Laparoscopic Sterilization Options

  • Determining which method to use is surgeon and hospital dependent
  • The number of trocars and ports are determined by equipment and technique chosen
  • It is best to have experience with more than one technique in case equipment fails or the woman’s anatomy limits the use of a technique (short or thick tubes)

Bipolar Electrocoagulation

  • Can be done with one, two, or three ports depending on equipment and anatomy
  • Device requires a 5-mm port and a foot pedal to activate
  • 3 cm of tube is destroyed by passing current through the tissue
    • Typically takes three sequential burns to destroy 3 cm
  • Can use resistance meter to demonstrate there is no flow through the tube
Bipolar electrocoagulation. 
Source: Berek Gynecology. Figure 10.11 page 247. Chapter 10 “Family Planning”.

Silastic (Falope) Ring

  • Can be done with one, two, or three ports depending on equipment and anatomy
  • Applicator requires 8-mm port
  • 2-3 cm segment of fallopian tube is drawn inside a narrow coneshaped applicator and a silicone rubber band is released onto the tubal loop
  • The silicone rubber band constricts the base of the loop and blocks the fallopian tube
  • Deprived of its blood supply, the constricted loop is replaced with scar tissue, and the remaining healthy tubal segments often separate

Placement of the Falope Ring

Placement of the falope ring. 
Source: Berek Gynecology. Figure 10.12 page 248. Chapter 10 “Family Planning”.

Filshie Clip

  • Can be done with one, two, or three ports depending on equipment and anatomy
  • Applicator requires 8-mm port
  • Titanium clip lined with silicone rubber is placed 3 cm from the cornua perpendicular to the tube
  • Complete blockage is ensured by viewing the front and back of the tube
  • The tube in the clip is occluded

United States Collaborative Review of Sterilization (CREST) Study

  • A prospective cohort study in U.S. academic medical centers (teaching hospitals)
  • 12,138 women who underwent tubal sterilization
    • Nine centers
    • Enrollment 1978-86
    • Followed patients for up to 10 years
  • Over 25 publications reporting risks, failures, and regret

Female Sterilization Failures per 1,000 Procedures

Method Failure Year 1 Failure Year 10
Postpartum partial salpingectomy 0.6 7.5
Monopolar coagulation 0.7 7.5
Bipolar coagulation 2.3  24.8
Silicone bands 5.9 17.7
Interval partial salpingectomy 7.3 20.5
Spring (Hulka) clips 18.2 36.5
All methods 5.5 18.5

Filshie clip: 1.7/1000 at Year 1; 9.7/1000 at 2 Years

Nonlaparoscopic Permanent Sterilization

  • Hysteroscopic sterilization (ESSURE) developed as an alternative to abdominal surgery for permanent female sterilization; available since 2002 in the United States
  • Coils are placed in the tubal ostia
  • The body scars and occludes the tubes over a period of 3 months
  • Requires hysterosalpingogram (HSG) to confirm tubal occlusion 3 months after the procedure. Patient must use reliable contraception during this time
  • Can be performed in the office setting with local anesthesia

Risk of Ectopic Pregnancy

  • 1 out of 3 of pregnancies poststerilization were ectopic
  • 10-year cumulative probability 7.3 per 1,000 procedures
    • Bipolar coagulation highest probability: 17.1/1,000
    • Postpartum partial salpingectomy lowest probability: 1.5/1,000
    • Age less than 30 years is an increased risk factor for ectopic pregnancy
  • Risk of ectopic pregnancy does not diminish over time

Source: N Engl J Med. 1997;336:762-7

Tubal Sterilization Regret

  • Cumulative probability of expressing regret during a follow-up interview within 14 years after tubal sterilization
    • 20.3% for women who were 30 years or younger at the time of sterilization
    • 5.9% for women were older than 30 years at the time of sterilization

Source: Obstet Gynecol. 1999;93:889-95

Summary

  • Several options for L/S sterilization
  • Not technically difficult and very safe
  • Women should be aware of risks/benefits/alternatives and fully understand the permanence of the procedure
  • Increasing interest in salpingectomy for increased success as well as decreased risk of ovarian cancer and tubal cancer

References

  1. Hillis SD, Marchbanks PA, Tylor LR, Peterson HB. Poststerilization regret: findings from the United States Collaborative Review of Sterilization. Obstet Gynecol 1999;93:889-95 2.
  2. Jamieson DJ, Hillis SD, Duerr A, Marchbanks PA, Costello C, Peterson HB. Complications of interval laparoscopic tubal sterilization: findings from the United States Collaborative Review of Sterilization.
  3. Obstet Gynecol 2000;96:997-1002.
  4. Nardin JM, Kulier R, Boulvain M, Peterson HB. Techniques for the interruption of tubal patency for female sterilisation. Cochrane Database Syst Rev 2002;(4):CD003034.
  5. Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussell J. The risk of ectopic pregnancy after tubal sterilization. U.S. Collaborative Review of Sterilization Working Group. N Engl J Med 1997;336:762-7.
  6. Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussell J. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996;174:1161-8; discussion 1168-70.
  7. Peterson HB, Xia Z, Wilcox LS, Tylor LR, Trussell J. Pregnancy after tubal sterilization with bipolar electrocoagulation. U.S. Collaborative Review of Sterilization Working Group. Obstet Gynecol 1999;94:163-7.
  8. UpToDate Surgical Sterilization of Women available at: http://www.uptodate.com/contents/ surgical-sterilization-ofwomen?source=search_result&search=female+sterilization& selectedTitle=1%7E150.

Contributing Authors

  • Elizabeth Britton Chahine, MD Washington, D.C.
  • Tamika C. Auguste, MD, FACOG Director of OB/GYN Simulation MedStar Washington Hospital Center Associate Professor, Obstetrics and Gynecology Georgetown University School of Medicine

Developed in association with the Society of Family Planning.

Version 1.0, posted October 2016