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FEMALE STERILIZATION

FEMALE STERILIZATION. MALA ARORA FRCOG, FICOG, FICMCH,DA (UK). 190 million female sterilizations as compared to 42 million male sterilizations across the world Permanent method and hence couple needs t be counseled about the same . PERMANENT, INVASIVE, EFFECTIVE.

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FEMALE STERILIZATION

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  1. FEMALE STERILIZATION MALA ARORA FRCOG, FICOG, FICMCH,DA (UK) MALA ARORA

  2. 190 million female sterilizations as compared to 42 million male sterilizations across the world • Permanent method and hence couple needs t be counseled about the same MALA ARORA

  3. PERMANENT, INVASIVE, EFFECTIVE IDEAL WHEN FAMILY IS COMPLETE AND YOUNGEST CHILD IS 1 YEAR OLD MALA ARORA

  4. PERMANENT • LIFE LONG CONTRACEPTION • NO LONG TERM SIDE EFFECTS • REVERSAL IS DIFFICULT & EXPENSIVE • POST REVERSAL PREGNANCY RATES ARE POOR MALA ARORA

  5. INVASIVE • INVOLVES PHYSICAL EXAMINATION • ANAESTHESIA • SURGERY • SURGICAL EXPERTISE MALA ARORA

  6. EFFECTIVE • VERY LOW FAILURE RATE • LESS THAN 2% (18/1000) OVER 10 YEARS OF USE • MAXIMUM FAILURE RATE IN THE FIRST YEAR MALA ARORA

  7. PROCEDURE LAPAROSCOPIC • CLIPS • FALLOP RING • TUBAL COAGULATION • POMEROYS TECHNIQUE • FIMBRIECTOMY MALA ARORA

  8. Laparaoscopic techniques • Coagulation Unipolar coagulation Bipolar coagulation MALA ARORA

  9. Laparaoscopic techniques • Rings Fallop ring Filschie clip MALA ARORA

  10. PROCEDURE MINI LAPAROTOMY • POMEROYS TECHNIQUE • FIMBRIECTOMY • SALPINGECTOMY MALA ARORA

  11. Laparotomy techniques • Pomeroy technique MALA ARORA

  12. Laparotomy techniques • Others Parkland Irving MALA ARORA

  13. PROCEDURE VAGINAL • NOT SO POPULAR • VAGINAL FLORA COMMONLY CONTAMINATES THE PERITONEUM • TUBAL ADHESIONS MAY CREATE DIFFICULTY IN IDENTIFYING THE TUBES • DYSPREUNIA DUE TO VAGINAL INCISION MALA ARORA

  14. LAPAROSCOPIC UNIPOLAR DIATHERMY HAS THE LOWEST FAILURE RATE but high rate of bowel complications and hence not recommended. Falope rings are still considered the Gold Standard for laparorowpfemale sterilization MALA ARORA

  15. ADVANTAGES • Permanent birth control. • Immediately effective. • Allows sexual spontaneity. • Requires no daily attention. • Not messy. • Cost-effective in the long run MALA ARORA

  16. DISADVANTAGES • Does not protect against sexually transmitted infections, including HIV/AIDS. • Requires surgery. • Has risks associated with surgery. • More complicated than male sterilization. • May not be reversible. • Possible regret. • Possibililty of Post Tubal Ligation Syndrome MALA ARORA

  17. HYSTEROSCOPIC STERILIZATION James A Greenberg, MD Rev Obstet Gynecol. 2008 Summer; 1(3): 113–121. MALA ARORA

  18. QUINACRINE PELLETS • Women received three transvaginal insertions of 250 mg of quinacrine pellets preceded by a single pellet of 20 mg of sodium thiopenthal as their only means of contraception. Lowest cost of $1 per case • At one year, the pregnancy rate was 3. I %,but cumulative pregnancy rate was 12% • Int J Gynaecol Obstet 18: 275-279, 1980 MALA ARORA

  19. QUINACRINE PELLETS • LOW COST • TERATOGENIC • RISK OF ECTOPIC PREGNANCY • REQUIRES TWO / THREE INSERTIONS • HIGH CUMULATIVE FAILURE RATE • Zipper J, Trujillo V. 25 years of quinacrine sterilization experience in Chile: review of 2,592 cases. Int J Gynaecol Obstet. 2003;83(suppl 2):S23–S29. MALA ARORA

  20. ESSURE - FDA approved • Essure® (Conceptus, Inc.,Mountain View, CA) • A metal microinsert is placed under hysteroscopic view into the interstitial part of the tube. • Loaded with a single-use inner coil of stainless steel and polyethylene terephthalate (PET) fibers and an outer coil of nickel-titanium (nitinol). • Tubal occlusion confirmed at 12 weeks by HSG • Additional contraception used for 12 weeks MALA ARORA

  21. Hysteroscopic techniques MALA ARORA

  22. ADIANA – THE FUTURE • The Adiana® (Hologic, Inc., Bedford, MA) sterilization method is a combination of controlled thermal damage to the lining of the fallopian tube followed by insertion of a nonabsorbable biocompatible silicone elastomer matrix within the tubal lumen • Johns DA. Advances in hysteroscopic sterilization: report on 600 patients enrolled in the Adiana EASE trial. J Min Inv Gynecol. 2005;12:S39–S40 MALA ARORA

  23. MALA ARORA

  24. Preparation for sterilisation • Advantages • Disadvantages & risks • All verbal counselling must be supported by accurate, impartial printed or recorded information to takeaway and read before the operation MALA ARORA

  25. Preparation for sterilisation • A history should be taken • An examination should be carried out • Counselling and advice on: • long-term reversible methods of contraception • Alternative (vasectomy) • Sterilisation irreversibility • Failure rates • Procedure complications MALA ARORA

  26. TIMING • Any time if certain she is not pregnant • Within 7 days of a period • During a cycle of OC pills / with IUD in situ • Within 7 days of childbirth • Within 48 hours of miscarriage • Post Emergency Contraception only after she has had a menstrual bleed MALA ARORA

  27. COST • It involves a one time cost investment which is higher than temporary methods • Cost is subsidised by the Government MALA ARORA

  28. Points of concern with TL • TL Deaths • Discussion at National level • Consent • Spouse No / Yes ?? • Training • IF MD/ DGO then, not needed by the GOI but still all health facilities insist for a separate training certificate • Registration • Needs yearly renewal • Empanelment • Private docotrs need to apply, but health officer are not cognizant of the fact or the procedure for empanelment MALA ARORA

  29. MALA ARORA

  30. Important Prerequisites • The final medical selection of the case should be based on the criteria for eligibility for sterilization provided in 1.3. • The operating surgeon must personally fill the client card/checklist placed at Annexure 4 before initiating the surgery as per the supreme court orders for all cases of TL MALA ARORA

  31. MALA ARORA

  32. National Insurance Scheme MALA ARORA

  33. GOI and United India Insurance Scheme for all the TL deaths , failures and major complications • Yearly premium is paid by GOI for all the doctors who are empanelled • Grey area who will empanel the private doctors ??? • ALL COMPLICATIONS, MAJOR OR MINOR, ARISING DURING SURGERY OR POST-SURGERY MUST BE REPORTED. MALA ARORA

  34. Summary • Sounder counseling can reduce post-sterilization regret • New techniques should ideally be • performed with inexpensive equipment— • if possible only standard surgical Instruments • New techniques for occlusion of the tubes should cause the minimum permanent damage, with the smallest possible length of tube involved (preferably in the isthmic portion) to increase chances for later reversal MALA ARORA

  35. Thanks to all contributors. Dr Adarsh Bhargava. Dr Ashwini Bhalerao. Dr Alka Kriplani. Dr. Kalpana Apte. Dr Mala Arora. Dr.Meenakshi Bharath. Dr. Mandakini Parihar. Dr.Nozer Sheriar. Dr.Parikshit Tank. Dr. Roza Olyai. Dr.Sasikala Kola. Dr.Sujata Mishra.

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