Male and Female Sterilization Procedure

Female Sterilization

Timing of Female Sterilization

Puerperal/Postpartum Ligation

Uterus involution: just after delivery, the uterus is at or just below the umbilicus Immediate postpartum sterilization can be done and is the most common timing of sterilization. 

This is best done within 2-3 days after delivery; the upper limit is 7-10 days (not 6 weeks). This is done while uterus is still an abdominal organ, as uterus becomes pelvic organ in 10–14 days and back to its normal size in 4-6 weeks 

Interval Sterilization

This is done after 6 weeks of delivery, commonly done by Laparoscopic methods

Concurrent Sterilization 

This is done along with MTPs or cesarean sections

Site of Ligation of Fallopian Tube

Site of tubal ligation of Fallopian Tube is the isthmus, as it has Isthmus uniform diameter (not isthmo-ampullary junction) Also, Isthemo isthmic reanastomosis has up to 80% success : thus prefer to ligate in an isthmic area

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Entry Into Abdomen

Laparotomy

[Minilap (1.5 to 2 inch incision, Most common)] 

Laparoscopy 

• Mostly for interval sterilization, but never do in puerperium as it can cause injury
• Failure chances are more: as the tube is edematous, the fallopian ring may slip from the tube

Techniques of Tubectomy

Pomeroy Technique

This is most commonly done, wherein a single ligature is used and ends are cut. However, the tube-cut ends are together, which can lead to fistula formation leading to failure. 

Parkland Technique

Double ligature is used such that tubes are ligated separately

Irving Procedure

One end of tube is buried into uterine musculature and the other end of tube is buried into mesosalpinx 

Sub-Serosal Dissection of Tube (UCHIDA'S Procedure): Serosa is lifted by needle & saline is injected, then serosa is incised, and tube is resected. The serosa is sutured again. The advantage is that fibrosis & adhesions are very few, as cut ends are within the serosa.

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Madlener's Method

The tubes are crushed, not resected. This procedure is not done these days due to high failure rates. 

Kroner's Fimbriectomy

Fimbria are excised; however, this procedure is also not done these days as no reversal is possible. 

Laparoscopic Clips/Rings

Best reversibility: laparoscopic clips application 

Cauterization of Tube

 Worst reversibility 

Wrong Ligations. Structures linked by mistake 

• Round ligament (MC). 
• Small bowel
• Ovarian ligament
• Ureter and uterine artery: can't be ligated by mistake as they are retroperitoneal · Incomplete ligation

Important Points

• Basic Steps to Follow to Avoid Ligating Other Structures: 
• After pulling out the structures with Babcock's Forcep (atraumatic grip), always look for and then ligate 

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Male Sterilization 

Non-Scalpel 

Vasectomy Procedure 

• Stabilize with ring forceps 
• Pull out the vas deferens with sharp artery forceps and ligate it.

Completion 

Sperm present in part distal to ligation can still cause pregnancy. For 3 months or 20 ejaculations, whichever is later, use barriers or other contraceptives. After 3 months, sterilization should be confirmed by semen analysis. At least 2 semen analyses should show azoospermia. 

Reversibility

• Around 30% 
• Drawback compared to tubectomy

Hysteroscopic Sterilization: Essure Ring

Implant of the Essure Ring is placed in bilateral fallopian tubes hysteroscopically under LA or GA. This causes fibrosis & blockage of the tube and takes 3 months to completely block the tube. Made up of Nitinol (an alloy of nickel & titanium). Hysterosalpingography is done to confirm blockage after 3 months. 

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Important points to remember

• Just after delivery the uterus is at or just below the umbilicus Immediate postpartum sterilization can be done and is the most common timing of sterilization.
• Sperm present in part distal to ligation can still cause pregnancy.
• Basic Steps to Follow to Avoid Ligating Other Structures: 
• After pulling out the structures with Babcock's Forcep (atraumatic grip), always look for and then ligate.
• Isthemo isthmic reanastomosis has up to 80% success, thus preferring to ligate in the isthmic area.
• Laparoscopy is mostly for interval sterilization, but never do the puerperium as it can cause injury.
• Ureter and uterine artery: can't be ligated by mistake as they are retroperitoneal.

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