Tubectomy / Tubal Sterilization / Female Sterilization

Overview
Nomenclatures: Tubectomy, Tubal Sterilization, Female Sterilization.

Tubal Sterilization is a permanent method of contraception where the fallopian tubes are blocked so that the ova or eggs are prevented from traveling to the uterus from the ovary.


Tubectomy also referred to, as Tubal Sterilization is a surgical procedure done on women as a permanent method of contraception. Gynaecologists, general surgeons and laparoscopic surgeons perform tubectomy.

The Fallopian Tubes are two in number and are attached on either side of the uterus at one end and the other end is open in the abdomen. The length of each Fallopian tube is about 10cm.When the ovum or egg is released from the ovary, it is picked up by Fallopian tube through which it moves into the uterus. If sperms are present in the Fallopian tubes, the ovum is fertilized and the resulting embryo is transmitted to the uterus where it is embedded. In short, we can say that Fallopian tubes are channels through which the eggs from the ovaries travel to the uterus. In Tubectomy the tubes are blocked or divided to prevent the eggs from entering the uterus. This prevents any future pregnancies to occur after the surgical procedure.

Anatomy Of The Female Reproductive System
Normal Anatomy of the Female Reproductive System


Types of Tubectomy

Blocking the fallopian tubes for Tubal sterilization can be done in several ways. The tubes can be closed by placing implants, by applying clips, clamps or rings and by cutting and tying the ends


The preferred method that is used commonly is to use a laparoscopic approach to identify the fallopian tubes on both the sides and apply plastic clips.

There are different surgical approaches for the tubal sterilization operations are

1. Laparoscopy
2. Microlaparoscopy
3. Laparotomy (concurrent with cesarean delivery)
4. Minilaparotomy
5. Hysteroscopy
6. Vaginal approaches.

The most popular is using a laparoscope; where the patient has just a couple of small scars and is discharged home the same day.

If laparoscopy is not available an open surgical operation maybe required. Here the tubes are completely divided and a section is excised.

Indications and Contraindications
Indications

Tubal Sterilization is indicated when the patient voluntarily requests for a permanent method of contraception.


Special legal and ethical criteria must be met in cases where the patient is undergoing sterilization and has a physical, psychological, or intellectual disability.

Contraindications

1. The patient should make the request herself, be of sound mind, and not act under external duress.

2. During delivery of the baby some women opt for sterilization; however this should be deferred if maternal or infant complications are anticipated.

3. Surgery is contraindicated in patients with active infections like Pelvic Inflammatory Disease (PID)

4. The laparoscopic approach is also contraindicated in patients with severe heart or lung problems.

5. Surgery is deferred in patients with suspected pregnancy.

Pre-operative Preparations

Pre-operative Preparations include counseling and measures to improve the outcome of surgery


1. Informed consent-written consent is obtained from the patient prior to performing the surgery

2. In Preoperative counseling the patient needs to be informed that the procedure of Tubal sterilization is permanent and irreversible and that a small chance of failure exists. The relative likelihood of an ectopic pregnancy is increased when sterilization failure occurs

3. It can be done as day-surgery or may require an overnight stay in the hospital

4. It is recommended that the patient take nothing by mouth (food, water, etc.) for at least 6 hours before the scheduled operation or after midnight if the operation is planned in the morning

5. Painkillers and antibiotics may be prescribed before the procedure

6. A sedative maybe useful to relieve the anxiety of surgery

7. The Abdomen and genital area may be shaved and prepared for the surgery

8. Before surgery or during the previous night a bath maybe advisable. During the bath thorough cleaning of the abdomen and genital area with soap and water a few times can help in lowering the bacterial count and lessen the chances of any infection from surgery

9. An enema maybe administered to the patient prior to performing the surgery. Sometimes a laxative maybe given to clear the bowels prior to the surgery

Investigations
Lab tests are performed prior to surgery to assess if any contraindications to the procedure are present.

Urine test: human chorionic gonadotropin (HCG) to detect pregnancy, which becomes positive approximately 1 week after conception.

Even if the test result is negative, the patient can possibly still be pregnant. For this reason, sterilization is best performed in the first few days of the menstrual cycle.

Urine analysis to rule out urinary tract infections

Complete haemogram to rule out anemia and bleeding tendencies.

Gonorrhea and chlamydia screening to rule out pelvic infections

Ultrasonography may be indicated when a pelvic mass is detected during the preoperative clinical examination

Surgical Procedures for Tubectomy

Tubal sterilization can be performed within 72 hrs of completion of a vaginal delivery. If it is performed at other times it is called interval sterilization.


Local anesthesia is used for more than 75% of sterilizations worldwide. Laparoscopic sterilization in performed under general anesthesia. Spinal anesthesia is preferred for procedures done immediately after delivery of the baby. Local anesthesia is the standard for the hysteroscopic approach, and it may be supplemented by oral or IV sedation if needed.

The actual procedure is done in an operating room, either in a hospital or a surgical center.

Laparoscopy for Tubal sterilization

Tubal sterilization can be performed within 72 hrs of completion of a vaginal delivery. If it is performed at other times it is called interval sterilization.


Local anesthesia is used for more than 75% of sterilizations worldwide. Laparoscopic sterilization in performed under general anesthesia. Spinal anesthesia is preferred for procedures done immediately after delivery of the baby. Local anesthesia is the standard for the hysteroscopic approach, and it may be supplemented by oral or IV sedation if needed.

The actual procedure is done in an operating room, either in a hospital or a surgical center.

Currently, Laparoscopy is the most popular method of female sterilization in nonpregnant women. It is performed under General Anesthesia. The surgery takes about half an hour.

1. In the Laparoscopy procedure, the abdomen is filled with carbon dioxide gas by introducing a needle so that the abdominal wall balloons away from the uterus and tubes.

2. The surgeon makes a small cut just below the navel and inserts a laparoscope, a small telescope-like instrument.

3. A second incision is made just above the pubic hairline to allow the entrance of another small instrument that can help with closure of the fallopian tubes.

4. Usually Falope rings or Filshie clips are placed on the fallopian tubes to block the tubes. Sometimes the tubes are cut and clipped

5. The skin incision is then closed with one stitch or a tape. The patient may feel well enough to go home from the outpatient surgery center in a few hours.

Advantages include small incisions, rapid access to the fallopian tubes and rapid recovery.

Disadvantages include the need for general anesthesia, the risks of injury to internal organs with needle insufflations. Difficulty associated with Laparoscopy in patients who are obese.

Micro-laparoscopy involves use of micro endoscopes of smaller diameter with 5 to 7 mm suprapubic incisions being made. This surgery is possible because of improved technology in light transmission and fiber optic bundles.

There are some theoretical advantages such as even smaller scars, less pain, less cost, and faster patient recovery. However the difference is so marginal that it has never become very popular despite being available for almost 20 years.

Other Surgical Procedures
1. Laparotomy (concurrent with cesarean delivery)

Laparotomy is an incision made in the abdominal wall to allow a physician to look at the organs. Bilateral tube ligation may be performed after closure of the uterine incision during cesarean delivery.

2. Mini-laparotomy

Periumbilical minilaparotomy is the most common procedure immediately after childbirth.

Postpartum tubal ligation is technically simple because the uterine fundus is at the level of the umbilicus, making the fallopian tubes readily accessible through a small periumbilical abdominal incision.

Minilaparotomy following delivery in the early puerperium is convenient, simple, and cost effective. However, if maternal or infant complications exist, sterilization should be delayed.

3. Hysteroscopy

The principle of this procedure is to place an implant in the fallopian tubes with the help of a Hysteroscope, which is a small telescope-like instrument, which is inserted into the uterine cavity.

The device works by inducing scar tissue to form over the implant, blocking the fallopian tube and preventing fertilization of the egg by the sperm. The small metallic implant is called the Essure System and hence the procedure is known as the Essure procedure.

   1. Under local anesthesia a 5-mm operative hysteroscope is inserted under direct vision through the cervical canal, and the uterine cavity is entered.

   2. The uterine cavity is distended with normal saline.

   3. A special catheter that is inserted through the vagina into the uterus and then into the fallopian tube.

   4. The catheter is retracted after placing the metal implant.

This process takes approximately 3 months to form complete occlusion, which is then documented by a hysterosalpingogram, where a dye is injected into the fallopian tubes and X-Rays are taken to document the block.

The patient must be counseled to use alternate forms of contraception for 3 months until a hysterosalpingogram can be obtained to confirm bilateral Tubal occlusion. This procedure cannot be reversed.

Unlike other currently available Tubal sterilization procedures for women, placement of an implant device does not require an incision or general anesthesia.

4. Vaginal approaches are rarely used because they are associated with a higher incidence of infection and are no longer recommended.

Complications

Complications due to anesthesia and surgery can occur during tubal sterilization


One must remember that rarely women have become pregnant after tubal ligation. It is estimated that about 1 in 200 women have had pregnancy after their tubes are ligated. This may be caused by an incomplete closure of the tubes.

Complications due to anesthesia are rare and include:

Reactions to Anesthetic medications

Breathing difficulties

Complications of surgery are rare, however these include -

Bleeding

Infection

Damage to the bladder

Puncture (perforation) of the uterus

Laceration (tear) of the cervix.

Perforation of the fallopian tube.

Perforation of major vessels - laparoscopy

Cardiac arrhythmias – due to CO2 - laparoscopy

If pregnancy occurs after the procedure, there is an increased risk for an ectopic pregnancy in which the pregnancy develops in the fallopian tubes.

Post-operative Care

Post-operative care involves the precautions that needs to be followed by the patient after the surgery


The follow-up visit for open or laparoscopic approaches is 1-2 weeks postoperatively.

Notify the health care provider if you develop fever (38°C or 100.4°F), increasing or persistent abdominal pain, or bleeding or purulent discharge from the incision.

Medications should be taken as per the doctor’s prescription.

Ensure to complete the whole course of the antibiotic.

Refrain from sexual intercourse for about a week after surgery or as advised by your doctor.

If you have delayed periods, vaginal bleeding/spotting, and severe abdominal pain, consult the doctor immediately, as it could be an ectopic pregnancy.

Conclusion
Tubal sterilization is intended to be a permanent method of birth control. This single procedure can provide highly effective protection against pregnancy for the remainder of a woman’s reproductive years. Temporary methods have an increased chance of failure and some may have bothersome side effects.

Sterilization is legal for mentally competent, adult women only if it is voluntary. Tubal ligation is considered a permanent form of birth control. It is NOT recommended as a temporary or reversible procedure.

Researchers continue to explore the possibility of using various substances that can be introduced through the cervix to occlude the tubal lumen through sclerosis or mechanical occlusion. Quinacrine, which is an antimalarial drug, has been used and introduced into the fallopian tube for sterilization. This process is still under study.

FAQs
1. Who performs a Tubal sterilization?

A Gynaecologist usually performs the Tubal sterilization procedure.

2. What is the best time to have a tubectomy done?

Tubectomy should be done best within a week after menstruation. Post partum sterilization is performed within 72 hrs of completion of a vaginal delivery.

3. Are there any precautions to be followed before a tubectomy?

Refrain from sexual intercourse for at least 4 days before tubectomy. If having sexual intercourse, use a condom.

4. Why are these precautions essential before undergoing Tubectomy surgery?

The sperms of semen are alive for 48-72 hours. If the women had sex about 2 days before operation, these sperms would be available in the Fallopian tubes and may fertilize the ova or egg. This fertilised ovum maybe implanted inside the uterus and she may become pregnant even after tubectomy.

There is another aspect of presence of viable sperms in the Fallopian tubes. These sperms may remain trapped at the far end of the Fallopian tubes and fertilize an ovum, even after Tubectomy. This fertilized ovum will not be able to pass into the uterus and hence will impregnate the thin Fallopian Tube resulting in ectopic pregnancy. This is a dangerous condition because ectopic pregnancy may result in rupture of Fallopian tube, severe hemorrhage and sometimes even death if not detected early enough.

5. Will tubectomy protect against sexually transmitted diseases (STDs)?

It's important to know that sterilization won't protect you against sexually transmitted diseases (STDs). Always use a condom during each sexual activity to prevent STDs.

6. How soon can I go back to work after sterilization?

That depends on your general health, your attitude, your job and the type of sterilization. Recovery is usually complete in a couple of days. You may want to take it easy for a week or so. Avoid lifting of heavy items for about a week.

7. Will I still have a period?

Yes. You will continue to have your periods. Sterilization won't make you less feminine. It doesn't cause weight gain or facial hair. It won't decrease your sexual pleasure or cause menopause.

8. What If Menstruation Does Not Take Place In Time?

Even after all the preoperative precautions, if you do not have menses - you should immediately go for pregnancy check up. Though tubectomy might have been done correctly, chances of spontaneous re-joining of the tubes are known to occur in rare instances.

9. Can Tubectomy Operation Be Undone?

Yes.Ligated and divided tubes can be successfully opened and their lumen restored by using microsurgery. However Tubal sterilization procedures like hysteroscopic placement of implants are permanent and so are not reversible. The results of subsequent pregnancy are however not high.

10. Which Doctor Should Be Chosen for recanalisation?

Plastic surgeons, who are expert in microsurgery; are usually competent doctors to open and recannalise the Fallopian tubes by microsurgery.

Glosssary
Cannula: A hollow tube

Conception: The creation of a new human life through the union of egg and sperm. Sometimes referred to as fertilization

Contraception: The practice of using drugs, procedures or devices intended to prevent conception

Ectopic Pregnancy: Pregnancies that occur outside the uterus. Ectopic pregnancies generally occur inside the Fallopian tube and are life-endangering to the mother

Fallopian Tube: The tubes that conduct the egg from the ovary to the uterus. Blockages in these tubes account for most cases of female infertility. Surgical sterilization is usually performed by cutting, burning, or tying off these tubes

Fertilization: The penetration of an oocyte by a sperm cell and the subsequent process of the combining of maternal and paternal DNA. The formation of an embryo

Hysterosalpingogram: Study of the female reproductive tract via X-rays and the injection of radio-opaque material to make the organs more visible to the operator

Hysteroscopy: The inspection of the uterus with a small lighted television device called a Hysteroscope

Laparoscopy: Examination of one or more organs in the pelvic region by means of a small-lighted television device known as a laparoscope

Menstruation: Beginning of the menstrual cycle, where the lining of the uterus is sloughed off and discharged

Ova: The woman's egg or gamete. Plural: ovum

Ovary: The female reproductive organs that store the ovum, or eggs

Postpartum: After birth

Sterilization: A surgical or chemically induced procedure that permanently or temporarily ends fertility in the male or female

Tubal Cautery: Sterilization of the Fallopian tubes by burning them

Tubal Ligation: The tying-off of the Fallopian tubes during a female sterilization procedure

Uterus: Muscular female organ within which the preborn child grows. Often referred to as the womb

Reference
1. http://www.emedicinehealth.com/
tubal_sterilization/article_em.htm

2. http://familydoctor.org/792.xml

3. http://www.fwhc.org/birth-control/
tubalig.htm

4. http://en.wikipedia.org/wiki/Tubal_ligation

5. http://www.gynob.emory.edu/
familyplanning/tuballigation.cfm

6. http://www.emedicine.com/med/
topic3313.htm

7. http://www.who.int/reproductive-health/
publications

Compiled by: Dr. Paderla Anitha.

Reviewed by: Dr. Shroff.

    

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