Female sterilization

Surgical Therapy
Surgical approaches for female sterilization include laparoscopy, hysteroscopy, microlaparoscopy,
laparotomy (concurrent with cesarean delivery), minilaparotomy, and vaginal approaches. Although
minilaparotomy is the most common approach worldwide, laparoscopy is used most commonly for
interval procedures in the United States. Hysteroscopic procedures are rapidly gaining popularity. For
postpartum procedures, although some studies describe successful use of laparoscopy, the
subumbilical minilaparotomy is used most commonly in the United States and worldwide. Vaginal
colpotomy approaches are rarely used because they are associated with a higher incidence of infection
and can no longer be recommended.
Local anesthesia is used for more than 75% of sterilizations worldwide. Although some US providers
use local anesthesia for laparoscopic sterilization, general anesthesia (for interval procedures) and
regional anesthesia (for postpartum procedures) are most common.
For the hysteroscopic approach, local anesthesia is the standard approach, and it may be supplemented
by oral or IV sedation as needed.
One meta-analysis identified 9 randomized, controlled trials that compared 5 commonly used
methods. [5] Aspects such as training, costs, and maintenance may be important factors in deciding
which method to choose.

Note the images below.

Elevation of the fallopian tube through the incision.
Puerperal tubal sterilization
In comparison with interval sterilization, infraumbilical minilaparotomy following delivery in the
early puerperium is convenient, simple, and cost effective. However, if maternal or infant
complications exist, sterilization should be delayed.

Bilateral tube ligation (BTL) may be performed after closure of the uterine incision during cesarean
delivery or following completion of a vaginal delivery within 72 hours. Postpartum BTL 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.
If the procedure is delayed for several days or if the patient has a significantly involuted uterus (as
might occur after delivery of a preterm infant), then delaying to an interval procedure is usually
prudent, although puerperal laparoscopic BTL has been reported.
Minilaparotomy
Minilaparotomy is defined as a laparotomy with an incision size smaller than 5 cm. The operation can
be performed through a suprapubic incision in the interval after pregnancy and through a subumbilical
incision within the first 48 hours after delivery.

A 2- to 5-cm periumbilical semilunar incision is made with the skin tented with Allis clamps.
Dissection is carried down to the fascia, which is grasped with hemostats or Allis clamps and opened
transversely, exposing the peritoneum, which can then be entered sharply. With uterine manipulation
and retraction, the tubes can be visualized and grasped with a Babcock clamp. Often, the oviducts can
be palpated at their utero-tubal junction and the uterus may then be rotated to position the isthmus of
the tube under the incision anteriorly with the aid of Army-Navy retractors. The fallopian tube is
"walked" with Babcock clamps until the fimbriated end is identified. A major cause of failure of
sterilization is the inadvertent ligation of the round ligament mistakenly identified as the fallopian
tube.

After the BTL, the minilaparotomy incision is closed in layers. Closure of the peritoneum is optional.
The fascia is closed with running 2-0 or 0 delayed absorbable suture. Subcutaneous closure is
optional, and the skin is closed with 3-0 or 4-0 absorbable suture in a subcuticular manner or with
acrylic glue.
Laparoscopy
Advantages include small incisions, full access to the oviducts, rapid recovery, and the ability to
inspect the pelvis and upper abdomen.

Disadvantages include the need for general anesthesia, the risks of vessel/viscera injury with needle
insufflation/trocar entry, and difficulty associated with laparoscopy in patients who are obese or in the
presence of abdominal and/or pelvic adhesions. Entry accounts for 30-50% of all laparoscopic
sterilization complications.

The failure rate of the laparoscopic approach according to the US Collaborative Review of
Sterilization (CREST) ranges from 7.5 per 1000 procedures for unipolar coagulation to a high of 36.5
per 1000 for the spring clip. The Filshie clip was not included in the CREST study, but its failure rate
is reported to be between 1 and 2%.

According to one study, the success rate of laparoscopic sterilization on the first attempt is 99%. The
same study estimates the success rate of hysteroscopy to be 88% on the first try. These rates account
for 6% of women whose first attempt with hysteroscopy is unsuccessful and are ultimately sterilized
via laparoscopy. [6]

The patient should always have an examination under anesthesia, and the bladder should be
catheterized. A uterine manipulator and the use of the Trendelenburg position enhance exposure.

Microlaparoscopy
Microlaparoscopy involves use of 1.2- to 2-mm microendoscopes with 5- to 7-mm suprapubic ports
for bipolar coagulation or mechanical occlusive devices. This surgery is possible because of improved
technology in light transmission and fiberoptic bundles.

The theoretical advantages of less pain, less cost, and faster patient recovery have not been assessed
through randomized, controlled trials, although several studies have been reported in an office setting.
Despite almost 20 years of availability, office microlaparoscopy has not become widely accepted.

Hysteroscopy
Advantages include offering the most cost-effective, minimally invasive approach without the need
for abdominal incisions or general anesthesia, thereby avoiding complications associated with trocar
injury or thermal burns. Hysteroscopy is regularly performed in an office setting using local
anesthesia, thus affording patients a rapid return to normal activity (usually within 24 hours).
Compared with laparoscopic techniques, hysteroscopic sterilization studies cite cost savings of >50%
in the OR. [7, 8, 9] Prior abdominal surgery and obesity are not contraindications for hysteroscopy, nor
are cardiovascular or anatomic contraindications to general anesthesia. Long-term 5-year Essure data
from the Phase II and Pivotal Trial continue to demonstrate safety, high patient satisfaction with zero
reported pregnancies. [10]

Essure has been shown to be 99.80% effective in preventing pregnancy after 4 years of follow-up.
Essure labeling reports a bilateral placement rate of 94.6%. [11] and published papers report placement
rates ranging from 96-99%. [12, 13, 14, 15, 16, 17] Since its approval in the commercial setting, the evaluable
performance of Essure is still consistent with the age-adjusted effectiveness of 99.85%. [10] The
hysteroscopic failure rate is the lowest of any surgical approach with 0.5/1000 at 1 year.

Hysteroscopy requires an FDA-mandated hysterosalpingogram to confirm correct placement and to

document tubal occlusion. Patients often find this procedure a reassuring confirmation that the tubes
are indeed occluded.

Puerperal Techniques
Pomeroy technique
This technique is the simplest and most commonly performed puerperal tubal sterilization.
The mid portion of the oviduct is grasped with a Babcock clamp, creating a loop, which is
tied with 2-0 or 0 plain catgut suture, and each limb of the tubal knuckle is cut separately.
Specimens are submitted to pathology. The endosalpinx at the cut ends may be cauterized
(optional). The ligation sutures are held while the tube is cut to prevent retraction of the tubal
stumps into the peritoneal cavity before they can be adequately examined for hemostasis.

The original description consisted of forming a loop of the ampullary segment of the fallopian
tube and ligating the base of the loop with a double strand of 1-0 chromic catgut, followed by
resection of the top of the ligated loop. The rationale for this technique is based on prompt
absorption of the suture ligature with subsequent separation of the cut ends of the tube,
which then become sealed by spontaneous reperitonealization and fibrosis. A resultant
natural gap of 2-3 cm should occur between the severed proximal and distal segments of the
tube.

Many modifications of the Pomeroy technique have been described; the most common
involves doubly ligating each loop.

Failure rates are reported to be 1 case in 300-500 patients.

Parkland technique
The Parkland technique is a midsegmental resection similar to the Pomeroy technique,
except each leg of the loop is tied separately. The Parkland technique was designed to
avoid the intimate approximation of the tubal cut ends, as occurs with the Pomeroy
technique, thereby theoretically reducing the risk of subsequent recanalization.

An avascular area in the mesosalpinx directly under the tube is perforated with a hemostat,
and the jaws are opened to spread the mesosalpinx, thereby freeing approximately 2.5 cm
of tube. The tube is then ligated proximally and distally with a 0 or 00 plain or chromic
suture, and a 1- to 2-cm tubal segment is excised and submitted for pathologic confirmation.

Failure rates are reported to be 1 case in 400 patients.

Uchida technique
The mid portion of the oviduct is raised with 2 Babcock clamps. The tubal serosa is
hydrodissected from the muscularis by subserosal injection of a dilute (1:100,000) saline
solution of epinephrine or isotonic sodium chloride solution. A linear incision is made parallel
to the axis of the tube in the ballooning serosa on the antimesosalpingeal aspect with a
scalpel, #15 blade. The serosal peritoneum is grasped on either side of the tubal incision
with hemostats, and a third hemostat is used to bluntly dissect and reflect the serosa and the
surrounding areolar tissue from the tubal muscularis. With the tubal muscularis exposed,

a relatively long (5 cm) segment of tubal muscularis is ligated proximally and distally with a 0
or 0-0 plain catgut suture and resected. The serosal edges are then reapproximated, burying
the proximal exposed tubal end within the leaves of the broad ligament, leaving the distal
end exposed.

During the puerperium, Uchida modified the sterilization procedure by including

fimbriectomy.

Clearly, the excision of such a large segment of tube, combined with a fimbriectomy,
accounts for the low rate of failure for this technique. For all practical purposes, it is a
salpingectomy.
Irving technique
The Irving technique is designed to be used in conjunction with cesarean delivery.

A mesosalpingeal window is created beneath the tube approximately 4 cm from the

uterotubal junction. The tube is doubly ligated with 0 or 00 absorbable suture and severed,
with the sutures on the proximal end left long. The proximal tubal stump may require
mobilization by dissecting it free from the mesosalpinx. A small nick is made into the serosa
on the posterior (or anterior) uterine wall near the uterotubal junction. A hemostat is used to
deepen the incision, creating a pocket in the myometrium approximately 1-2 cm deep. The 2
free ends of the proximal stump ligature are then individually threaded onto a curved needle
and brought deep into the myometrium tunnel and out through the uterine serosa. Traction
on the sutures draws the proximal tubal stump deep into the myometrial tunnel, and the
sutures are tied. The serosal opening of the tunnel is then closed around the tube with fine
absorbable suture.

An additional option is to bury the distal end of the tube between the leaves of the broad
ligament as originally described by Irving.

Failure rates are less than 1 case in 1000 patients.

Tubal ring The silastic band or tubal ring method involves a doubling over of the fallopian
tubes and application of a silastic band to the tube

Follow-up
The follow-up visit for open or laparoscopic approaches is 1-2 weeks postoperatively.
Instruct the patient to notify her health care provider if she develops fever (38°C or 100.4°F),
increasing or persistent abdominal pain, or bleeding or purulent discharge from the incision.
Patients who have undergone hysteroscopic sterilization must be counseled to use an
alternate form of contraception for 3 months at which time a low-pressure
hysterosalpingogram must be obtained to confirm placement and bilateral tubal occlusion.
The importance of the 3-month hysterosalpingogram needs to be communicated to patients
at the time of microinsert placement; subsequent office follow-up may be required to ensure
patients comply with confirmation test.
Inform all women who have undergone sterilization about the signs and symptoms of
pregnancy (eg, amenorrhea, vaginal bleeding/spotting, abdominal pain) and ectopic
pregnancy, and advise these women to seek immediate medical attention if such signs
occur.

Complications
Mortality
The risk of death from tubal sterilization is 1-2 cases per 100,000 procedures; most of these
are complications of general anesthesia. The most common cause of death during
laparoscopic BTL appears to be hypoventilation related to anesthesia. Cardiopulmonary
arrest and hypoventilation are reported as the leading cause of death in most cases. Sepsis
as a cause of death from laparoscopic sterilization is directly related to bowel perforations or
electrical bowel burns. The mortality rate is low when compared with the risk of death from
hysterectomy (5-25 cases per 100,000 procedures) and from pregnancy (8 cases per
100,000 live births in the United States and 500 cases per 100,000 live births in developing
countries).
No deaths have been reported from the hysteroscopic approach.
Unintended laparotomy
Unintended laparotomy occurs with 1-2% of laparoscopic procedures; most of these
conversions are attributable to technical inability to complete the laparoscopic procedure
rather than to complications of the procedure.
Bowel injury
Bowel injury can occur during insertion of the insufflation needle or trocar or during
electrocoagulation. Small injuries from the needle or trocar with no bleeding or leakage of
enteric contents can usually be managed expectantly; otherwise, prompt laparotomy is
indicated.
Vascular injury
Vascular injury can occur during insufflation needle or trocar insertion. Injury to a large
vessel is a life-threatening emergency. Perform an immediate laparotomy with direct
pressure over the injury to control bleeding until repair (usually by a vascular surgeon) can
be performed.
Method failure (pregnancy or ectopic pregnancy)
Although sterilization is highly effective and considered the definitive form of pregnancy
prevention, it has a failure rate during the first year of 0.1-0.8%. At least one third of these
are ectopic pregnancies. Recent findings suggest that pregnancy is somewhat more
common than previously estimated, that the risk of pregnancy persists for many years after
sterilization, and that the risk varies by method and patient age at sterilization.
In the CREST study, 10,685 women were enrolled from 1978-1986; follow-up continued until
1994. The CREST study reviewed procedures performed at 10 large teaching institutions,
and the data may not reflect the experience from the private sector. Whether the findings
can be extrapolated to the general population is unclear. In addition, the Filshie clip, which
has a lower incidence of failure than the other laparoscopic techniques, was not included in
this study. The 10-year cumulative probability of pregnancy varied from 7.5 cases per 1000
procedures for postpartum partial salpingectomy and unipolar coagulation to 36.5 cases per
1000 procedures for spring clip application. The CREST study identified a 10-year
cumulative failure rate of 18.5 failures per 1000 patients for all methods combined.
Pregnancies occurring in the 10th year after sterilization were identified for all methods of
laparoscopic occlusion evaluated.
Rodriquez et al also found decreased efficacy with the titanium clip than partial
salpingectomy and does not recommend using the titanium clip during the postpartum
period. [20]
The risk of pregnancy varied by patient age at sterilization and by method, with the highest
risk among young women sterilized with bipolar coagulation (54.3 cases per 1000
procedures). Overall, women sterilized at age 34-44 years were half as likely to become
pregnant after sterilization compared to women sterilized at age 28-33 years and were
approximately one third as likely to become pregnant as women sterilized at age 18-27
years. When pregnancy occurs after BTL, the risk of ectopic pregnancy is high. The CREST
study reported a 32% rate of ectopic pregnancy following tubal ligation. Several studies
suggest that the risk is highest after bipolar coagulation, with more than 50% of pregnancies
being ectopic.
BTL failures can be grouped into the following categories:
 Luteal phase pregnancy is defined as a pregnancy in which conception occurs before
the BTL, but pregnancy is diagnosed after an interval tubal sterilization. Strategies to
reduce the incidence (reported to occur at a rate of 1-15 cases per 1000 interval
sterilizations) include effective contraception, scheduling of BTL during the proliferative
phase, and preoperative urine enzyme-linked immunoassay pregnancy testing.
 Misidentification of the oviduct because of poor visualization from inadequate
exposure, adhesions, adnexal pathology, or poor lighting may result in mistakenly
ligating the round ligament, ovarian ligament, infundibular ligament, or dilated broad
 ligament blood vessels instead of the oviduct. Therefore, initially identifying the
fimbriated tubal ends and then tracing the tube medially to the isthmic region is
imperative. In postpartum minilaparotomy BTL, Babcock clamps should be placed
sequentially along the oviduct until the fimbria is visualized.
 Incomplete occlusion of the oviduct occurs because of poorly placed mechanical clips
or the use of mechanical devices on edematous or dilated tubes. With correct clip
application, the mesosalpinx on the surface of the tube is pulled upward to resemble
the flat triangular shape of an envelope flap (the Kleppinger envelope sign). When
silastic rings are used, the tubal serosa, but not the tubal lumen, may be pulled into the
ring, with absence of the vertical crease formed when the entire loop of tube is
included in the ring.
 Incomplete tubal occlusion with electrocoagulation is generally associated with too
brief an application of current or with the use of modulated/coagulation current instead
of unmodulated/cutting current.
 Improper technique occurs with the use of the wrong sutures or failure to preserve a 2-
cm proximal tubal segment. If a short proximal stump is left, the fluid pressure from
uterine contractions could either prevent complete closure of the tubal lumen during
healing or cause a fistula to form to relieve pressure after healing is complete.
Pain
After laparoscopy, patients may experience some degree of chest and shoulder pain due to
trapped gas. Mechanical blocking devices are believed to cause ischemic pain, but this has
not been established in a randomized, controlled trial. Mild analgesics are usually sufficient
to control postprocedure pain.
Hysteroscopic sterilization has been reported to be similar to the pain experienced during
menses and is generally limited to the procedure and immediate postprocedure time
period. [21, 22]
Infection/hemorrhage
Wound infections and hematoma have been associated with minilaparotomy. Pelvic
infections and hemorrhage are associated with vaginal approaches. Although prophylactic
antibiotics are recommended for women at risk for subacute bacterial endocarditis who are
scheduled to undergo a procedure that may lead to bacteremia, the American Heart
Association does
not recommend antibiotic prophylaxis for BTL. Hemorrhage is a rare complication (30-90
cases per 100,000 procedures) that usually occurs following major vessel injury during
laparoscopic entry and occasionally occurs following mesosalpingeal vessel injury during the
occlusion procedure.
Visceral (bowel, bladder, uterus) injuries
Organ injuries can occur from sharp trauma (eg, insufflation needle, trocar, scalpel), blunt
trauma (eg, from adhesiolysis), or electrical-thermal trauma. Injuries can also occur during
inadvertent application of the occlusion device to the incorrect structure. If recognized at the
time of occurrence, injuries to the bowel and bladder (which are more common in the
presence of adhesions) are relatively easy to manage and will not result in long-term
adverse sequelae. Injuries to the uterus, most often caused by uterine manipulators, do not
usually lead to adverse sequelae unless bowel or bladder has been perforated
simultaneously.
Patient regret
Sterilization is intended to be permanent, but patient regret is not rare. Poststerilization
regret is a complex condition often caused by unpredictable life events. Risk factors for
regret that may be useful in presterilization counseling include young age, low parity, and
single parent status or being in an unstable relationship. As many as 6% of women who are
sterilized report regret or request information about tubal reversal within 5 years of the
procedure. Follow-up interviews 14 years postprocedure demonstrate that regrets were
expressed by 20.3% of women aged 30 years or younger at the time of BTL and by 5.9% of
women older than 30 years at time of procedure.
The proportion of women who actually undergo microsurgical tubal reanastomosis is only
0.2% in the first 5 years after BTL. The most important factor in determining the success of
reversal by tubal anastomosis is the length of healthy tube remaining after sterilization.
Isthmic-to-isthmic anastomoses are most likely to be successful. Sterilization reversal using
a sutureless laparoscopic approach yielded a 59% ongoing pregnancy rate with a 3.9%
ectopic rate. Age, previous pregnancy, and sperm quality were major factors affecting the
outcome. [23]
Relevant Anatomy
See the list below:
 The 2 fallopian tubes (oviducts) lie on either side of the uterus in the upper margin
(mesosalpinx) of the broad ligament. Each tube is divided into 4 parts. From lateral to
medial, the parts are as follows:
 The fimbriated end (infundibulum) is a bugle-shaped extremity with a fimbriated ostium
that overlies the ovary, to which an elongated appendage (the fimbria ovarica)
adheres.
 The ampulla is wide, thin-walled, and somewhat tortuous and is the largest portion of
the tube, both in length and caliber.
 The isthmus is a narrow, straight, thin-walled portion of the tube immediately adjacent
to the uterus. The ampullaryisthmic junction is the site where the fertilized egg pauses
in its transit to the endometrial cavity, waiting for the progesterone produced by the
corpus luteum to create a favorable environment for implantation. The isthmic portion
of the fallopian tube is the site for all sterilization procedures that depend on intra-
abdominal tubal occlusion. When a segment of tube is removed, as in the Pomeroy or
Uchida technique, the isthmus is the preferred site of excision because of the relative
ease of reanastomosis should the procedure be reversed in the future.
 In the intrauterine or intramural portion of the tube, the lumen narrows to approximately
1 mm or less as it pierces the uterine wall, terminating in the tubal ostium, which is
located on the superolateral aspect of the uterine cavity.
Although the mesonephric (wolffian) ducts degenerate in females, duct remnants may be
sites of cyst formation.
 Epoophoron (homologous to the epididymis) - Constantly lies in the lateral portion of
the mesosalpinx and mesovarium
 Paroophoron (homologous to the paradidymis) - Variably lies more medially in the
mesosalpinx
 Hydatid cysts of Morgagni (homologous to the appendix of epididymis) - Represent the
most cranial remnant of the mesonephric duct

Tubal ligation adalah operasi perut. Satu studi menemukan bahwa komplikasi pasca operasi dari ligasi
tuba lebih mungkin terjadi dibandingkan dengan vasektomi dan lebih mahal. [19] Di negara-negara
industri, angka kematian adalah 4 per 100.000 ligasi tuba, versus 0,1 per 100.000 vasektomi. [20]

Tubal ligation memiliki biaya awal yang lebih besar daripada metode kontrasepsi lainnya. Mungkin
diperlukan waktu lebih dari satu dekade penggunaan ligasi tuba untuk menjadi efektif biaya seperti
metode jangka panjang yang sangat efektif lainnya seperti AKDR atau implan. Biaya metode lanjutan
atau biaya dari kehamilan yang tidak diinginkan membuat banyak metode lain atau lebih mahal
daripada ligasi tuba jika digunakan selama beberapa tahun. [19] Biaya ligasi tuba berkurang jika
dilakukan selama operasi caesar, karena tabung sudah terbuka selama laparotomi.

Ligasi tuba dapat mengurangi risiko kanker ovarium, dengan beberapa penelitian memperkirakan
risiko relatif pada 0,66 untuk tipe epitel, 0,40 untuk tipe endometrioid dan 0,73 untuk tipe serosa. [21]
Kebijakan tuba ligasi (sterilisasi) saat ini di Amerika Serikat memberlakukan waktu tunggu wajib
untuk sterilisasi tuba elektif pada penerima manfaat Medicaid. Dengan tidak adanya periode tersebut
bagi penerima manfaat swasta, beberapa dokter dan ilmuwan percaya bahwa "kebijakan penundaan
wajib yang berusia puluhan tahun ini memang bermaksud baik, namun sekarang memiliki efek untuk
membatasi akses perempuan terhadap sterilisasi tuba dan ketidakadilan secara elektif"