Permanent contraception (sterilization): Clinical sciences

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Introduction0:00–0:35

Permanent contraception, or sterilization, refers to surgery that closes off or removes the fallopian tubes to prevent fertilization of an egg by sperm, thereby preventing pregnancy.
Female sterilization can be achieved by occluding the fallopian tubes, removing a portion of the fallopian tubes, or removing the tubes entirely.
It is a good option for patients who have contraindications or barriers to using other forms of contraception as well as those who do not wish to use other forms of contraception.

Focused History0:35–1:58

When a patient presents for permanent contraception, your first step is to obtain a focused history. Assess the patient’s age, gravidity, and parity.
Keep in mind that there is no minimum necessary age, number of pregnancies, or number of children required for a patient to undergo sterilization.
Next, assess their medical and surgical history. Specifically ask about conditions such as endometriosis or a history of extensive surgery resulting in adhesions, which may distort the normal anatomy making a procedure technically more difficult.
Finally, assess the patient’s preference for contraception. There are many reversible contraceptive options available, including long-acting reversible contraceptives or LARCs.
Patients should never feel pressured or coerced into a permanent procedure such as sterilization. If the patient no longer desires permanent contraception, or remains unsure, do not proceed with permanent sterilization and instead counsel them on all available contraceptive options.
On the flip side, if the patient continues to desire permanent contraception, your next step is comprehensive counseling.You can begin by counseling on all contraceptive options available.

Comprehensive Counseling1:58–5:28

Many patients are not aware of options beyond condoms and birth control pills. LARCs are just as effective as sterilization and provide patients with a good alternative to surgery.
Some patients may also choose for their partner to undergo sterilization, which can be achieved via vasectomy. Here’s a clinical pearl!
Vasectomy blocks the ability of the sperm to fertilize an egg by occluding the vas deferens and making ejaculate sterile.
This is completed during an outpatient procedure with local anesthesia. In fact, vasectomy is more effective, less expensive, and safer when compared to female sterilization.
Keep in mind that vasectomy is not immediately effective and that the patient must follow up in 3-6 months to confirm azoospermia with a semen analysis.
Be sure to counsel the couple on backup contraception until the confirmatory test is completed! Okay, let’s get back to counseling our patient.
As with any patient undergoing surgery, discuss the safety of surgery and possible complications including bleeding, infection, and injury to surrounding structures.
In general, laparoscopy is considered very safe with low rates of complications and rare procedure-related morbidity. Take into consideration the patient’s medical and surgical history and address any comorbidities as not all patients are optimal candidates for surgery.
These include patients with a history of severe cardiac or pulmonary disease and those with morbid obesity, which can make it more difficult to ventilate patients during general anesthesia.
Also optimize those with uncontrolled diabetes or patients who use tobacco, which can result in poor wound healing. In these cases, it is often reasonable to offer contraceptive alternatives or postpone surgery to enhance health status.
However, it is always important to weigh the individual risks of an unintended pregnancy versus the risks of elective surgery as there are no absolute contraindications to permanent sterilization.
A unique consideration in regards to sterilization is the risk of regret, specifically in patients who are less than 30 years old and those with low parity.
Make sure they understand that if they change their mind regarding future pregnancy, a reversal procedure is expensive, often not covered by insurance, and may not be possible or successful.
Additionally, they may require the use of in vitro fertilization, which also may not be covered by insurance. This is by no means a contraindication to proceeding with surgery but should always be reviewed so the patient is well informed.
Additionally, be sure to discuss the different surgical techniques available and the timing of the procedure based on the selected technique.
Finally, you must let your patient know that while permanent contraception is highly effective, nothing is 100% guaranteed, and that rarely pregnancy may occur.
Rates of failure depend on the surgical technique chosen and the time since sterilization. It's also important to counsel a patient that they are at a higher risk of an ectopic pregnancy if a future pregnancy occurs.
Ultimately, the decision to proceed with permanent contraception lies with a well-informed patient.Now that you have counseled the patient and they elect to proceed, you and the patient must determine which surgical option is best for them.

Management5:28–9:57

All options will be performed either via laparotomy or laparoscopy. If the patient is currently pregnant they may elect for a postpartum sterilization, also referred to as postpartum tubal ligation.
This can either be at the time of c-section or after a vaginal delivery prior to discharge. If performed after a vaginal delivery, sterilization occurs via a mini-laparotomy just below the umbilicus.
This is because the immediate postpartum uterus is enlarged and at the level of the umbilicus, allowing for easy access to the fallopian tubes!
In terms of anesthesia, a spinal or epidural is most often used, making it safer for patients with medical comorbidities than general anesthesia.
Here is a clinical pearl! Some state insurance programs require patients to obtain consent at least 30 days prior to the procedure.
If you are counseling a pregnant patient who may desire postpartum sterilization, have the patient sign the consent form during their prenatal visit, just in case.
Okay, time to discuss postpartum tubal ligation surgical techniques. The three most common methods to consider include partial salpingectomy techniques like Pomeroy and Parkland, and salpingectomy.
Both the Pomeroy and the Parkland techniques separate the proximal and distal portion of the fallopian tube thereby preventing sperm from fertilizing an egg.
On the other hand, salpingectomy means the removal of the entire fallopian tube. This option eliminates the risk of the ligated ends of the tube reconnecting however there is a slightly increased risk of bleeding.
It also reduces the risk of developing ovarian cancer as it is believed that epithelial ovarian cancer originates in the fimbriae of the tube.Here’s a clinical pearl!
Make sure you confirm that you are ligating the fallopian tube by following the tube distally to the fimbriated end. Sometimes the round ligament is mistakenly ligated!
Now, if the patient desires to wait until they have recovered from delivery, they can choose an interval sterilization. Interval sterilizations are performed via laparoscopy, generally 6-8 weeks after delivery.
Laparoscopy is also an option for those who are not pregnant or recently postpartum. There are three laparoscopic methods to consider: salpingectomy, either complete or partial, electrocoagulation, or mechanical devices.
Complete salpingectomy, or full removal of the fallopian tube is preferred because it has the lowest risk of failure. A partial salpingectomy may be necessary in patients with extensive adhesive disease in which it is difficult or impossible to fully access the fallopian tube.
You can also consider electrocoagulation, which involves using bipolar electrocautery to coagulate part of the isthmic portion of the fallopian tube.
Finally, mechanical devices can also be utilized. The most common options are the silicone rubber band, spring-loaded clip, and titanium clip lined with silicone.
All three are placed on the fallopian tube and cause occlusion. These options are best used on normal and mobile fallopian tubes.
If the tubes are thickened, dilated, or have adhesive disease there is an increased risk of failure. Also, keep in mind that electrocoagulation and mechanical devices have the highest risks of failure.Let’s wrap this up with a clinical pearl!
Though there are currently no available devices in the United States, female sterilization has been performed hysteroscopically.
This included inserting a hysteroscope into the uterus, visualizing the tubal ostia, and placing a device into each tube, which stimulates tissue growth causing occlusion.
Similar to vasectomy, patients must return in 3 months for a hysterosalpingogram to confirm tubal occlusion. However, due to complications related to this device, it is no longer utilized.Alright, as a quick recap… Female sterilization is a permanent contraceptive option that requires surgery to achieve.

Review9:57–10:37

If your patient is unsure, do not proceed with sterilization and consider alternative contraception. If they desire permanent contraception, you must extensively counsel the patient.
A complete salpingectomy is a viable option for both postpartum and interval tubal ligation. Additional techniques to select from include the Pomeroy and the Parkland methods, electrocoagulation, and mechanical devices.
Selection depends on when sterilization is being performed in relation to postpartum status and the patient’s