Female Sterilization Procedure

Female sterilisation (bilateral tubal ligation or occlusion) permanently blocks the fallopian tubes so that sperm cannot reach the egg. It is more than 99 percent effective, with fewer than 1 pregnancy in 100 women in the first year, and does not change menstrual cycles or hormones. It is done by a trained provider under local anaesthesia with sedation, or general or spinal anaesthesia, and requires careful counselling and signed consent.

Indications. A woman who has completed her family or does not want children, understands that the procedure is permanent, and consents voluntarily. It is also done at caesarean section or other abdominal surgery when planned and consented beforehand.

Who should not have the procedure now. Young women or women without children who are unsure about future fertility, and any woman who does not give voluntary informed consent. Where a woman has an intellectual disability, written consent is obtained from the parent or guardian after consultation with a colleague and with the woman's own assent.

Counselling and consent. Counsel on permanence, regret (higher in young women, in women with few children and after a change in relationship), failure rate, ectopic pregnancy risk if failure occurs, the surgical and anaesthetic risk, and the alternatives, including long-acting reversible methods and vasectomy. The patient signs a consent form in every case. Do not obtain consent during labour or when the patient is in pain or distress. Spousal consent is not required.

Timing.

• Interval: at any time when pregnancy is excluded, ideally in the first half of the menstrual cycle.

• Postpartum: within 7 days of delivery, best within 48 hours.

• Postabortion: immediately, if there is no infection.

• At caesarean section or other abdominal surgery.

• Switching: from combined pills, perform immediately and finish the pack; from injectables, before the next injection is due; from an IUD, remove it at the time of the procedure if within 7 days of menses, otherwise leave it until the next menses.

Preconditions. Facility with a minor theatre, appropriate equipment, infection prevention measures, emergency drugs and equipment and a referral system. The procedure is performed by a doctor or registered clinical officer with post-basic training; one surgeon performs no more than 15 procedures in a day, and not more than 30 procedures are done in one operating room in a day.

Preoperative assessment. History, blood pressure, pulse, weight, haemoglobin, pregnancy test on the day, abdominal and pelvic examination, anaesthetic assessment, fasting for 6 hours before sedation or general anaesthesia, and an empty bladder.

Anaesthesia. Local infiltration with lidocaine 1% (maximum 4.5 mg/kg) with light intravenous sedation titrated by a trained provider and verbal contact kept, or spinal or general anaesthesia for postpartum, caesarean or difficult cases. Give paracetamol 1 g and an NSAID before the procedure.

Minilaparotomy (interval, postpartum or postabortion).

• Incision of 2.5 to 5 cm: suprapubic for interval procedures, and just under the umbilicus for postpartum procedures when the fundus is high.

• Enter the peritoneal cavity, bring the tube into view with a tube hook or forceps, follow it to the fimbrial end to avoid ligating the round ligament.

• Occlude each tube, most commonly by the Pomeroy technique: lift a loop of the mid-portion, tie the base with absorbable suture and cut off the loop (about 1 cm), then check the cut ends for bleeding and confirm tissue sent for histology, where required.

• Return the tubes, check haemostasis and close the fascia with absorbable suture and the skin with subcuticular suture or adhesive strip.

Laparoscopic occlusion (interval). Create a pneumoperitoneum, place a clip or ring on the isthmic part of each tube about 2 to 3 cm from the uterus, confirm correct placement and the whole width of the tube within the clip or ring, release the gas and close the port sites. Electrocoagulation is avoided because of a higher risk of burns and ectopic pregnancy.

Salpingectomy. Removal of the tubes at caesarean section or at interval procedures is an alternative, with the added benefit of lower ovarian cancer risk.

Procedure record. Record the technique, the findings, the procedure on each side and any complication.

Overall complication rate. About 0.4 to 2.0 percent.

Complications and responses.

Recovery. Observe for 4 to 6 hours after a day case procedure and discharge when vital signs are stable, the patient can walk, pass urine and take fluids, and pain is controlled.

Analgesia. Paracetamol 1 g orally every 6 hours (maximum 4 g daily) and ibuprofen 400 mg orally every 8 hours with food for 3 to 5 days.

Wound care. Keep the dressing dry and in place for 24 to 48 hours; avoid heavy lifting and strenuous work for 1 week; resume sex when comfortable, usually after about 1 week.

Contraception. Protection starts immediately when the procedure is performed with certainty that she was not pregnant; use condoms for STI protection.

Return urgently for fever, increasing abdominal pain, heavy bleeding, wound discharge or redness, fainting, or a missed period or positive pregnancy test.

Follow up. A wound check at 7 to 14 days. Menstrual cycles continue as before.

Special groups. Postpartum and postabortion procedures need consent obtained before delivery or abortion. Patients living with HIV can be sterilised with the same precautions and must not be pressured. Patients with disability need supported decision making.

Referral and escalation. Refer failed or difficult procedures, suspected visceral injury, pregnancy after sterilisation, and regret requests for reversal.