Female Sterilization

Female sterilisation is bilateral occlusion of the fallopian tubes by cutting and tying, clipping, banding, coagulating or removing them, so that sperm cannot reach the ovum. It is a minor surgical operation that can be done on a conscious patient under local anaesthesia and is a permanent method for women who want no more children. It does not alter ovarian hormones, menses, sexual function or breastfeeding.

Classification by access. Minilaparotomy (interval, postpartum or postabortion), laparoscopy (interval only), and occlusion during caesarean section or other abdominal surgery.

Classification by occlusion. Partial salpingectomy (modified Pomeroy, Parkland, Irving), mechanical clip, silicone ring, bipolar electrocoagulation, and bilateral total salpingectomy.

Effectiveness. First-year pregnancies are 0.5 per 100 women with typical use and 0.5 per 100 women with perfect use, which is under 1 per 100. Failure continues at a low rate for years after the procedure. It is higher in women sterilised under 30 years and with clips or coagulation, and lowest with partial salpingectomy after birth and with total salpingectomy. About one third of pregnancies after failure are ectopic.

Onset. Protection starts when the procedure is complete.

Return to fertility. None is expected. Microsurgical reversal depends on the occlusion method, the length of healthy tube remaining and the patient’s age, and success cannot be guaranteed.

Non-contraceptive benefit. Ovarian cancer risk falls, and pelvic inflammatory disease risk may fall. Total salpingectomy is an additional route to ovarian cancer risk reduction.

Ideal candidates. Women of any parity who have completed their family, understand permanence and consent voluntarily after being offered reversible long-acting methods.

Women who should not have the procedure. Women uncertain about future fertility, and women who have not given voluntary informed consent.

Accept.

• Any parity
• breastfeeding
• postpartum under 7 days or over 42 days
• mild pre-eclampsia or past pre-eclampsia
• uncomplicated postabortion state
• past ectopic pregnancy
• smoking
• past venous thromboembolism
• migraine
• benign ovarian tumours
• cervical intraepithelial neoplasia
• benign breast disease
• HIV including clinical stage 1 or 2
• uncomplicated schistosomiasis
• non-pelvic tuberculosis
• compensated mild cirrhosis
• sterilisation at caesarean section

Caution.

• Obesity
• hypertension controlled under 160/100
• past ischaemic heart disease or stroke
• uncomplicated valvular disease
• current breast cancer
• epilepsy
• depressive disorders
• fibroids
• uncomplicated diabetes
• hypothyroidism
• anaemia
• kidney disease
• previous abdominal or pelvic surgery
• uncomplicated lupus
• severe nutritional deficiency
• past pelvic inflammatory disease without later pregnancy

Delay.

• Young age with no living children (delay up to one month for counselling)
• prolonged rupture of membranes
• puerperal or postabortion sepsis
• severe antepartum or postpartum haemorrhage
• genital tract trauma
• severe pre-eclampsia or eclampsia
• current deep vein thrombosis or pulmonary embolism
• unexplained vaginal bleeding
• malignant trophoblastic disease
• cervical, endometrial or ovarian cancer
• current pelvic inflammatory disease or purulent cervicitis
• active gallbladder disease or viral hepatitis
• haemoglobin under 7 g/dL
• sickle cell disease
• abdominal skin infection
• acute respiratory or systemic infection

Special.

• Uterine rupture or perforation
• fixed uterus from surgery, pelvic inflammatory disease or endometriosis (avoid laparoscopy)
• abdominal wall or umbilical hernia
• known pelvic tuberculosis
• multiple cardiovascular risk factors
• blood pressure 160/100 or higher
• hypertension with vascular disease
• complicated valvular disease
• diabetes with vascular disease
• hyperthyroidism
• severe cirrhosis
• coagulation disorders
• venous thromboembolism on anticoagulants
• lupus with positive or unknown antiphospholipid antibodies or severe thrombocytopenia or immunosuppression
• chronic respiratory disease
• AIDS
• allergy to local anaesthetics

Choice of technique. After birth within 7 days: minilaparotomy with partial salpingectomy through an infraumbilical incision. Interval: minilaparotomy or laparoscopy. At caesarean section: partial salpingectomy through the open abdomen. Clips and rings are less suitable on the thickened postpartum tube.

Investigations. Blood pressure, haemoglobin when anaemia is suspected, pregnancy exclusion, pelvic examination for uterine position and mobility.

Regimen line. Procedure: tubal occlusion by the chosen technique. Anaesthesia: lidocaine 1% (10 mg/mL) infiltrated into the skin and tissue layers about 5 minutes before incision, up to 4.5 mg/kg without adrenaline (maximum 300 mg, which is 30 mL) or up to 7 mg/kg with adrenaline (maximum 500 mg). Reduce the dose in significant liver disease and in the elderly, and avoid in documented allergy.

Lidocaine is compatible with pregnancy and breastfeeding at these doses. Light sedation may be added while keeping the patient able to talk. Protection: immediate, lifelong. Backup: none. Missed-use rules do not apply.

Pregnancy exclusion. Reasonably certain if no intercourse since last menses, consistent use of a reliable method, within 7 days of menses start, within 4 weeks postpartum, within 7 days of an abortion, or fully breastfeeding amenorrhoeic under 6 months postpartum. Otherwise test for pregnancy. Do not operate on a positive test.

Start timing.

• Within 7 days of birth, or at caesarean section.
• Interval: any time once pregnancy is excluded, ideally in the first 7 days of menses.
• Postabortion: when the abortion is uncomplicated, without sepsis or perforation.
• Delay between 7 and 42 days postpartum.

Switching. Pills: operate at once and finish the pack. Injectable: operate before the next injection is due. Intrauterine device in the first 7 days of menses: remove and operate with no backup. Later in the cycle: operate and keep the device until the next menses.

Technique steps (minilaparotomy). Empty bladder, sterile preparation, local infiltration, small suprapubic incision for interval cases or infraumbilical incision after birth, identify and deliver each tube, confirm by seeing the fimbria, occlude, return the tube, close in layers.

Documentation and limits. Signed consent on the file. One surgeon performs no more than 15 procedures in a day and one operating room no more than 30.

Follow up. Observe until recovered, discharge when walking and passing urine. Wound review within 2 weeks. Return for fever, wound discharge, severe pain, missed menses or fainting.

Expected effects. Incisional pain for several days, shoulder pain after laparoscopy for up to 72 hours, mild bruising.

Wound infection regimen. Cefalexin 500 mg orally every 6 hours for 5 to 7 days, maximum 4 g daily. When creatinine clearance is 15 to 29 mL/min give 250 mg every 8 to 12 hours, and under 15 mL/min give 250 mg every 24 hours. No liver adjustment is needed. It is compatible with breastfeeding. In severe penicillin or cephalosporin allergy give clindamycin 300 mg orally every 6 hours for 5 to 7 days, maximum 1.8 g daily, and watch a breastfed infant for diarrhoea.

Analgesia. Paracetamol 1 g orally every 6 hours, maximum 4 g daily (3 g daily in liver disease or weight under 50 kg). Add ibuprofen 400 mg orally every 8 hours with food for up to 3 days, maximum 1.2 g daily, and avoid it in creatinine clearance under 30 mL/min, peptic ulcer or anticoagulant use. Both are compatible with breastfeeding.

Referral and escalation. Refer suspected visceral injury, uncontrolled bleeding, peritonitis, ruptured ectopic pregnancy, or any patient requiring care beyond the facility’s theatre and anaesthesia capacity.