Interval Tubal Sterilization

Interval tubal sterilisation is tubal occlusion done at a time unrelated to pregnancy: not within 7 days of birth, not at the time of abortion and not during caesarean section. It is performed from 42 days after birth onward, by minilaparotomy under local anaesthesia or by laparoscopy. It is a permanent method with no hormonal effect.

Mechanism. The tube is interrupted so that sperm and ovum cannot meet.

Effectiveness. First-year pregnancies are 0.5 per 100 women with typical use and 0.5 per 100 women with perfect use. Protection begins at once and lasts for life. Failure risk persists over years and is higher in women under 30 at the time of the procedure.

Return to fertility. None is expected. Reversal is not assured.

Menses. Cycle length, flow and ovarian function are unchanged. Women switching from hormonal methods return to their own pattern.

Ideal candidates. Women who have completed their family, have made a voluntary and informed choice, and are not pregnant.

History. Reproductive intentions, parity and age of the youngest child, relationship stability, previous pelvic or abdominal surgery, pelvic infection, bleeding pattern, medicines and allergies, previous anaesthetic reactions.

Examination. Blood pressure, weight, cardiorespiratory examination when indicated, abdominal examination for scars and hernia, bimanual pelvic examination for uterine position, size and mobility.

Investigations. Pregnancy test when not reasonably certain of non-pregnancy. Haemoglobin when anaemia is suspected. No routine blood tests otherwise.

Class assignment.

• Delay: young age with no children, current pelvic inflammatory disease, unexplained vaginal bleeding, current deep vein thrombosis, acute respiratory or systemic infection, abdominal skin infection, haemoglobin under 7 g/dL, sickle cell disease, active hepatitis, gynaecological cancer.
• Special: fixed uterus or suspected adhesions (avoid laparoscopy), hernia, pelvic tuberculosis, blood pressure 160/100 or higher, diabetes with vascular disease, coagulation disorders, anticoagulant use, chronic respiratory disease, AIDS, local anaesthetic allergy.
• Caution: obesity, controlled hypertension, uncomplicated diabetes, epilepsy, depressive disorders, previous pelvic surgery, anaemia, kidney disease.

Special groups. Women living with HIV at clinical stage 1 or 2 are eligible in a routine setting, and advanced disease needs a delay or referral. Women with sickle cell disease need delay for optimisation. Adolescents under 18 years give assent and need consent in line with the law, and age alone does not bar the procedure but young age with no living children calls for delay of up to one month.

Regimen line. Procedure: minilaparotomy or laparoscopic occlusion by partial salpingectomy, clip or ring. Anaesthesia: lidocaine 1% (10 mg/mL) infiltrated about 5 minutes before incision, up to 4.5 mg/kg without adrenaline (maximum 300 mg, 30 mL) or up to 7 mg/kg with adrenaline (maximum 500 mg), with less in liver disease. Protection: immediate and lifelong. Backup: none after the procedure. Late or missed use rules: not applicable.

Timing in the cycle. Any day once pregnancy is excluded. Ideal timing is the first 7 days of menses, when pregnancy is least likely and no test is needed.

Pregnancy exclusion. No intercourse since last menses, consistent 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.

Switching.

Preparation. Written consent confirmed, bladder emptied, sterile skin preparation, instruments and emergency drugs ready, venous access for patients with comorbidity.

Choice of route. Minilaparotomy needs a small suprapubic incision and an elevator in the uterus, and suits most facilities with a minor theatre. Laparoscopy needs a trained surgeon, insufflation equipment and usually general anaesthesia or deep sedation, and is avoided with a fixed uterus.

Recovery and follow up. Observe until the patient is walking, comfortable and passing urine. Advise rest for 1 to 2 days, no heavy lifting for 1 week, and sex when comfortable. Wound review within 2 weeks. Return urgently for fever, wound discharge, worsening abdominal pain, fainting or a missed period.

Expected effects. Incision pain, mild bruising, shoulder pain after laparoscopy for up to 72 hours, bloating from gas.

Complications. Anaesthetic reaction, bleeding, haematoma, wound infection, bladder, bowel or vascular injury, gas embolism at laparoscopy (rare), ectopic pregnancy after failure.

Wound infection. Cefalexin 500 mg orally every 6 hours for 5 to 7 days, maximum 4 g daily, reducing to 250 mg every 8 to 12 hours when creatinine clearance is 15 to 29 mL/min and 250 mg every 24 hours under 15 mL/min. For severe penicillin allergy give clindamycin 300 mg orally every 6 hours for 5 to 7 days, maximum 1.8 g daily. Drain an abscess. Compatible with breastfeeding.

Pain. Paracetamol 1 g orally every 6 hours, maximum 4 g daily (3 g in liver disease or under 50 kg), with or without ibuprofen 400 mg every 8 hours with food for up to 3 days, maximum 1.2 g daily, avoided in creatinine clearance under 30 mL/min. Persistent or worsening pain needs examination for infection, haematoma or visceral injury.

Failure. Missed period or pelvic pain after the procedure needs a pregnancy test. If positive, exclude ectopic pregnancy by ultrasound and serial hCG.

Referral and escalation. Refer visceral injury, haemodynamic instability, suspected ectopic pregnancy and Special class patients when the team or anaesthesia capacity is lacking.