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  • postpartum TL may have slightly higher failure rate vaginal TL is effective, but limited by inc risk infection hysterectomy is no longer recommended as a primary means of sterilization in the absence of additional indications. Rare pregnancies have resulted post-hysterectomy fimbriectomy-higher failure rate, hydrosalpinx formation hysteroscopic monopolar electrosurgery used to be done and was technically not very difficult, but was abandoned due to cornual perforations and bowel burns. Discuss bipolar vs monopolar, and higher failure rate w bipolar
  • cutting waveform better than coag ammeter not always reliable failures require reoperation, with attention directed towards proximal stump avoid surgery close to cornua-higher fistula rate
  • sterilization

    1. 1. David Blair Toub, M.D. Dept. of Obstetrics and Gynecology Pennsylvania Hospital
    2. 2. Overview: <ul><li>most reliable form of contraception </li></ul><ul><li>most prevalent form of contraception in US (~25% of couples) </li></ul><ul><li>60:40 female-male ratio </li></ul><ul><li>considered permanent </li></ul>
    3. 3. Considerations: <ul><li>?postpartum procedure </li></ul><ul><li>?is patient certain of decision </li></ul><ul><li>number of children, stable relationship </li></ul><ul><li>operative risk </li></ul><ul><li>failure rate and potential complications </li></ul><ul><li>MA: 30 waiting period (72h if preterm delivery), 21 yo minimum with parity </li></ul>
    4. 4. Potential Benefits: <ul><li>Reliable contraception </li></ul><ul><li>Reduced ovca risk </li></ul><ul><li>Reduced PID risk </li></ul><ul><li>Reduced endometriosis risk </li></ul>
    5. 5. Complications: <ul><li>failure (1:200 on average, higher for bipolar electrosurgery, clip methods) </li></ul><ul><li>ectopic pregnancy (~50% of pregnancies) </li></ul><ul><li>surgical/anaesthesia risks </li></ul><ul><li>chronic pelvic pain, menstrual abnormalities </li></ul>
    6. 6. Options: <ul><li>Pomeroy * </li></ul><ul><li>Modified Pomeroy * </li></ul><ul><li>Uchida * </li></ul><ul><li>Irving * </li></ul><ul><li>Kroener Fimbriectomy * </li></ul><ul><li>Electrosurgery </li></ul><ul><li>Fallope Ring </li></ul><ul><li>Hulka Clip </li></ul><ul><li>Hysteroscopic Occlusion </li></ul><ul><li>Vasectomy (male) </li></ul>* can be done immediately postpartum laparoscopic
    7. 7. The Filshie Clip: <ul><li>Recently approved in US by FDA </li></ul><ul><li>Relatively simple to learn, more reliable than other clip methods </li></ul><ul><li>Combines benefits of Fallope Ring and Hulka Clip </li></ul>
    8. 8. CREST Study, 1996: <ul><li>Multicenter, prospective cohort study </li></ul><ul><li>Failures can occur many years postop </li></ul><ul><li>Identified higher failure rates than previous reports </li></ul><ul><li>Postpartum and monopolar much better than bipolar, clip and ring methods </li></ul><ul><li>No evidence found to support post-tubal ligation syndrome </li></ul>Peterson, HB, et al Am J Obstet Gynecol 1996;174:1161-1170
    9. 9. Ten-Year Cumulative Probability of Pregnancy (per 1000 procedures) method 24.8 7.5 17.7 36.5 20.1 7.5 18.5 probability per 1000 procedures
    10. 10. Tubal Ligation Failures: <ul><li>tubo-peritoneal fistula formation </li></ul><ul><li>surgical misadventure (round ligament ligation) </li></ul><ul><li>inadequate coagulation </li></ul><ul><li>failure to excise entire lumen </li></ul><ul><li>pathology is advisable </li></ul>
    11. 11. Management of TL Failures: <ul><li>Notify original surgeon </li></ul><ul><li>Counsel patient re: need for resterilization </li></ul><ul><li>Chromopertubation </li></ul><ul><li>Resect tube (esp proximally) and send for path with Trichrome stain </li></ul><ul><li>Avoid “tubal litigation” </li></ul>
    12. 12. Monopolar Vs. Bipolar Electrosurgery: <ul><li>lower </li></ul><ul><li>no difference </li></ul><ul><li>yes </li></ul><ul><li>higher </li></ul><ul><li>no difference </li></ul><ul><li>no </li></ul>monopolar bipolar failure rate risk of bowel burns ground needed?
    13. 13. Strategies to Minimize Bipolar Electrosurgery Failures: <ul><li>Use cutting, rather than coagulation waveform </li></ul><ul><li>Dessicate Ќ 3 contiguous portions of the isthmus </li></ul><ul><li>Utilize an ammeter to confirm resistance to electron flow </li></ul><ul><li>25 W current against 100 ћ load </li></ul>Soderstrom RM, Levy BS, Engel T. Obstet Gynecol 1989;74:60-3
    14. 14. Vasectomy: <ul><li>~ 500,000 / year in US </li></ul><ul><li>?? increased risk prostate ca </li></ul><ul><li>complications : hematoma, epididymitis, failure, infection </li></ul><ul><li>may be done in clinic setting </li></ul><ul><li>two semen analyses must confirm azoospermia (1-2 months postop) </li></ul><ul><li>generally safer than TL </li></ul>
    15. 15. Tubal Reanastamosis <ul><li>~2% of sterilized women desire reversal </li></ul><ul><li>~25% of sterilized women regret their decision (especially if done < 30 yo) </li></ul><ul><li>Success rate (avg) = 60% </li></ul><ul><li>Best rates with Uchida </li></ul><ul><li>May be done via laparotomy or laparoscopy </li></ul>
    16. 16. Secondary Sterilization: <ul><li>hysterectomy, bilateral salpingo-oophorectomy </li></ul><ul><li>RT </li></ul><ul><li>hypophysectomy </li></ul><ul><li>PID, other tubal diseases </li></ul>
    17. 17. Conclusions: <ul><li>Sterilization is effective, reliable contraception </li></ul><ul><li>Surgical technique and choice of procedure influences success rates </li></ul><ul><li>Many patients under 30 will ultimately desire reversal </li></ul><ul><li>Laparoscopy has revolutionized female TL </li></ul><ul><li>Monopolar electrosurgery and postpartum TL fail less often than clip, ring, interval and bipolar methods </li></ul>