The document provides an overview of female sterilization methods, highlighting the historical context, various techniques employed, and their associated failure rates. It discusses the demographics of women opting for these procedures, as well as considerations and potential regrets following sterilization. The findings emphasize the importance of informed consent and the permanent nature of these methods.

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PERMANENT METHOD
OF FAMILY PLANNING
Dr. Subha Shrestha
Obgy dept.
COMS

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Learning objectives:
• Female Sterilization Overview
• Methods of Female Sterilization
• Studies and Findings: Sterilization failure rate, Ectopic
pregnancy rate with failure
• Other Considerations
• Summary of Female Sterilization

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Overview:
• Younger women (ages 20-29) are more likely to
undergo postpartum sterilization procedures
• Approximately 50% of the tubal ligations
performed annually are postpartum
• Most postpartum procedures are performed
within 24 hours
• Older women (ages 35-49) are more likely to
undergo interval procedures

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Overview:
• Younger women (ages 20-29) are more likely to undergo
postpartum sterilization procedures
• Approximately 50% of the tubal ligations performed
annually are postpartum
• Most postpartum procedures are performed within 24
hours
• Older women (ages 35-49) are more likely to undergo
interval procedures

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The History of Female Sterilization
• 1823 – First proposed by James Brundell in
London
• 1880 – First published report of procedure by
Lungren in Toledo, Ohio
• 1930 – First publication of the Pomeroy
Technique, Pomeroy, New York State Journal
of Medicine
• 1936 – Bosch performed the first laparoscopic
tubal occlusion in Switzerland

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• Increased interest in family planning coupled
with safer and more effective methods
allowed sterilization to become a viable
method of contraception.
• Widespread acceptance of laparoscopy led
to the development of several methods
• Electrocautery (mono-polar and bi-polar)
• Clips (Hulka and Filshie)
• Bands (Yoon Band, Falope Ring)

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Female Sterilization Overview
Anatomy
Ampulla
Isthmus
Fimbria
Infundibulum

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Methods of Female Sterilization
Interval
• Laparoscopic
• Electrocoagulation (Mono
and Bi -Polar)
• Falope Ring
• Hulka Clip
• Filshie Tubal Ligation
System
• Hysteroscopy
• Essure
• Adiana
Post Partum/ Labor & Delivery
• Pomeroy
• Parkland
• Irving
• Uchida
• Filshie Tubal Ligation System

9. Procedure Timing Technique
Minilaparotomy • Post Partum
• Post Abortion
• Interval
• Mechanical Devices
(Clips, Rings)
• Tubal Ligation or
Excision
Laparoscopy • Interval Only • Electrocoagulation
(Unipolar, Bipolar)
• Mechanical Devices
(Clips, Rings)
Laparotomy In conjunction with
other surgery
(Cesarean section,
salpingectomy, ovarian
cystectomy, etc.)
• Mechanical Devices
(Clips, Rings)
• Tubal Ligation or
Excision
1
Female Sterilization In: Landry E, ed. Contraceptive Sterilization: Global Issues and Trends. New York: Engender Health; 2002: 139-
160
Methods of Female Sterilization1
Since 2002, hysteroscopic methods are available and can be performed
interval-only (Essure and Adiana).

10. Methods of Female Sterilization
Laparoscopic
• Proposed in 1937 by
Anderson
• Complications
• Bowel Burn
• Bleeding
• Longer portion of tube is
damaged
• Failures and ectopic
pregnancy
• Transection is frequent
1
Peterson LS Contraceptive use in the United States: 1982 -90. Advance Data: From Vital Health
Statistics February 1995; 260 1-8
Failure Rate: 7.5/1000 (.07-.75%)1
Monopolar Coagulation

11. Methods of Female Sterilization
Laparoscopic
• Introduced in 1973 by
Jacques Rioux
Benefits
• Most common method of
laparoscopic sterilization
• Burn several locations along
the tube
Complications
• Formation of uteroperitoneal
fistulas
• High rate of ectopic
pregnancy
• Potential for bowel burns
• Reversals are potentially
more difficult due to the
extent of tube damage
1 Peterson HB, et al. The risk of pregnancy after tubal sterilization: Findings from the U.S. Collaborative
Review of Sterilization. Am J obstet. Gynecol. 1996; 174 (4):1161-1170
Failure Rate:
24.8/10001
(.2-2.5%)
Bipolar Coagulation

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Methods of Female Sterilization
Destruction of the Entire Fallopian Tube: “Three Burn” Technique

13. Methods of Female Sterilization
Laparoscopic
• Mechanical occlusion invented in
1974
• Tubal occlusion accomplished by
placing a silicone band around
the tube in a similar fashion to
Pomeroy-technique
• Thicker tubes may be
problematic
• May not be suited for postpartum
Complications
• Increased patient discomfort
during recovery – large area of
necrosis
1
Peterson HB. Et al. The risk of Pregnancy after tubal sterilization: Findings from the U.S. Collaborative Review
of Sterilization. Am Journal of Obstetrics and Gynecology. 1996; 174(4): 1161-1170
Falope Ring (Yoon band)
Failure Rate: 17.7/10001
(1.8%)

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Methods of Female Sterilization
Falope Ring/Yoon Band

15. Methods of Female Sterilization
Laparoscopic
• Tubal occlusion is
accomplished by placing a
spring clip (plastic and
gold plate) across the
fallopian tube
• Hulka clip has limited tubal
capacity
• Not magnetically inert
• Potential patient allergy
due to gold plate
1
Pregnancy After Tubal Sterilization with Bi-Polar Electrocoagulation. Obstetrics and GYN. August 1999
Volume 94. Herbert B Petterson et al for the CREST Working Group
Failure rates 36.5/1000 (3.7%) (Ectopic 8.5/1000)1
Hulka Clip

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Methods of Female Sterilization
Hulka Clip

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Methods of Female Sterilization
Hulka Clip

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Laparoscopic and Minilapararotomy
• FDA approved in 1996 (post CREST
study)
• Tubal occlusion accomplished by placing
a titanium hinge clip lined with silicone
rubber across the fallopian tube
• Large tubal capacity
• Magnetically inert (okay for MRI)
• Minimal post operative pain
• Designed for use interval and post
partum (post vaginal birth and at the
time of C-section)
• Clip migration rare but possible
Methods of Female Sterilization
1 A Penfield, MD. The Filshie Clip for Female Sterilization: A Review of World Experience. American Journal of
Obstetrics and Gynecology, March 2000
2 Failure Rates from Family Health International, used in the initial FDA PMA Submission for the Filshie Clip
Filshie®
Tubal Ligation System
Failure rate of 2.7/1,000 (.27%)1,2

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Methods of Female Sterilization
Filshie®
Clip – Laparoscopy

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Methods of Female Sterilization
Filshie®
Clip – Laparoscopy

21. Methods of Female Sterilization
Hysteroscopic (Hospital and Office-based
procedure)
• Approved in 2002
• Micro-insert placed into each tube, PET fibers
stimulate in-growth over several weeks
• 86% Success Rate for 1st
time placements of
micro-inserts
• 3 months of alternative contraception until
HSG procedure confirms occlusion
• Not suitable for patients with known allergies
to contrast media or hypersensitivity to nickel
• Irreversible
• May limit a patients ability to have in vitro
fertilization, should patient change her mind
• May limit the ability to perform endometrial
ablation in the future
• ACOG does not recommend
concomitant endometrial ablation
FDA. Essure System: Summary of Safety and Effectiveness. November 4, 2002 available at
http://www.fda.gov/cdrh/pdf2/p020014b.pdf 1
UpToDate – Hysteroscopic Sterilization; Jan 2010
Essure®
Failure rate .26%1
(5 year rate)

22. Methods of Female Sterilization
Hysteroscopic (Hospital and
Office-based procedure)
• Approved in 2009
• Catheter delivers low RF energy for
one minute then a 3.5 mm non-
absorbable silicone elastomer matrix
is placed in each tubal lumen
• 3 months of alternative contraception
until HSG procedure confirms
occlusion
Photograph from Adiana website
1
Adiana Transcervical Sterilization System PMA P070022 Draft Panel Discussion Questions, p.2, December 14, 2007.
Adiana®
Failure rate 1.8%1
(2 year rate)

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Methods of Female Sterilization
Postpartum
• Pomeroy
• Parkland
• Irving
• Uchida
• Filshie®
Tubal Ligation System

24. Methods of Female Sterilization
Developed in 1930 by Ralph
Hayword Pomeroy
• Incision – suprapubic and
subumbilical (PP)
• Isthmic portion is ligated twice
with 0 or 2-0 plain catgut suture
• Segment is then excised
• Inspect for hemostasis and the
presence of the tubal lumen
Benefits
• Easy technique
• Highly effective
• Relatively inexpensive (excluding
lab costs for pathology)
Complications
• Infection and bleeding
• Potential ectopic pregnancy
1
Pregnancy After Tubal Sterilization with Bi-Polar Electrocoagulation. Obstetrics and GYN. August
1999 Volume 94. Herbert B Petterson et al for the CREST Working Group
Pomeroy Technique
Tied
Cut
Final result
Failure Rate: 7.5/1000

25. Methods of Female Sterilization
Introduced in the 1900s
• Isthmic portion of tube is
segmented and ligated at
two points
• An avascular area in the
mesosalpinx is opened
• 0 or 2-0 plain catgut passed
through the opening
• Proximal and distal ligated
and segment excised
Parkland Technique
Failure rate not reported1

26. Methods of Female Sterilization
Benefits
• Designed to reduces
natural tube re-attachment
• Good success rates
• Few complications
• Inexpensive to perform (if
no pathology)
Complications
• Ectopic pregnancies,
infection, bleeding
• Time required to perform
procedure properly
Parkland Technique (continued)
Failure rate not reported1

27. Methods of Female Sterilization
Method published in 1924
• Was developed for sterilization
at C/S
• Bury the proximal tubal stump
within the myometrium
• Original description – distal tube
buried in the broad ligament
Benefits
• Used in conjunction with
cesarean delivery
Complications
• Moderate level of difficulty to
perform
• Pomeroy and Parkland are
quicker
1. Sterilization. The University of Kentucky Department of OB-GYN Women’s Health Curriculum.
Irving Technique
Failure rate: 1/10001
1 Up to Date – Sept 2010, Stovall T. et al. Surgical Sterilization of Women

28. Methods of Female Sterilization
Introduced by Hajime Uchida in the
1940s
• Most complex method
• Inject saline into the subserosal layer
2 cm distal to the cornua
• Incise serosa to free a 2 to 3 cm
segment
• Ligate proximal and distal end of
freed tube
• Proximal tube “dunked,” distal is
“exteriorized” and serosa is then
closed
Benefits
• Can be performed immediately
postpartum
Complications
• Moderate level of difficulty to perform
• Pomeroy and Parkland are quicker
1 Sklar AJ. Tubal Sterilization. eMedicine. November 15 2002. Available at
http://www.emedicine.com/med/topic3313.htm
Failure rate: more than 20,000 cases
performed by Uchida personally without
a failure 1
Uchida Technique

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• At the time of C-section or
minilaparotomy Post Vaginal Birth
• FDA approved in 1996 (post CREST
study)
• Tubal occlusion accomplished by placing
a titanium hinge clip lined with silicone
rubber across the fallopian tube
• Large tubal capacity
• Minimal post operative pain
Methods of Female Sterilization
Filshie®
Tubal Ligation System
Failure rate range: 0-
1.15% *
* Olgibo N. Pomeroy technique or Filshie clips for postpartum sterilisation? Retrospective
study on comparison between Pomeroy procedure and Filshie clips for a tubal occlusion
at the time of Caesarean Section. Arch Gynecol Obstet, 11 Dec 2009
* Yan J.S., Hsu J. and Yin C.S. Comparative study of Filshi e clip and Pmeroy method for
postpartum sterilization. Int. J. Gynecol. Obstet., 1990, 33: 263-267

30. Methods of Female Sterilization
Filshie®
Clip: Postpartum Sterilization (Mini-laparotomy)

31. Methods of Female
Sterilization
Filshie®
Clip: Postpartum Sterilization (Cesarean)

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Methods of Female Sterilization
Postpartum: Filshie®
in place

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Methods of Female Sterilization
Randomized Trial to compare perioperative outcomes of
Filshie clip vs. Pomeroy technique for postpartum and
intraoperative Cesarean tubal sterilization: a pilot study.
Kaunitz et al
• 32 Randomized Patients were sterilized by Filshie Clip or
Pomeroy
• Filshie mean duration 7 min faster (p=0.08)
• Filshie rated as easier by the operator (p=0.03)
• 70% of surgeons preferred the Filshie clip
Filshie®
Tubal Ligation System and Pomeroy Postpartum

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Studies and Findings
MATERIALS AND METHODS
• 10,685 WOMEN STERILIZED (1978-1986)
• MEDIAN AGE: 30 years old
• FOLLOW-UP: 8-14 years
• METHODS OF STERILIZATION:
• Yoon band 31.2 %
• Bipolar 21.2 %
• Postpartum 15.3 %
• Hulka clip 14.9 %
• Unipolar 13.4 %
The U.S. Collaborative Review of Sterilization (CREST )

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Studies and Findings
RESULTS: Failure Rates
• 34 Luteal phase pregnancies
• 143/10,685 True failures (1.34%)
• 15% Spontaneous abortion
• 18% Induced abortion
• 29% Deliveries
• 3% Ongoing pregnancy at time of study
• 33% Ectopic pregnancy
• 2% Status unknown
Findings from CREST

36. Studies and Findings
0/30,000**
procedures
0.22%**
Filshie®
Clip
17.1/1000*
procedures
2.4%*
Bipolar Cautery
1.5/1000*
procedures
0.75%*
Pomeroy (PP)
Ectopic Preg
Failure rate
Method
* The Risk of ectopic Pregnancy after tubal sterilization, Peterson H. NEJM March 13, 1997
** Kovacs et al. Female Sterilization with Filshie clips: What is the risk of failure? A retrospective survey of 30,000 applications. J. of
Family Planning and Reproductive Health Care. 2002: 28(1): 34-35
Most Common Methods Failure Rates and Ectopic Pregnancy

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Studies and Findings
• CREST – 10,685 women followed for 8-14 years
• Devices
• RF – monopolar and bipolar
• Banding – Falope Ring
• Clip – Hulka Spring Clip
• Partial Salpingectomy – interval and postpartum
• Failure Rates – 1.38%
• IUP
• Ectopic*
• “Although tubal sterilization is highly effective, the risk of
sterilization failure is higher than generally reported.”
Major Studies
* Pregnancy After Tubal Sterilization with Bi-Polar Electrocoagulation. Obstetrics and GYN. August 1999
Volume 94. Herbert B Petterson et al for the CREST Working Group

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Other Considerations
Discussion with patient must take place and cover the following
details:
• It must be a voluntary decision
• Discussion of other options
• Discussion of method of sterilization
• Sterilization is permanent
• Must be 21 years of age or older
• Probability of failure
• Discussion about methods of contraception for prevention of STDs
• Special consideration for women with mental disabilities
Informed Consent
Information taken from the Dept. of Health and Human Services Form: http://www.hhs.gov/forms/HHS-687.pdf

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Other Considerations
Women may experience regret post-procedure
• 2-26% of women express regret post-sterilization
• 1-2% will seek reversal
• Sterilization is permanent
• Association with age at time of sterilization, change in
marital status and future regret
• Requests for reversals and/or IVF possible
Regret
* Chi, I.C., Jones D.B. Incidence, risk factors, and prevention of poststerilization regret: an updated international review
from an epidemiological perspective. Obstet Gynecol Surv 1994;49:722-32
* Van Voorhis BJ. Comparison of tubal ligation reversal procedures. Clin Obstet Gynecol 2000;43:641-9 Curtis, K.,
Mohllajee, A.P., and Peterson, H.B. Regret Following Female Sterilization at a Young Age: A Systematic Review.
Contracep 2006;73:2. P 205-210

40. Other Considerations
• All surgical tubal occlusion
procedures are considered to
be permanent female
sterilization methods.
• Changes in lifestyles and life
situations among some women
has led to instances of regret
after sterilization regardless of
the method used.
• The application of the
Filshie®
clip in tubal ligation
results in an avascular
necrotic segment of the
fallopian tube of about 4 mm.
• The result is complete tubal
occlusion with minimal tubal
damage.
Reversibility

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Summary of Female Sterilization
• Tubal occlusion is an effective method of female
sterilization regardless of method chosen
• Failures will occur in some percentage female
sterilization procedures regardless of method utilized.
• IUP
• Ectopic Pregnancy

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Male Sterilization
• Safe and permanent birth control procedure
• US: 1 of 5 men over age 35 has had a vasectomy
• 500,000 vasectomies in the US each year
• 4 million world wide each year
• Cost (US) of procedure $500-$1000
Vasectomy

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Female Sterilization
• A surgical procedure
About female sterilization:
• Fallopian tubes that carry eggs to the womb are blocked or
cut and sealed (womb is left untouched).
• May hurt for a few days after.
• Usually woman not put to sleep but gets injection to prevent
pain.
• Usually can go home in a few hours.
• Usually cannot be reversed.
• “Please consider carefully: might you want children in the
future?”
• Ask about partner’s preferences or concerns.
• Vasectomy might be another good choice. Vasectomy is
simpler and safer to perform and slightly more effective.
• One of the most effective family planning methods for
women.
• Very rarely, pregnancy does occur.
• For STI/HIV/AIDS protection, also use condoms.
• Serious complications of surgery are rare (risk of
anaesthesia, need for further surgery).
“Do you want to know more about sterilization, or talk about a different method?”
If client wants to know more
about sterilization, go to next
page.
Next Move:
• Permanent—for women who
will not want more children
• Very effective
• No long-term side-effects
• No protection against STIs
or HIV/AIDS
• Very safe
• Check for concerns, rumours:
“What have you heard about problems with sterilization?”
Use Appendix 10 to talk about myths about contraception.
• Explain that all women can have sterilization if they want,
even those with no children.
• Womb is NOT removed.
You will still have menstrual
periods.
S1
Female
Sterilization
To discuss another method, go
to a new method tab or to
Choosing Method tab.

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When you can have
sterilization
But may need to wait if:
Most women can have
sterilization at any time
• May be
pregnant
• Gave birth
between 1 and
6
weeks ago
• Infection or
other problem
in female
organs
• Some other
serious health
conditions

45. dr subha/8th sem pbl 45
Thank you
for
your
attention