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MRCOG PART 2 SBAs and EMQs

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ESSAY 174 - Sterilisation

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		Posted by Srivas P. Fri Jan 6, 2006 01:50 pm
The woman should be told that sterilization is a permanent method of contraception. It is necessary to ensure that she and her partner have weighed the pros and cons of the procedure, told about various methods to achieve it?minilaprotomy versus laproscopic methods, the pros and cons of both these procedures, potential risks and complications involved etc. The couple should be told about other methods of long-term contraceptive methods like copper IUD?s, Mirena, implants and male sterilization, with advantages, disadvantages and relative failure rates of each method. The female sterilization has higher failure rate of 1: 200 compared to failure rate of 1:2000 for vasectomy. Vasectomy is simpler, needs no timing, more easily and successfully reversed compared to female sterilization while female sterilization should be done in early follicular phase, may need hospitalization, complication may involve laprotomy and reversal involves major surgery and also has lower success rate of reversal of around 60 % compared to male reversals of around 80%. Woman should however be counseled against sterilizations if she contemplates possibility of reversal operations later. If the woman is very obese or has had repeated abdominal surgeries with possibility of adhesions, she may end up with Laprotomy. She may be offered male sterilization as a better. alternative. She should be told that sterilization could be done, as daycare procedure if surgeon trained in laproscopy and the necessary equipment is available. This can be done under General or local anaesthesia and should preferably be at least 6weeeks after her previous delivery so that complication and failure rates are minimum. Minilaprotomy will need admission in hospital for 3-4 days. She should use contraception till the day of sterilization and up to next menstrual cycle, as wrong timing in luteal phase can be one of the causes for failed sterilization. If sterilization is timed soon after delivery and the tubes are edematous the chances of failure are more. Also inexperienced doctor may identify wrong structure and may ligate the round ligaments or other structures and not the fallopian tubes. If the whole circumference of the tube is not taken in ligature or ring or filshie clip, this too may cause failed sterilization. The legal implications of failed sterilization can be enormous for the doctor concerned and psychologically demoralizing for the patient. Hence counseling should be complete and notes should be recorded systematically.
		Posted by Sreekala S. Fri Jan 6, 2006 11:33 pm
Female sterilization is a permanent method of contraception which involves occlusion of the fallopian tubes and impedes the sperm transport to ampulla of the tube and prevents fertilization. The woman should be adequately counselled regarding the procedure, failure rates, possible complications and the other alternatives to the procedure. She should be asked if she was sure of the decision as it would be a permanent procedure and cannot bear any more children in the future after it. The alternatives to female sterilization like vasectomy, long acting reversible contraceptive methods like the implants, injectables and the levonorgestrel intrauterine system should be discussed. Majority of the female sterilizations are performed as a day case procedure under general anaesthesia although it can be performed under local anaesthesia. Although the failure rate of the female sterilization depends on the age of the woman and the type of occlusion undertaken , the overall failure rate is 1 in 200 as compared to 1 in 2000 for vasectomy. It is estimated that about one third of pregnancies resulting from failure of female sterilization result in Ectopic pregnancy. Most of the female sterilization procedures are undertaken laparoscopically and carry the risk of bowel injury (0.4/1000) and major vessel damage (0.2/1000) and may need laparotomy if complications arise. She should be made to understand that compared to vasectomy , female sterilization carries 10 times higher risk of failure rate and 20 times higher risk of major complications and needs general anaesthesia while vasectomy can be performed under local anaesthesia. As female sterilization is a permanent method, the reversibility of sterilization is a difficult procedure with a low success rate about 30-70% re-anastamosis rates with a high probability of resulting in an ectopic pregnancy later. Also, reversal of sterilization may not be funded by the NHS under usual circumstances as she is a mother of 4 children. A detailed history and examination should be undertaken in the clinic to assess her suitability for the sterilization to be done under general anaesthesia if she wants to go ahead for it after the discussion. Her obstetric history, past medical/surgical history and medications should be taken. Abdominal examination should be done to look for any abdominal masses or operative scars and BMI should be recorded to assess her suitability for laparoscopy. She should be provided with the RCOG patient information leaflet on ?Sterilization for women and men : what you need to know? and arrange for further appointments if she wishes and opportunity should be provided to ask any questions. She needs someone to accompany her home in the evening after the procedure as she may feel drowsy and may require time off work for about 2-3 days depending on her recovery. Advice should be given about effective contraception which she needs to use until the surgery and continue until the next period after the procedure to avoid pregnancy. Informed consent should be taken and documentation of the discussion should be made in the notes. Failed sterilization has implications both to the NHS with regards to litigation and also to the woman and her family as pregnancy after sterilization is associated with psychological trauma and emotional upset. Therefore, measures should be taken to prevent failure of sterilization. Failed sterilization can occur under 3 circumstances: Firstly, Pre-existing pregnancy which may be due to luteal phase pregnancy in the current cycle or due to conception in previous cycles. Secondly, early failures may be due poor technique resulting from partial occlusion of tubes, application to wrong structures(round ligament instead of the fallopian tube), faulty equipment or spillage of occlusive clips. Thirdly the later failures are due to recanalization of the tubes which cannot be prevented. To prevent pregnancy following sterilization, it is advisable to undertake the sterilization in the follicular phase of the cycle as close to the period as possible. But, it may not be practical for the woman or the service providers. Adequate contraceptive advice should be given to the woman pre-operatively which needs to be used until the surgery and continued until the next period. If the woman has been using combined oral contraceptive pills then she should be advised to finish the current packet; if on the mini pill then she should continue until the end of the packet or next period whichever is earlier. If she has an intra uterine contraceptive device, then she should get it removed at the next period., if using the LNG system then she should get it removed at least 7 days after the sterilization procedure. If she insists for the intra uterine contraceptive device to be removed at the same time as the sterilization procedure, then she should be advised to use a contraceptive pill during that cycle and continue until the next periods or use barrier method of contraception. There is no evidence to suggest that oral contraceptives if used before the sterilization increases the likelihood of thrombo-embolism. Urine pregnancy test should be done on the day of the surgery although a negative cannot always rule out a pregnancy. She should be seen on the day of the surgery by the surgeon performing it and a detailed history should be taken about her menstrual period/LMP, sexual history and contraception and the consent form counter signed by the surgeon. The procedure should be postponed if there is any suspicion of pregnancy or delayed periods. Adequate training should have been undertaken by the person performing the surgery to prevent the failure rates. RCOG recommends atleast 25 sterilization procedures to be performed under supervision by a trainee to be able to perform it without supervision.
		Posted by adnan S. Sat Jan 7, 2006 08:43 am
Sterlisation (tubal occlusion) remains a popular method of contraception despite the increase availability of acceptable long acting reversible methods. I will inform her that sterlisation is intended to be permanent.The reversal and treatments like IVF and ICSI may not be available on the NHS.The intrauterine pregnancy rate of reversal of sterlisation is between 31 -92% with an ectopic pregnancy rate of 0-7%.Iwill inform her other methods of long term reversible contraception like CuT380A and LNG-IUS.The cumulative pregnancy rate after 12 years with CuT380Ais 1.9% and after 5 years with LNG-IUS is 1.1%. Iwill inform her other option like vasectomy,which carries lower failure rate of 1:2000 than tubal sterlisation 1:200life-time,and carries fewer risks.Tubal ligation is associated with risk of ectopic pregnancy if fails,hence she should be advice to seek medical advice if thinks she is pregnant,or abnormal abdominal pain,or vaginal bleeding.Risk of ectopic pregnancy is lower after sterlisation as compare to non sterlisation. Iwill inform the different methods like laproscopy and mini- laprotomy. Hystroscopic methods are under evaluation,culdoscopy is not used because of unacceptably high incidence of technical difficulty and major complications.Laproscopic approach to the fallopian tubes is quicker and results in less minor morbidity compared with mini-laprotomy with no significant difference in major morbidity.The risk associated with laproscopy are possibility of requiring laprotomy particularly if previous abdominal surgery or obesity. Iwill inform her that tubal ligation is not associated with increase risk of menorrhagia.There is an association with increase hysterectomy rates,although there is no evidence that tubal occlusion leads to problems that require a hysterectomy. There is no increase in testicular cancer or heart disease associated with vasectomy,but there is possibility of chronic testicular pain.Although not a legal requirement better to involve her partner in the decision making . Iwill advice to use effective contraception until the date of procedure and continue the next period.All verbal counselling is supported by accurate ,impartial printed information is given to her ,which she can take home and read before the operation. Consent should be sought regarding the following aspect of sterlisation .Iwill make a note in the file that information leaflet is given to her. To minimize the risk of failed sterlisation preoperative assessment is done by detailed history and examination.Acareful menstrual ,sexual and contraceptive history should be taken on the day of surgery.Failed sterlisation is the commonest cause of litigations in gynaecology .If she has missed a period the operation should be postponed.Luteal-phase sterlisation in those at risk of pregnancy should be postponed.If irregular cycles high risk of undetected pre-existing pregnancy,a pregnancy test must be performed on the day of surgery.Negative test does not exclude luteal phase pregnancy.Routine curettage to prevent luteal phase pregnancy is not recommended.Effective contraception should be ensured until the date of surgery ,otherwise defer the surgery until the follicular phase and continued contraception till the next period . During laparascopic surgery correct identification of fallopian tube and correct application of filshie clip ,right angles to the isthemic portion of the tube ,1-2cm from the cornu,making surethe whole width of the tube is encased in the clip,which should be confirmed and documented .Hulka clip associated with higher rate of failure.Diathermy should not be used as primary method,carries increased risk of ectopic pregnancy. Postoperatively the method used and any technical difficulties
		Posted by wer W. Sat Jan 7, 2006 08:43 am
conselling re sterilization should address the following points:- Maternal reasons for sterilization, including failure of alternative methods either through non compliance or inherent failure rates. Medical reasons for not having more children should be addressed, ie previous caesereans, diabeties with poor control, other medical reasons. Social reasons for not having sterilization should be explored, such as an unstable relationship, differing views between the patient and her partner. The woman should be warned of the risk of regret with sterilization, though the principle risk factors of having fewer than 3 children or being under 30 do not apply. Counselling should include exploring suitability off alternate contraceptions with explanations of the advantages and disadvantages. (1) combined oral pill. Previous VTE, multiple or a high risk inherited thrombophilia (ie antithrombin III) deficiency, migraines, liver disease would be considered ab
		Posted by adnan S. Sat Jan 7, 2006 08:48 am
Sterlisation (tubal occlusion) remains a popular method of contraception despite the increase availability of acceptable long acting reversible methods. I will inform her that sterlisation is intended to be permanent.The reversal and treatments like IVF and ICSI may not be available on the NHS.The intrauterine pregnancy rate of reversal of sterlisation is between 31 -92% with an ectopic pregnancy rate of 0-7%.Iwill inform her other methods of long term reversible contraception like CuT380A and LNG-IUS.The cumulative pregnancy rate after 12 years with CuT380Ais 1.9% and after 5 years with LNG-IUS is 1.1%. Iwill inform her other option like vasectomy,which carries lower failure rate of 1:2000 than tubal sterlisation 1:200life-time,and carries fewer risks.Tubal ligation is associated with risk of ectopic pregnancy if fails,hence she should be advice to seek medical advice if thinks she is pregnant,or abnormal abdominal pain,or vaginal bleeding.Risk of ectopic pregnancy is lower after sterlisation as compare to non sterlisation. Iwill inform the different methods like laproscopy and mini- laprotomy. Hystroscopic methods are under evaluation,culdoscopy is not used because of unacceptably high incidence of technical difficulty and major complications.Laproscopic approach to the fallopian tubes is quicker and results in less minor morbidity compared with mini-laprotomy with no significant difference in major morbidity.The risk associated with laproscopy are possibility of requiring laprotomy particularly if previous abdominal surgery or obesity. Iwill inform her that tubal ligation is not associated with increase risk of menorrhagia.There is an association with increase hysterectomy rates,although there is no evidence that tubal occlusion leads to problems that require a hysterectomy. There is no increase in testicular cancer or heart disease associated with vasectomy,but there is possibility of chronic testicular pain.Although not a legal requirement better to involve her partner in the decision making . Iwill advice to use effective contraception until the date of procedure and continue the next period.All verbal counselling is supported by accurate ,impartial printed information is given to her ,which she can take home and read before the operation. Consent should be sought regarding the following aspect of sterlisation .Iwill make a note in the file that information leaflet is given to her. To minimize the risk of failed sterlisation preoperative assessment is done by detailed history and examination.Acareful menstrual ,sexual and contraceptive history should be taken on the day of surgery.Failed sterlisation is the commonest cause of litigations in gynaecology .If she has missed a period the operation should be postponed.Luteal-phase sterlisation in those at risk of pregnancy should be postponed.If irregular cycles high risk of undetected pre-existing pregnancy,a pregnancy test must be performed on the day of surgery.Negative test does not exclude luteal phase pregnancy.Routine curettage to prevent luteal phase pregnancy is not recommended.Effective contraception should be ensured until the date of surgery ,otherwise defer the surgery until the follicular phase and continued contraception till the next period . During laparascopic surgery correct identification of fallopian tube and correct application of filshie clip ,right angles to the isthemic portion of the tube ,1-2cm from the cornu,making surethe whole width of the tube is encased in the clip,which should be confirmed and documented .Hulka clip associated with higher rate of failure.Diathermy should not be used as primary method,carries increased risk of ectopic pregnancy. Postoperatively the method used and any technical difficulties encounterd like tubal occlusion in doubt should be informed and effective contraception should be continued and an HSG arranged.
		Posted by Geeta N. Sat Jan 7, 2006 09:28 am
The women and her partner should be counselled together in a sensitive, non-judgemental manner and all discussions should be documented carefully. Written information should be provided to the couple as this improves knowledge, leads to less regret and litigation. A detailed history and examination should be conducted on the couple. Gynecological history and examinaton will indicate any significant pelvic pathology like fibroids which may influence the decision and need alternative surgery like hysterectomy. Obstetric history will reveal if any abdominal deliveries were undertaken. It is important to know the age of the partner, the duration and stability of their relationship and if he has fathered any of her four children to reduce the risk of regret. Medical and surgical history would reveal any anaesthetic and surgical risk factors and influence which partner should go forward with the sterilization. Enquiry in to their current contraceptive method is important. History and examination of the partner is important as presence of hernia or hydrocele which may be operated upon at the same time as the vasectomy. Discussion should involve information about non surgical options of long term reversible contraceptives like Mirena (licenced for 5 year use and failure rate 1.1/100 wome.) , Cu T safe 380 (licensed for 7 years and failure rate of 1.1/100 women) Implants like Implanon (3 years us fiailure rate -<1/100 women They.-have comparable failure rate as tubal ligation.1.8/100 women years. They should be given the option of vasectomy which can be done under LA and is associated with fewer operation related risks and a lower failure rate than tubal ligation (I in 2000) vs 1 in 200). However, it is not immediately effective and needs the use of contraception until azoospermia is confirmed. They are reassured that it does not increase the risk of testicular or prostate cancer and heart disease. It is however associated in genitor-urinary infections. A female sterilization involves bilateral occlusion of the tubes performed either via laparoscopy or mini-laparotomy as a day case under GA. At laparoscopy, tubes are ligated using Filshe clips or rings or diathermy. At mini-laparotomy, tubes are ligated surgically or mechanically with clips. The risk of major complications of injury to the bladder, bowel or blood vessel requiring laparotomy should be explained. The failure rate is 1 in 200 with increased risk of ectopic pregnancy and death occurs in 1 in 12000 cases. Vasectomy and tubectomy are both intended to be permanent procedures; however reversibility is possible. Failure rates can be minimized by appropriate training of staff and supervision. All equipment should be in good condition. Patients should be properly selected for surgery and the appropriate mode of access to the tubes (mini-laparotomy or laparoscopy) chosen. A senior surgeon should operate on difficult cases. The surgery should be scheduled soon after menses in the follicular phase, if possible. If scheduled in the luteal phase, the surgeon should be confident that she is using effective contraception until the day of surgery. The COC pill should be continued until the end of packet and the IUCD should be removed following next menses. A pregnancy test should be done prior to surgery. Post-partum and post-abortal procedures carry a higher failure rate and tubal occlusion should be done where possible at an appropriate interval after pregnancy. At laparoscopy, Hulka clips and diathermy should be avoided as they are associated with high failure rates. Filshe clip or fallope rings should be used and correctly applied to the mid-isthmic portion ,,1-2 cms away from the cornua, at right angles, encasing the full width of the tubes. This should be explicitly checked by the operating surgeon. Routine use of more than one Filshe clip does not reduce failure rate. At mini-laparotomy, the Madlener or fimbriectomy should be avoided. A modified Pomeroy?s method rather than the Filshe clip should be used at post-partum sterlization as it is associated with a lower failure rate.
		Posted by Louis A. Sat Jan 7, 2006 10:14 am
Ascertain her reasons for wanting a sterilisation. She may not be aware of other reliable methods available to her. Explain that this is a permanent method of contraception and is not without risks. Discuss with her other longterm forms of contraception i.e. subdermal implants, IUCD`s, Mirena,or vasectomy. This might prompt her into enquiring about an alternative form, rather than sterilisation. Inform her of how the sterilisation is performed: If she is a suitable candidate then this can be performed as a daycase under general anaesthetic. One aims to perform this laparoscopically, but a mini laparotomy may be required in the event of poor access or complications of the laparoscopy. The fallopian tubes are identified and occluded by Filschie clips, rather than diathermy, or Hulka clips and are applied perpendicular to the tube in its proximal 1/3. Photos can be taken of this placement. She needs to be briefed regarding the complications as well. Serious complications are injury to bowel, bladder,vessels with a frequency of 3:1000, unplanned pregnancy rate of 1:200 and if this occurs a chance of an ectopic pregnacy, uterine perforation and a 1:12000 risk of death. The more frequent, but less serious complications are bruising around the port sites and shoulder tip pain. Enquire what form of contraception she is taking at present. This should be continued for another week. It is vitally important that she understands her periods will return to how they were before she started taking the contraceptive pill and that the sterilisation does not alter her menstrual cycle or cause an earlier menopause. Part of the counselling process is also a risk assessment of the patient for the particular procedure.It would for example not be appropriate to perform a laparoscopy on a patient with multiple abdominal scars and a BMI of 40. During the history taking concentrate on any medical conditions,or previous abdominal surgery. On examination note her BMI,and abdominal scars. The findings may make her unsuitable for daycase surgery. Surgical inexperience also adds to complications and hence the operator should be clinically skilled in performing the procedure as stated by the RCOG. The fallopian tubes need to be accurately identified and distinguished from the round ligament to ensure correct placement of the Filshie clips. Finally the patient is given an information leaflet regarding the procedure. Leaflets regarding alternative methods of contraception can also be issued.
		Posted by Vaani M. Sun Jan 8, 2006 12:51 am
Sterilisation is a commonly used method of permanent contraception. Since this woman has 4 children and wishes to be sterilised it is important to know that she understands every aspect of the method. She needs to be counselled about other longterm methods of contraception as intrauterine devices.If she has a history of menorrhagia an intrauterine progesterone system as mirena would be more suitable for her. If she requires the method could be reversed when she wishes if she is not absolutely certain about not having any more children. If she has a steady partner the couple need counselling about vasectomy as a method of sterilisation for the partner. It is a very simple procedure done under local anaesthesia, with less complications and a very less failure rate compared to tubal ligation for the woman. The failure rate with vasectomy would be 1 in 2000 in comparision to 1 in 200 for tubal ligation. Tubal ligation could be done laparoscopically or by mini-laparotomy. The procedure is usually done laparoscopically under anaesthesia and is associated with complications of laparoscopy, namely injury to vessels or bowel and haemorrhage and anaesthetic complications. If she is obese or has had previous surgeries as caeserean sections a mini-laparotomy would be more suitable than laparoscopy. The procedure is a permanent method of contraception but may be associated with failure, early failure could be because of wrong application of the clips to other structures other than the tubes, or a pre-existing pregnancy prior to the procedure. A pregnancy test has to be done on the day of surgery to rule out any pregnancy, but a luteal phase pregnancy can still not be detected. If she is using another method of contraception it is advisable to continue that method until her next menstrual cycle after the surgery to avoid an unwanted pregnancy. Failure of procedure could occur later also due to recanalisation of the ligated tubes. Reversal of the procedure is also possible if needed but will not be funded by the NHS. A Pomeroy\'s method of sterilisation where the tubes are cut and ligated is associated with less failure. A diathermy used for tubal ligation also is associated with less failure. These would be the chosen methods if she is post abortal or post delivery and is requesting the sterilisation now. She should be given information leaflet to read, understand the procedure and all the related information before giving an appropriate consent prior to the surgery if she still opts for sterilisation.
		Posted by M H. Sun Jan 8, 2006 05:37 pm
In the initial consultation, it would be prudent to further explore firstly the reasons for her wanting sterilisation and to obtain further history to enable us to plan for a suitable method of contraception together. I deally the counselling sessions should include her partner. It would be important to discuss other options of long term contraception prior to embarking on sterilisation eg IUCD (3-5 year duration), vasectomy (lower failure rate 1:2000; can be done under local anaesthetia); Progesterone implants (5 year duration). It should be highlighted to her that sterilisation intended to be a permanent procedure and reversal of the procedure, is difficult and may be costly. The failure rate is 1 in 200 for tubal ligation and if the procedure fails, she should be made aware of the increased risk of an extrauterine pregnancy. We should then discuss about the various procedures available for tubal ligation, either using a laproscopic approach or via mini laparotomy. Discussion should include whether the Fischie clip, the Fallops ring or the modified Polmeroy?s method would be used and the advantages and disadvantages of each method. She also should be made aware of the risk of bowel or vessel injury (in laparoscopic approach). If the laparoscopic method is chosen, she also should be counselled that there will be a possibility of a laparotomy if the procedure whether cannot be done laparoscopically or a complication arises. As the procedure requires a general anaesthetic, she also should be made aware of the anaesthetic risks To minimise her risk of a failed sterilisation, it is important ascertain her last menstrual period, her current contraception of choice and explore the possibility of failure of contraception. Ensure proper contraceptive methods are used (and in appropriate manner), till the date of surgery. If possible, the surgery should be scheduled early in her menstrual cycle. On the day of surgery, it is again important to ask for her LMP. A urine pregnancy test should be performed and it would be important to tell this lady that a negative result does not preclude a luteal phase pregnancy. If there is a remote chance of pregnancy, the surgery should be re-scheduled for a later date. It is important to that her current contraception is used till her next menstrual period after the surgery.
		Posted by Geeta N. Mon Jan 9, 2006 03:50 am
The women and her partner should be counselled together in a sensitive, non-judgemental manner and all discussions should be documented carefully. Written information should be provided to the couple as this improves knowledge, leads to less regret and litigation. A detailed history and examination should be conducted on the couple. Gynecological history and examinaton will indicate any significant pelvic pathology like fibroids which may influence the decision and need alternative surgery like hysterectomy. Obstetric history will reveal if any abdominal deliveries were undertaken. It is important to know the age of the partner, the duration and stability of their relationship and if he has fathered any of her four children to reduce the risk of regret. Medical and surgical history would reveal any anaesthetic and surgical risk factors and influence which partner should go forward with the sterilization. Enquiry in to their current contraceptive method is important. History and examination of the partner is important as presence of hernia or hydrocele which may be operated upon at the same time as the vasectomy. Discussion should involve information about non surgical options of long term reversible contraceptives like Mirena (licenced for 5 year use and failure rate 1.1/100 wome.) , Cu T safe 380 (licensed for 7 years and failure rate of 1.1/100 women) Implants like Implanon (3 years us fiailure rate -<1/100 women They.-have comparable failure rate as tubal ligation.1.8/100 women years. They should be given the option of vasectomy which can be done under LA and is associated with fewer operation related risks and a lower failure rate than tubal ligation (I in 2000) vs 1 in 200). However, it is not immediately effective and needs the use of contraception until azoospermia is confirmed. They are reassured that it does not increase the risk of testicular or prostate cancer and heart disease. It is however associated in genitor-urinary infections. A female sterilization involves bilateral occlusion of the tubes performed either via laparoscopy or mini-laparotomy as a day case under GA. At laparoscopy, tubes are ligated using Filshe clips or rings or diathermy. At mini-laparotomy, tubes are ligated surgically or mechanically with clips. The risk of major complications of injury to the bladder, bowel or blood vessel requiring laparotomy should be explained. The failure rate is 1 in 200 with increased risk of ectopic pregnancy and death occurs in 1 in 12000 cases. Vasectomy and tubectomy are both intended to be permanent procedures; however reversibility is possible. Failure rates can be minimized by appropriate training of staff and supervision. All equipment should be in good condition. Patients should be properly selected for surgery and the appropriate mode of access to the tubes (mini-laparotomy or laparoscopy) chosen. A senior surgeon should operate on difficult cases. The surgery should be scheduled soon after menses in the follicular phase, if possible. If scheduled in the luteal phase, the surgeon should be confident that she is using effective contraception until the day of surgery. The COC pill should be continued until the end of packet and the IUCD should be removed following next menses. A pregnancy test should be done prior to surgery. Post-partum and post-abortal procedures carry a higher failure rate and tubal occlusion should be done where possible at an appropriate interval after pregnancy. At laparoscopy, Hulka clips and diathermy should be avoided as they are associated with high failure rates. Filshe clip or fallope rings should be used and correctly applied to the mid-isthmic portion ,,1-2 cms away from the cornua, at right angles, encasing the full width of the tubes. This should be explicitly checked by the operating surgeon. Routine use of more than one Filshe clip does not reduce failure rate. At mini-laparotomy, the Madlener or fimbriectomy should be avoided. A modified Pomeroy?s method rather than the Filshe clip should be used at post-partum sterlization as it is associated with a lower failure rate