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MRCOG PART 2 SBAs and EMQs

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ESSAY 230 - STERILISATION

Page 1 of 1 [1]
		Posted by Sarwat F. Tue Feb 20, 2007 05:07 am
Woman should be counseled about risks and failure of procedure and alternatives available. She should be asked about reason for request for sterilization over and above other long term reversible methods of contraception. She is asked about possibility of wanting more children. Previous methods of contraception are enquired and what current method of contraception she is using. She is specifically asked about any problems with previous and current contraceptive methods. Stability of marriage is assessed by asking about relationship with partner in a careful manner to exclude any possibility of breakdown. She will be explained that sterilization is meant to be a permanent method of contraception and failure rate is 1 in 200. If however pregnancy occurs after sterilization there is an increased risk of ectopic pregnancy. there is a risk that woman may regret their decision of undergoing sterilization and may ask for reversal of sterilization procedure. The success rate of reversal of sterilization varies according to method employed for tubal occlusion and is roughly around 60 to 70% but live birth rate is only 30 to 40%. This is in contrast with male sterilization, vasectomy where reversal has a higher success rate and is technically easier with less complication. She will be explained about the risks associated with the procedure itself which include anaesthetic complications, intraoperative and postoperative complications. Intraoperative complications include direct trocar trauma to bowel bladder blood vessels, haemorrhage, uterine perforation and failure to gain entry in abdominal cavity. She will be explained that in case of haemorrhage and visceral injury laparotomy may be needed to repair the damage. There is a risk of death associated with this procedure of about 1 in every 12000 procedures. Postoperative complications include shoulder tip pain and wound bruising. Regarding longterm problems related to menstrual dysfunction she should be explained that available evidence does not support any menstrual irregularity associated with sterilization procedure. Patient should be provided with information about other longterm methods of contraception like progesterone injections, implants, MIRENA and copper coil. Written information in the form of leaflets should be provided. Woman should be given chance to discuss with her partner and another appointment made for final decision. Regarding measures to minimize the risk of failed sterilization, trainees should have adequate supervision when performing the procedure. Each trainee should have done a specific number of procedures before allowed to do unsupervised. Fallopian tube should be identified especially the fimbrial end to avoid confusion with round ligament of uterus. There is no advantage of applying double filshie clips. Clips should be applied in the manner to occlude whole fallopian tube. Curettage at the same time as sterilization is not recommended in reducing the chances of failure. To avoid luteal phase pregnancy women must be advised to continue using the method of contraception until the day of surgery. For women with irregular cycles procedure can be performed in first half of menstrual cycle and they are advised to continue contraception until the next period.
		Posted by Abi T. Tue Feb 20, 2007 06:29 am
a)I will ascertain that she is sure that her family is complete and the request for sterilization is not under any coercion or in reaction to a sudden loss(death of partner, dissolution of relationship). Alternative forms of long term contraception should be discussed, including advantages and disadvantages, such as the copper IUD, LNG-IUS and subdermal implant. Vasectomy should also be discussed as it has a lower failure rate (1:2000) compared to sterilization and lower morbidity and mortality. She should be made aware that sterilization is a permanent method of contraception. Reversal may not be available under the NHS and has a pregnancy rate of 31-92% with an ectopic rate of 0-7%.If she desired a pregnancy later IVF/ICSI would not be available under the NHS. There is a lifetime failure rate of 1:200 with sterilization. This is associated with a risk of ectopic pregnancy in the range of 4-76% depending on the method of sterilization. I will explain that the recommended method is laparoscopically with the application of clips or rings. Sterilization can be done via a minilaparotomy but the laparoscopic approach has a shorter operating time and quicker recovery. This is done under GA usually and is a day case procedure. There are risks of organ injury which would require a laparotomy, risk of bleeding,infection and risk of death (1:12000). Most deaths are due to anaesthetic complications. If she has had previous abdominal surgery or high BMI, she should be counselled regarding higher risk of failure to gain entry which may require a mini-laparotomy. She should be reassured that there is no increased risk of menorrhagia following sterilization. The above information will be supported with leaflets and time allowed for the patient to decide, preferably discussing it with her partner and a further appointment offered. She should be advised to continue her current method of contraception or offered a short term reliable form of contraception, until the operation date. b)Sterilization has a higher failure rate if done under 6 weeks postpartum or post TOP. Sterilization can be done at any time in the menstrual cycle provided the patient has been on a reliable form of contraception. Other wise it should be avoided in the luteal phase. A preoperative urine pregnancy test should be done and even if it is negative, it should be explained to the patient that a luteal phase pregnancy may be present (if patient not on any contraception) and the procedure deferred. If there is a midline abdominal scar or very high BMI, a mini-laparotomy may be a safer approach. The modified Pomeroy method has lower failure rates with this approach compared to filshie clips. Diathermy should not be used as a primary method as it carries a higher risk of ectopic. If it has been used, written information should be provided detailing symptoms of bowel injury and prompt medical advice sought. TRainees should be supervised and must have done at least 25 laparoscopic procedures prior to independant operating. Direct visualization of the whole length of tube is pertinent prior to applying clips or rings. The FIlshie clip has lower failure rate than the HUlka clips. The clip should be applied at right angles to the isthmic portion of the tube, 1-2cm from the cornu and ensure that the whole width of the tube is occluded. Pictorial evidence is helpful when documenting in the notes. If tubal occlusion is in doubt, effective contraception should be provided post op and an HSG arranged. Written information should be provided to the women regarding method of sterilization used and any intraoperative complications encountered. She should also be adviced to seek urgent medical attention should she suspect a pregnancy after the procedure.
		Posted by NIRMALA SARASWA P. Tue Feb 20, 2007 06:35 pm
Counselling starts with explaining the women about the various options available,both surgical and the non surgical methods,the advantages and the risks associated with each method,enabling the women to make an informed decision.Also,before offering counselling,it is better to ensure that,she is certain of her decision to undergo sterilization. Surgical methods of sterilization can be done either by laporatomy or laparoscopy.If the women wishes to undergo surgical method,it is important to explain her that,the method should be best done as an interval procedure inorder to avoid,failure and regrets,following the procedure.If the decision is taken, to perform the procedure,I will ensure that she is not pregnant by doiing pregnant test before the procedure,though this does not exclude early pregnancy.Appropriate history of effective contraception and the sexual history also will provide a clue,to carry on with the procedure and if any suspicion of a pregnancy, the procedure may be abandoned and carried out in the next cycle,during follicular phase.If the women persists,to perform the surgery,then whole discussion may be clearly documented that may help in risk management process.So,once assertained that she is not pregnant,the procedure,may be done by laporoscopy,or by laporotomy.Laporoscopic sterilization is widely used in the UK.Falope rings,Hulka clips,may be applied,double application of the rings is contraindicated. Curettage following the procedure is not advisable.Diathermy is not advisable,because it is associated with increased ectopic pregnancy rates and if reversal is required it is difficult to achieve.The risk of Laporotomy associated is 1-3/1000 procedures and the risk of death with laporoscopy procedure is 1/12,000.It should always be informed to women that is a permanent method and if she wishes to know about the chances of reversal,she may be explained that the reversal is possible but the success rate is variable and approximately 30%,and it depends on the type of sterilization done,and the remaining fallopian tube.The failure rate associated with sterilization is 1/200.The cumulative pregnancy rate following 10yrs after fallope ring is 1-2/1000. Vasectomy,does not affect female sterilization and it is associated with less complication and relatively an easy procedure.There is no increased risk of coronery artery disease,prostrate cancer.The couple should be advised to use effective contraception until the semen shows <10,000/ml motile sperms on semen analyses,because at this levels,no pregnancies have been reported. Mirena coil as a contraceptive,is licensed in the Uk and its contraceptive efficacy is equivalent to female sterilization,it is effective for 5yrs.CuT380Ag,IUCD,is effective,for 8yrs.The risk with these are that she may feel little discomfort during insertion,and the risk of infection,but which again depends on her life stlyle. Implanon derivative of desogestrel,also effective for 3yrs,and if women is obese,the efficacy of it decreases gradually and she may need to use another contraceptive.It is an effective contraceptive as well. combined pills,progesterone only pills,injectable progestogens also can be advised ,if the women is interested in pills,and compliant enough,as their contraceptive efficacy is compliant dependent and also they can be prescibed if the women is not having any contraindications.All the above information need to be reinforced by providing her information leaflet,where she takes home and read it leisurely.Once informed consent is made then the appropriate method is performed.
		Posted by neera B. Wed Feb 21, 2007 03:10 am
a) I shall ascertain her desire for more children, previous abdominal surgeries, cardiopulmonary disease, regularity of cycles and current contraception being used. I shall tell her sterilization is a method intended to permanently stop an individual?s capacity to bear a child. It can be performed under general or regional anaesthesia. The anaesthetist would discuss this in more detail with her at a separate meeting. A 1 cm cut will be made under the belly button through which a telescope is passed. A smaller nick is made on one side of belly through which an instrument is passed to apply 1 clip on each of her fallopian tubes. But it has risk of failure in 1 case of every 200 sterilizations performed. Failure may occur even 10 years or more after sterlisation. It has benefit of being permanent with no recurrent costs . But it may involve serious life threatening risk like bowel injury necessitating an open operation ( laprotomy) with bowel repair in less than 1 in 1000 cases or blood vessel injury or very rarely death in 1 in12000 cases. Frequent minor risks like wound sepsis, keloid , postoperative pain may occur. I shall inform her of alternatives to female sterilization like male sterilization that can be performed under local anaesthsia and has lower failure rate of 1 in 2000, with lesser risks. Otherwise, she has the option of Mirena which is as effective as sterilization, reversible, but needs a change after 5 years and has minor side effects like acne, mood changes, irregular bleeding and very rarely uterine perforation . Copper bearing IUCD are also reversible, for 5 ? 10 years but may cause increase risk of PID in first 20 days and heavy bleeding or occasional uterine perforation . Implanon which is effective, reversible , for 3 yrs will also be offered. Reversal, if desired is successful in about 70% cases but pregnancies after reversal or failure of sterilization are more likely to be ectopic which could be life threatning. Thus the need to consult her GP if she misses a period. I shall ask her if she has any questions. Leaflets will be given to enable her to make informed choice. b) To minimize failure , sterilization will be scheduled in post menstrual phase ideally .If this is not possible , a pregnancy test would be done on the day of surgery to decrease chance of luteal phase pregnancy . Routine curettage is not recommended at time of sterilization . A trained surgeon should perform sterilization after carefully identifying fallopian tubes, as being at cornu between the round ligaments anteriorly and ovarian ligament posteriorly. Reliable contraception should be used from beginning of period till day of sterilization to minimize chances of preexisting fertilized zygote at time of luteal phase sterilization.
		Posted by Farzana N. Wed Feb 21, 2007 04:59 pm
a) Counseling is the most important aspect before sterilization, as this avoids litigations as well as enables the woman to give informed consent .The woman?s capacity to provide consent should be first ascertained and if there are any concerns she should be referred to court. Verbal counseling should be supported by accurate written information. She should be told that sterilization is intended to be a permanent method of contraception. She should be given information on advantages and disadvantages and failure rates of other long-term reversible contraception. Cumulative pregnancy rate after 12yrs with CuT380A is 1.9 % and after 5yrs with LNG is 1.1%. Intrauterine pregnancy rate after reversal of sterilization may be 31-91% with an ectopic pregnancy rate 0-7%.She should also know that in case she desires pregnancy in future, reversal of sterilization and treatments like ICSI and IVF may not be available on NHS. She also has the option that her husband can have vasectomy. This has lower failure rate, 1:2000as compared to tubal ligation-1: 200,with fewer complications. There is no increase in testicular cancer or heart disease associated with vasectomy. In case the tubal ligation fails, there is a risk of ectopic pregnancy. She should be told to seek medical advice in case there is abnormal abdominal pain or vaginal bleeding. Detailed medical and surgical history should be taken and examination done to assess fitness for anesthesia. Method of surgery can be laparoscopy or mini laparotomy based upon the history and examination. If she is obese with previous h/o abdominal surgeries, there is high risk of adhesions. Laparoscopy may not be successful in such a case and mini laparotomy may have to be done.Laparoscopy can be done as day case procedure. The associated risks of anesthesia, bowel and visceral injury should be explained. There is a small chance that in case of difficulty in getting access she may require laparotomy, which is associated with higher risk of hemorrhage ,infection and VTE. At her age of 37yrs, there is no increased risk of menorrhagia b) Tubal ligation may fail due to preexisting pregnancy, technical or operator fault in early period. Later due to recanalisation or in rare cases due to presense of tuboperitoneal fistula.To minimize the risk of failure woman should be advised to use effective contraception until the date of procedure and continue until the next period.Procedure should ideally be performed during the follicular phase. On the day of procedure a thorough h/o last menstrual period ,contraception and any unprotected sexual intercourse is taken.Pregnancy test should be done and result should be known before the patient is anesthetised.According to RCOG recommendations trainees should perform 25 laparoscopic tubal ligations before operating without supervision.Partial application or application to wrong structures,e.g round ligament may result in early failure.
		Posted by sailaja devi K. Thu Feb 22, 2007 01:55 am
I will tell her sterilization is a permanent method to prevent pregnancy.It involves operation.She should know both metods of sterilization with its advantages & failure rates .In females it is tubal occlusion ,in males it is vasectomy.Vasectomy is associated with less failure rate & less postoperative morbidity. Find out the reason for seeking sterilization as some may seek this as cure to menstrual disturbance ,sexual problems.Ask if she is interested in having more children.Enquire about previous & current contraception & any problems with it. She should know that both the methods are associated with failures. In general failure rate for tubal occlusion is 1 in 200 & with vasectomy it is 1 in 2000.She should know that long term studies in UK are there for use of Filshie clip ,at ten years 2-3 per 1000 is the failure rate. All sterilization operations are permanent ,the chances to reverse has variable success rate 60%- 70%.The best chance of success is when clips or rings were used for sterilization She should be given information about alternative reversible long term contraceptive methods with its advantages & disadvantages.Intrauterine contraceptive device where in the coil is inserted into the womb.It can be retained for 8 years.Mirena device can be used for 5 years.It is as effective as vasectomy & more effective than tubal occlusion.Progesterone implant wherein the implant is placed under the skin, can be used for 3 years. She should be informed that if failure occurs chance of ectopic pregnancy are more.She should seek medical advice if she experience delayed period, abnormal pain & vaginal bleeding after tubal occlusion. No precaution can be guaranteed to avoid early pre existing pregnancy.Advice her to use contraception till surgery & continue till next cycle. She should be reassured that tubal occlusion is not associated with menstrual problems.No evidence that tubal occlusion has effect on sex drive.No evidence that tubal occlusion cause problems that may need hysterectomy. She should be sure of the decision & that fully understand what it will mean.No one can force her. She should know that surgery is done under local or general anaesthesia.She should know the route of access & the method of tubal occlusion to be used in her case,alternate methods to be used if the intended method fails. Laproscopy procedure done as day care procedure . Procedures involves two small nicks on abdomen one just below the navel , one low done ,to one side or bikini incision.Once tubes were identified clips were applied.If the laproscopy is not successful minilaprotomy is done .She should know she may need mini-laprotomy if she is overweight or had previous abdominal operations.Recovery time is longer with laprotomy,she should know she may need to stay in the hospital for an extra day. Inform her she may have pain & need to take analgesics.She should know all operations carry risk,but the risk of complications is low.Injuries to the bowel ,bladder & vessels are rare ,can be serious & may need laprotomy. Following operation she should know method of tubal sterilization used & any complications encountered during the procedure. She should know if she used contraceptive pill before she may have heavier periods.This is quite nonmal. She should inform if she has fever or generally unwell or severe pain. b)Failure of sterilization is common cause of litigation among gynaecologists.Measure to be taken to avoid failure of sterilization.The date of last menstrual period should be checked.Ensure she used contraception till date.If not used plan surgery after next cycle.Otherwise do pregnancy test ,negative pregnancy test will not exclude luteal phase pregnancy.Routine curettage at the time of occlusion ,in order to prevent a luteal phase pregnancy is not recommended.Advise her to continue contraception until her next cycle. . Mechanical occlusion of the tubes by either Filshie clips or rings should be the method of choice for laproscopic tubal occlusion.Identify the tubes ,see for fimbrial end & apply the clips.Do not apply clips to round ligament . A modified Pomeroy rather than Filshie is preferable for postpartum sterilization performed by mini-laparotomy or at the time of caesarean section ,as this leads to lower failure rates.Send the tube for histologic examination if in doubt. Sterilisation procedure should be done by trained person.Trainees should perform at least 25 supervised laproscopic tubal occlusions before operating without supervision. If hysteroscopic sterilization is done ensure she uses contraception till 3 months ,till the tubal occlusion is confirmed.
		Posted by Randa E. Fri Feb 23, 2007 03:38 am
Failure of appropriate counselling and therefore failure to take an appropriate informed consent is an important cause for litigation. In counselling this patient it is important to explore the reasons behind this wish. A history including previous delivery modes, previous contraceptive, regularity of cycles methods and stability of relationship should be included in the discussion.BMI should also be noted. This woman should be told that sterilization is intended to be permanent but is associated with a failure rate of 1:200/lifetime.The risk of ectopic pregnancy in the case of failure varies from 4-76% but is still lower in sterilised than non-sterilised fertile women. She should also be told that some methods are sometimes reversible and this depends upon the amount of normal tube preserved. Less destructive methods such as clips and bands have reversal rates varying from 31-92% but are associated with higher failure rate and pregnancy (36.5/1000 over 10 years). Following Pomeroy technique(tie the base of a loop of tube and cutting off the top of the loop) reversal rate approaches 50% but has a failure rate of 20.1/1000 over 10 years. Following electrcoagulation reversal rates are around 41% with a low failure rate(7.5/1000) but injury to adjacent structures and unacceptably high incidence if ectopic pregnancy are more common.She should also know that reversal and treatments like IVF or ICSI may not be available in the NHS. The method of access for tubal ligation should be discussed. Laproscopic tubal ligation is quicker and carries lower minor morbidity rate compared to mini-laparotomy with no significant difference in major morbidity rate. It is usually done under general anaesthesia but local anaesthesia can be an alternative. It has the added advantage of the possibility of being performed as a day case. Filshie clips or rings are the method of choice. Laproscopy is associated with a risk of laprotomy(1.4-3.1/1000) with a risk of death of 1:12000. Other risks e.g.inadvertent injury during access, application of clip accidently to bowel , perforation and haemorrhage should also be discussed. Recanalization, fistulae and migration of clips should also be discussed. Anaesthesia risks should be discussed and an appointment with aneathesist provided. Transvaginal tubal ligation via coldotomy or coldoscopy is technically more difficult and has a higher infection rate. However it is associated with less discomfort post operatively. Hysteroscopic methods are still under evaluation. Other alternatives for contraception e.g Implanon, CuT380A and Mirena which are effective contraceptives with easy reversibility should be discussed. . If in a stable relationship vasectomy might also be an alternative. It carries lower failure rates (1:2000lifetime) and fewer risks. She should be told that there is no increased risk of mennorhagia after sterilization but there seems to be an increased risk of hystrectomy. She should be told that she herself is responsible for any pregnancy that could have been conceived before the procedure. She should be advised to use effective contraception until the date of the procedure and continue until the next period. Her wishes should be regarded and documented and leaflets provided. b) The first measure to be taken is to make sure that a detailed history involving the womens menstrual history, and contraception is taken accurately. It must be ensured that the women has used effective contraception up until the date of the procedure, otherwise defer the procedure until the follicular phase while advising the woman to use effective contraception until next period. Pregnancy test should be done but it should be born in mind that a negative test does not exclude a luteal phase pregnancy and woman advised accordingly. Procedure should be performed by trained staff or by trainees under supervision. If Filshie clips are used they should be applied at right angles to the isthmic portion of the tube, 1-2cm from cornu, making sure that the whole width of the tube is encased. This should be confirmed at the end and documented. If technical difficulties were encountered such that the tubal occlusion is in doubt effective contraception should be continued and an HSG arranged.
		Posted by GBENGA O. Fri Feb 23, 2007 05:55 am
A)counselling will involve exploring her reason for desiring sterilisation,her current contraception method and reason for change,her current social andfamily circumstances(wether in a bad relatioship or breaking up). Her menstrual historyand mode of delivery of her 2 kids ,C/S or other abdominal surgery could reflect possible difficulty at sterilisation ,assessment of her BMI willalso be relvant. I will explain available methods and alternatives to her- Tubal occlution at laparoscopy by filshce clip or ring is recommended and widely used, it has lifetime failure fate of1:200; done as a day proceedure usually under GA (but may be done under local)it carries the risk of injury to bowel and blood vessels at laparoscopy and possible laparotomy, also risk of ectopic if it fails. Tubal occlusion can also be done by minilaparotomy, with filsche clip or tubal excision, but has the disadvantage of longer hospital stay and more post op pain. Hysterocopic tubal ooclusion is a method still under evaluation with a 90% proceedure success at occlusion and no long term data as yet, therefore, should only be used under strict guidance for new surgical proceedures. Sterilisation is potentially irreversible; Although laparoscopic tubal occlusion may be reversed, reversal may not be available on the NHS and subsequent pregnancy rate is low I will inform her of male vasectomy which is suitable if she is in a stable relationship, has a better lifetime failure rate of 1:2000, easier to perform, with fewer side effects, but require continued contraception until vas sperm clearance is confirmed. She should also be awareof other contraceotive methods-OCPwhich is suitable if she\'s not a smoker but carries ~1% failure rate and hormonal side effects of breast tenderness, bloating, requiring regular oral intake. Cu IUCD which are effective but may cause irregular bleeding and carries risk of insertional uterine perforation PID especially if there is untreated genital infection. The MIRENA IUS is long term & effective for upto 5 years but may cause irregular bleding, amenorrhoea, bloating, acne, mood changes. Progestogen injection(Depo provera), also long term,involves repeated injection.and implant(implanon) are also options I will give her information leaflets on the subject and give her time to consider her options B)Surgeon performing proceedure must be well trained or a trainee under supervision. Proper patient selection, noting BMI and previous abdominal surgeries to avoid a difficult proceedure and plan for minilaparotomy sterilisation or alternativecontraception in cases with extensive abdominal adhesions. Pregnancy test must be done before lap steri although this does not rule out a lutel phase pregnancy, Therefore adequate contraception must be used up to the time of sterilisation and continued until the next period. Proceedure should be done in the next follicular phase if there is inadequate contraception upto the time. At laparoscopy fallopian tubes should be properly identified to the fimbrial end and the filche clip applied one to the full width of each of the tubes. If there is doubt about full width application a second clip may be applied and a dye test done to confirm occlusion, this however does not affect the quoted failure rate.
		Posted by TAIWO NURENI Y. Fri Feb 23, 2007 06:00 am
Sterilisation for female is achieved by cutting or blocking the fallopian tube to effect a permanent contraception.Firstly,history of contraceptive method she is using and the number and mode of her deliveries need to be taken so that appropriate counselling can be given.History of previous surgeries or medical problem as well.I also have to establish that she is sure of completing her family and that she is not under any coercion from her husband in deciding for this form of contraception. Female sterilisation could be attained by blocking the tube or cutting it.Hysterectomy could also be a form sterilisation if there other indications for it.It could be done laparoscopically under GA.The tube is located laparoscopically and clips are applied about 2cm from the cornua end to each tube.It is done as day case but in case of complication laparotomy could be done and the stay has to be for couple of days.Laparoscopy is associated with frequent complication like shoulder pain & wound infection.Serious complication like bowel injury in4 per10,000 cases and vessel injury in 2 per 10,000cases.Bladder injury can also happen.However ,the recovery is quick and cost effective.Mini laparotomy is another method usually employed when there is failure of entry at laparoscopy or in obese woman or those with previous abdominal surgeries with adhesions.Here apart from clips the tube can be ligated with sutures and part of it removed.Diathermy could also be used to intersect the tube and ends burnt out.This is associated with the worst outcome of reversal.Recovery is longer in this and more analgesia requirement post op.A newer method of sterilisation is the Essure which is blokade of tube hysteroscopically.It is however still at early stage and not yet available in many hospitals.Failure rate for female tubal ligation is 1 in 200.It is permanent though can be reversed with varying degree of success depending on the method used in sterilisation.Reversal is not available on the NHS .Pregnancy rate after also varies from 30-70% with ectopic risk up to 5% compare with background risk of 1%. Male sterilisation is an alternative in which the vas deferens is intercepted to prevent passage of spermatozoa from the testis.It is 3 times cheaper ,10times less likely to fail(Failure rate1/2000)and 20 times less likely to have serious complication compared with female sterilisation.There also other form of long term contraception like the IUCD.CuT380A has a 12years preg rate of 1.9 while that of mirena IUD is 1.1 at 5years.The mirena has the advantage of reducing menstrual flow in 90% of users at the end of ist year.Implanon a single rod containing desogestrel inhibits ovulation in all users and last 3years.It however need minor surgery to insert. Sterilisation is been found to be associated with increase in hysterectomy rate.Association with mennorrhagia has not been proven.All the discussion will be documented and written information provided to enable informed consent. b)Contraception should be continued until next period .Procedure should be carried out in follicular phase except an effective contraceptive method is in use,then anytime in the cycle .Having confirm that,pregnancy test need to be performed prior to the procedure.The surgeon should be well trained or supervised in carrying out the procedure to ensure the tube and not the round ligament is clipped .The whole diameter of the tube should be enclosed by the clip and filshie is said to have a lower failure rate than Hulka clip
		Posted by Shyamaly S. Sun Feb 25, 2007 12:05 am
A healthy 37 year old mother of 2 children has been referred to the gynaecology clinic because she wishes to be sterilised. (a) How would you counsel her? [14 marks]. (b) Which measures will you take to minimise the risk of a failed sterilisation? [6 marks]. A) I would discuss her reasons for seeking sterilisation and for how long she has been considering it. I would determine whether there was a recent change in her circumstances in order to elucidate whether this is her own decision taken in sane mind. I would ask when and how her 2 children were delivered- sterilisation soon after delivery is associated with higher regret rates, and CS maybe associated with increased intrabdominal adhesions making laparoscopic surgery difficult. For this reason, I would enquire about any other abdominal/ pelvic surgery, PID or endometriosis. I would ask her what contraception she is currently using and how she feels about it ? it is important that she continues this in the interval. Her menstrual history should be taken- if she suffers with dysmenorrhoea or menorrhagia, this may become unmasked following sterilisation when COC is discontinued. On examination I will note her BMI- obesity increases anaesthetic complications and increases the risk of requiring a laparotomy. Abdominal examination will show evidence of previous surgery, and bimanual will be used to assess the mobility of the uterus. Reduced mobility is associated with intraabdominal adhesions and increased likelihood of a failed laparoscopy. Since sterilisation involves instrumentation of the uterus, I would screen for STIs using vaginal, cervical and urethral swabs. I will explain that sterilisation is a reasonable request in the right person at the right time, and that we need to discuss whether this is her best option. I will ensure that she knows that sterilisation should be considered irreversible. It can be reversed but the success rates are variable (27-92%) and this surgery is only available privately. Sterilisation carries a failure rate of 1 in 200. If she has abnormal abdominal pain, bleeding or is pregnant she should seek medical assistance as an ectopic pregnancy may occur. Sterilisation would usually be performed under general anaesthetic laparoscopically. The risks include bowels, bladder or vascular damage requiring laparotomy, infection and significant bleeding. I would also discuss other forms of long-term sterilisation. Vasectomy of her partner has fewer risks, can be performed under local anaesthetic and failure rate of 1 in 2000. The progesterone implant can also be used for 3 years, is reversible, but may cause erratic bleeding, breast tenderness and mood disturbance. The IUS acts for 5 years. It reduces menstrual flow, but can cause erratic bleeding for the first 3-6 months. Insertion maybe painful, associated with perforation or expulsion. Both these methods are reversible, have similar failure rates as sterilisation. I would give her info leaflets to support this discussion and give her the opportunity to consider them before she makes her final decision. B) It is the surgeon?s responsibility to ensure the risk of pregnancy is minimised. Pre op assessment minimises the risk of failure- sterilisation within 6 weeks of pregnancy is associated with higher failure rates so this should be avoided. Obese women or those with adhesions may not afford good laparoscopic tubal views, so minilaparotomy maybe more appropriate. A pregnancy test should be performed on the day of the surgery. A negative pregnancy test result does not exclude luteal pregnancy (her LMP should be known), so it is important that she has been using reliable contraception. If not, it is reasonable to reschedule surgery to the follicular phase. The equipment should be checked prior to surgery. The operator or the supervisor should have adequate experience (should have performed at least 25 laparoscopic sterilisations). Diathermy should be avoided ? it is associated with higher failure rates. Laparoscopic Filshie clip or ring application is associated with higher maintained success rates. The fallopian tube should be visualised ensuring that it is not mistaken for the round ligament and a single clip placed 2cm from the medial end perpendicularly, ensuring that the tube is completely occluded. If there is any doubt, a dye test should be performed. If laparoscopy fails, laparotomy should be performed and the modified Pomeroy technique used for tubal occlusion. There is no place for D&C of the uterus (if a luteal pregnancy is present this is unlikely to remove it and if it does, constitutes TOP). The patient should continue contraception until her next period, but should be advised that there is no guarantee against failure, which can even occur years later.
		Posted by Parveen Q. Mon Feb 26, 2007 04:11 am
Counselling involves giving information , explaining the risks and benefits and enabling her to come to an informed choice. I will ask her about her mentrual cycle, last menstrual period, if she has used any contraception before, any medical history, casarean sections in the past , last child birth and any abdominal surgeries before. I will tell her that tubal ligation is a permanent and irreversible procedure, and the decision cannot be taken in haste or under pressure to avoid regret later on. It can be perfomed laprocopically or by mini laprotomy. It can be performed under general or local anasthesia, the decision will be taken by anaesthetist along with her wishes. Laprocopy is associated with 3%risk of short term morbidities like shoulder pain, nausea, and serious complications like injury to bowel , blood vessls or urethra. Tubal ligation canbe done by laprotomy, if she had previous abdominal surgeries, or if she is over weight, BMI more than 30. Many methods are used to block the tubes, like the silicone rubber band, spring clip, unipolar or bipolar coagulation of the fallopian tubes , but the most commonly used is flishie clips. Modified pomeroy\'s technique is associated with lower failure rate and preferred to flishie clips if need to be performed postpartum at casarean section.Hysteroscopy tubal ligation is another option using essure,but are still under evaluation. Reversal procedurals are available but expensive and not covered by NHS. The failure rate is 1/200. The risk of ectopic pregnancy rate is 4-76%depending on the method ,but risk is less than unsterilised women. She may experience increased abnormal bleeding for which she may need hysterectomy. Vasectomy , male sterilisation, is associated with less morbidity and the failure rate is 1/2000. The other long term alternate options for the woman is implanon, which can be used for 3years. Mirena, licensed for use for 5years, but effective upto 8years. This is a suitable , alternate option to laproscopic sterilisation if she has mennorhagia, 97% of reduction within 1year of use. Cu 380 can be used upto 5years. she will be given leaflets and the information documentd and allowed to come to an informed decision. (b)Failed sterilisation is the commonest cause for litigation. pregnancy test should be done to exclude existing pregnanccy, but negative test cannot rule out luteal phase pregnancy.Ensure that untill the procedure effective contraception is used and contiued till next period. Postpartum or post TOP tubal ligation is associated with increase failure rates. The procedure should be done by competent surgeon or trainess under supervision. Flishie clip should be applied onthe isthmus of the tube about 1-2cm from the cornua . Ensure that the tube is enclosed in the clipp, confirmed and documentd at the end of the procedure. Guidelines and protocols should be adhered to.
		Posted by AMNA K. Mon Feb 26, 2007 07:07 pm
A. This women must know that sterilization deem to be a permanent method although success rate associated with reversal must be told to her, should this procedure be necessary, and that reversal operations are rarely provided within NHS service. Reasons of sterilization must be explored and history of previous cycle, regulatory of cycle, previous and current contraception and certainty of the decisionand stablity of relationship with the partner must be enquired. Alternative methods of contraception with positive health benefits (depot MPA & LNGIUS) and option of vasectomy must be offered to her partner. She should know vasectomy (male sterilization) is associated with less risk and less failure rate (1/2000) then female sterilization although, there is problem of chronic testicular pain but no such risks like prostatic cancer, testicular cancer or cardio vescular problems. On the other hand female sterilization is associated with increase risk of failure (1/200) and should failure occur there is high likely hood that resulting pregnancy will be an ectopic pregnancy. She must be told that majority of procedures are carried out as a day case procedure and approach to the tube is usually made leproscopically or through mini leprotomy incision and mode of anesthesia is usually general anesthesia, but local anesthesia is also an acceptable alternative. Hysteroscopic method of sterilization is under evaluation. If leproscopy is the chosen mode of the procedure then risk of bowel injury (.4/1000) and blood vessels injury (.2/1000) and this may required leprotomy and even without these complications leprotomy may be required in few cases for the completation of the procedure. Myths regarding irregulatory of cycles, change in circumstances, reduced libido and regret must be discouraged. All verbal counseling must be supported written information. B. To reduce the risk of failure detail history which include regulatory of menstrual cycle, LMP, missed period and method of contraception (current and previous), medical conditions likely to effect pneumoperitonium like severe asthma/ heart disease. Examination like body mass index and exclusion of abdominal pelvic pathology must be done. Adequate contraceptive advise must be given to her pre-operatively which needs to be continued, not only till the date of surgery but also till the next period Pregnancy test must be done before the procedure although a negative pregnancy test cannot rule out a luteal phase pregnancy. Surgery needs to be performed by an experienced operator after gaining an appropriate expertise as per RCOG recommendations that trainee should have performed 25 supervised procedures before performing independently. During laparoscopy correct identification of the tube, proper application of clips at right angle to the isthimic portion of the tube 1 to 2 cm from cornue ensuring that whole width of the tube is encased in the clip, which should be confirmed and documented. Whenever possible post partum and post abortal sterilization should be avoided. Filshie clip, fellow and pomeryo technique are effected methods of sterilizations while diathermy and hulka clips are associated with increase failure rate. Detailed documentation of discussion and procedure performed is very important as failed sterilization is one the commonest reason of litigation in gynecology.[:)]