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By:

Armando L. Gopez, M.D


- Professor -
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FAMILY PLANNING
Objective – To insure safe motherhood & child
survival
 Article XV, Section 3.1 – The state shall defend
the right of the spouses to found a family in
accordance w/ their religious convictions and
demands of responsible parenthood.
Goal – to improve the quality of life; directed
 Toward birth spacing, in order to allow mothers to
rest & regain their health before the next pregnancy
 Birth limitation, when desire number had reached
 Helping infertile couples to have children
2
FAMILY PLANNING
METHODS
Temporary methods –
 Traditional – coitus interruptus

 Natural family planning (NFP) –

 Cervical mucous (Billing’s method)

 Basal body temperature (BBT)

 Sympto-thermal

 Lactation amenorrhea (LAM)

 Rhythm method
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FAMILY PLANNING
METHODS
Temporary methods –
 Artificial methods:
 Hormonal
 Pills – combined & progestin only
 Injectables – DMPA, megestron, noresterat

 Implants - noresterat

 IUD

 Barrier
 Mechanical – condoms, diaphragms
 Chemical – vag. tabs; gels; cream; vag. sponge

4
FAMILY PLANNING
METHODS
Permanent methods –
Female sterilization – bilateral tubal
ligation
Mini-laparotomy

Laparoscopy

Culdoscopy

Colpotomy

Male sterilization - vasectomy 5


FAMILY PLANNING
Sterilization is the most effective method of
contraception
 Effectivity– up to 99.97% by most investigators
 Offers distinct advantage over artificial methods
 Eliminated fear of systemic & local side effects from
use of drugs & gadgets
 Dispenses long & regular follow-up (drop-out)

Often called voluntary surgical contraception


(VSC); distinguished from castration (removal of
gonads); sterilization is prevention of union of egg
& sperm by occluding the tubes & deferens
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FAMILY PLANNING
Policy of VSC –
 That these methods do not consist of abortions
(termination of pregnancy prior to 20 wks AOG)
 That the client is thoroughly informed of the medical
implications of the procedure; regarding the
irreversibility of the procedure
 That other methods of contraception have been
explained, that that it is taken on a voluntary basis
 That written consent of spouse is obtained
 That the procedure is performed by a duly trained &
accredited physician
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FAMILY PLANNING
Mechanism of action –
 Female – by obstructing the continuity of the tube
 Older method – mutilating surgical methods &
use of radiation for castration (Not use anymore)
 Accepted methods – is tubal ligation or occlusion

 Tying & cutting

 Applying clips or rings

 Cauterization of tubes

 Tubectomy

 Hysterectomy – only when there is pathology

in uterus
 Male – vasectomy (occlusion of vas deferens)
8
Tubal ligation methods:
1. Pinching off the tube in a loop with a band
2. Cutting and electro-cauterizing the tube ends
3. Cutting and tying off the tube ends

9
Methods of Tubal
Ligation

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Methods of Tubal
Ligation
Partial salpingectomy, being the most common occlusion
method. The fallopian tubes are cut and realigned by
suture in a way not allowing free passage. The Pomeroy
technique, is a widely used version of partial
salpingectomy, involving tying a small loop of the tube by
suture and cutting off the top segment of the loop. It can
easily be applied via laparoscopy. Partial salpingectomy is
considered safe, effective and easy to learn. It does not
require any special equipment to perform; it can be done
with only scissors and suture. Partial salpingectomy is not
generally used with laparoscopy.
Clips: Clips clamp the tubes and inhibits blood flow to the
portion, causing a small amount of scarring or fibrosis, in
turn, preventing fertilization. The most commonly used
clips are the Filshie clip, made of titanium, and the Wolf clip
(or "Hulka clip"), made of plastic. Clips are simple to insert,
but require a special tool to put in place
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Methods of Tubal
Ligation
Silicone rings: Tubal rings, similarly to clips, block
the tubes mechanically. It encircles a small loop of
the fallopian tube, blocking blood supply to that
small loop, resulting in scarring that blocks
passage of the sperm or egg. A commonly used
type of ring is the Yoon Ring, made of silicone
Electrocoagulation or cauterization: Electric
current coagulates or burns a small portion of each
fallopian tube. It mostly uses bipolar coagulation,
where electric current enters and leaves through
two ends of a forceps applied to the tubes. Bipolar
coagulation is safer, but slightly less effective than
unipolar coagulation, which involves the current
leaving through an electrode placed under the
thigh. It is usually done via laparoscopy.
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COAGULATION
METHODS
Bipolar Coagulation - is the most
popular method of laparoscopic female
sterilization.
With this method of tubal ligation, the
fallopian tube is grasped between two
poles of electrical conducting forceps,
and electrical current passes through
the tube between the two ends of the
forceps.
Damage to the tube is limited to the
segment between the forceps. Often,
two or three adjacent sites are
coagulated resulting in loss of
approximately 2-3 cm of fallopian tube.
Bipolar tubal coagulation is a good
method of female sterilization for
women who decide to have a tubal
reversal procedure. Pregnancy rates
after reversal of bipolar tubal
coagulation are approximately 60%.
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COAGULATION
METHODS
Monopolar coagulation of
the fallopian tubes is less
common than bipolar
coagulation tubal ligation.
The electrical current
spreads outward from the
coagulating forceps, so
monopolar coagulation
damages more of the
fallopian tube than bipolar
coagulation. In most
cases, the tube is also cut
after it has been
coagulated
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SURGICAL METHODS
Female sterilization – when done:
When she is not pregnant
Just after delivery (post-partum)

After abortion (post-abortion)

At the time of other pelvic or


abdominal surgery

15
FEMALE
STERILZATION
Sterilization can be done any time & often done
during caesarean section
Who delivered vaginally – early puerperium is
convenient; Oviducts are accessible at the navel
directly beneath the abdominal wall for several
days after delivery
 Advantage – technically simple; hospitalization
need not be prolonged; & less dangerous technic
Others, in immediate puerperium
 Has disadvantage
 Prefer to wait 12 – 21 hrs (Parkland, AM after
delivery; post-partum bleeding in multis
subsides remarkably 12 hours after delivery
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OVER-VIEW
Tubal ligation (also commonly referred to as having your
tubes tied) is surgery that closes off a woman's fallopian
tubes. Once the tubes are closed or "tied," sperm will not
be able to reach an egg, so pregnancy cannot take place.
Also Known As: Tying the tubes, tubal sterilization, female
sterilization, having your tubes tied, sterilization surgery –
female, tube tying, and permanent infertility.
o A tubal ligation procedure results in permanently sterile
This procedure is usually recommended for adult women
who are certain that they do not want to get pregnant in the
future.
 Tubal ligation is considered a permanent birth control method
 It tends to be a popular choice because women realize that this
method can offer extremely effective pregnancy protection for the
rest of their reproductive years.
 Women tend to prefer tubal ligation because of its convenience and
lack of side effects that are associated with temporary birth control
methods.
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OVER-VIEW
Tubal ligation (also commonly referred to as having your
tubes tied) is surgery that closes off a woman's fallopian
tubes. Once the tubes are closed or "tied," sperm will not
be able to reach an egg, so pregnancy cannot take place.
o A tubal ligation procedure results in permanently sterile
This procedure is usually recommended for adult women
who are certain that they do not want to get pregnant in the
future.
 It tends to be a popular choice because women realize
that this method can offer extremely effective pregnancy
protection for the rest of their reproductive years.
 Women tend to prefer tubal ligation because of its
convenience and lack of side effects that are associated
with temporary birth control methods. 18
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OVER-VIEW
The Tubal Ligation Procedure: A tubal ligation occurs
in a hospital or outpatient clinic. It can be performed
with:
 Conscious sedation - woman is awake, relaxed,
and drowsy
 Deep sedation - woman is asleep
 Anesthesia - local (woman is awake), regional
(body is numb from the navel down), or general
(woman is asleep)
During the procedure, the fallopian tubes are closed.
Some may require a few small incisions made in the
abdomen; in these procedures, the tubes are clipped,
cut and/or cauterized (sealed shut). Another option,
known as Essure, doesn't require an incision and
uses micro-inserts to stimulate blocking of the tubes.

20
OVER-VIEW
After a Tubal Ligation Procedure:
 Most women can return to work within a few days after
having a tubal ligation. Pain medication can help to
relieve any discomfort. It is recommended that women
avoid strenuous exercise for several days. In general,
most women feel ready to have sex again within a
week.
 The majority of women recover from this procedure
with no problems. Unlike with male sterilization
(vasectomy), no tests are required to check for
sterility.
 A tubal ligation does not decrease a woman's sexual
pleasure and doesn't affect her femininity. Since no
glands or organs are removed or changed and all
hormones will still be produced, a tubal ligation should
not change sexuality or interfere with the functioning
of a woman's sexual organs.
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OVER-VIEW
Effectiveness:
 Tubal ligation is more than 99 percent effective in the first year.
This means that that out of every 100 women who have this
procedure done, less than one will become pregnant during the
first year of use.
 Up to one out of every 100 women will become pregnant in each
subsequent year following the first year (when the procedure was
done). This is due to a slight possibility that fallopian tubes may
reconnect by themselves.
 Of every 1,000 women who have undergone tubal ligation,
approximately 18.5 will become pregnant within 10 years. These
statistics were concluded by the U.S. Collaborative Review of
Sterilization in their hallmark Crest study. However, depending on
the method used and the age of the woman when she has the
procedure done, this rate might be higher or lower.
 If a pregnancy does occur after a tubal ligation, there is a 33%
chance of it being an ectopic pregnancy. However, the overall
rate of pregnancy is so low, that a woman’s chance of having an
ectopic pregnancy is much lower than it would be provided she
did not have the tubal ligation done in the first place.
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TUBAL LIGATION

23
24
TUBAL LIGATION

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OVER-VIEW
Advantages -
 Permanent birth control.
 Immediately effective.
 Allows sexual spontaneity.
 Requires no daily attention.
 Not messy.
 Cost-effective in the long run.
Disadvantages –
 Does not protect against sexually transmitted infections, including
HIV/AIDS.
 Requires surgery.
 Has risks associated with surgery.
 More complicated than male sterilization.
 May not be reversible.
 Possible regret.
 Possibililty of Post Tubal Ligation Syndrome 26
FEMALE
STERILZATION
Risk associated w/ ligation –
 Due to actual procedure – include incomplete
closure of tubes (becoming preg.- approximately 1
out of 200 women); injury to near-by organs or
structures caused by surgical instruments;
increased possibility of ectopic if pregnancy occurs
after ligation
 Stemming from use of anesthesia – includes
reactions to drugs & breathing problems
 Risks of surgery in general w.c includes infection &
bleeding
27
FEMALE
STERILZATION
Method-associated sterilization failure – some
methods are associated w/ lower failure rate
 Puerperal sterilization & interval uni-polar
coagulation appear to have the lowest rate
 1/2 of pregnancy occurring after failed electro-
coagulation is ectopic preg. w/c is 10% compared
to ring, clip or tubal resection; compared to non-
sterilized, 1%
 Any symptoms of pregnancy after sterilization
must be investigated & ectopic must be ruled out
 Post-tubal ligation syndrome – characterized by
pelvic discomfort, ovarian cysts formation; esp.
menorrhagia 28
FEMALE
STERILZATION
Failures – reasons:
 Surgical errors account for 30 – 50%
 She was already pregnant

 Due to fistula formation from cauterization;


faulty clips (not occlusive enough); or tube
undergo re-anastomosis
 Equipment failure as in electro-cautery

Puerperal sterilization failure –


 Surgical errors
 Formation of fistula tract of cut tubes or re-
anastomosis 29
FEMALE
STERILZATION
Type of tubal ligation procedure use –
 Status of women’s health will signify w/c tubal
lig. option is best suited; 2 factors when
deciding –
 Safest procedure & include body weight

 Whether she had or not previous surgery

 More than half are done right after NSD thru a


small incision near navel; during C.S. or
abortion
 Essure (no incision) can’t be done until at least
6 wks after giving birth; had abortion; or
miscarriage 30
METHODS of
sterilization
Female sterilization can be done either by – 1)
Surgery or 2) Non-surgical methods
Accepted female sterilization is tubal ligation or
occlusion – done either by abdominal or vaginal
route
Abdominal route – mini-laparotomy and
laparoscopic sterilization
Vaginal route includes – colpotomy (trans-V);
coldoscopic sterilization; & trans-cervical route
by hysteroscopic sterilization
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TYPES OF OPERATIONS
Laparoscopy:
 Laparoscopic sterilization is one of the two most common
methods of sterilization. Typically, given general or regional
anesthesia. He will make a small incision, about half an inch
long, in or bellow the belly button. A harmless carbon dioxide
gas is injected into the abdomen, elevating the abdominal
wall off of the pelvic organs and allowing your surgeon to get
an unobstructed view as well as room to operate
 Next, a laparoscope (a small, telescope-like instrument with
a light) is inserted through the incision to view the tubes.
 The surgeon then inserts a smaller device used to move,
hold, and close off the fallopian tubes. This device could be
inserted either through the laparoscope or through a second,
tiny cut made just above the pubic hairline. The surgeon
closes the fallopian tubes by using rings, clamps, clips, or by
sealing them shut with an electric current (electrocautery).
The laparoscope is withdrawn, and the surgeon will then
suture the incision(s) closed. 32
LAPAROSCOPIC

33
LAPAROSCOPIC

34
TYPES OF
OPERATIONS
Mini-laparotomy (mini-lap) – small supra-pubic or
infra-umbillcal incision thru w/c the tubes can be
approached
 Not dependent on complicated, sophisticated
instruments; hence widely used
 Not new but later introduction of uterine elevator
made it popular w/c bring the tubes closer to the
incision
 Criteria to be called mini-lap – length of incision is
2 cm or less
 Generally – 2.5 – 3 cm vertical or transverse
incision about 2 fb above the upper borer of s.pubis
35
TYPES OF
OPERATIONS
Mini-laparotomy (mini-lap) –
 Interval mini-lap is done w/in the 1st 7 days of menstrual
cycle or any time during the cycle if she is taking pill
properly or has IUD & menstruating regularly
 Can also be done during interval period following vag.
delivery or abortion – Pomeroy method is preferred
 Immediate post-partum – w/in the 1st 48 hrs following
vaginal delivery – uterus is enlarged, so tubes are
higher in location & incision is just below the umbilicus
 Others prefer to do right after delivery (4th stage) when

still under OB anesthesia


 But some prefer to wait longer; done only when

secure that severe post-partum bleeding necessary


for hysterectomy will no longer occur 36
MINI-LAP LIGATION

37
POST-PARTUM
A postpartum tubal ligation is done to permanently
prevent a woman from getting pregnant. During this
procedure, the doctor makes a cut (incision) near the
belly button (navel) rather than in the pubic area. This
is because the uterus is enlarged from the pregnancy,
and the fallopian tubes are located higher in the
abdomen. The dotted line on the figure shows where
the cut is made below the belly button. The dotted
lines on the fallopian tubes show where they are
closed.
Postpartum tubal ligation is usually done as a mini-
laparotomy after childbirth. The fallopian tubes are
higher in the abdomen right after pregnancy, so the
incision is made below the belly button (navel). The
procedure is often done within 24 to 36 hours after the
baby is delivered. 38
POST-PARTUM LIGATION

39
TYPES OF
OPERATIONS
Laparoscopic – laparoscopy is used to visualized the
organs thru the anterior abdominal wall
 Tubal occlusion is done by – electro-cautery;
application of silastic rings or clips
Culdoscopic – culdoscopy is used to see pelvic organs
thru the posterior vagaginal fornix
Tubes are grasped, brought to vagina then do tubal
oclusion currently acceptable
 Commonly done is Pomeroy’s method

Colpotomy – same as above


Transvaginal approach – those who wish no visible
scar
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CULDOSCOPY

41
NON-SURGICAL METHDS
Culdoscope is an instrument, a kind of endoscope, used to
visualize female pelvic organs, introduced through the
vagina into the cul-de-sac (which is also called the
rectouterine pouch or the pouch of Douglas). The procedure
of inserting the culdoscope into the rectouterine pouch is
termed culdoscopy
The word culdoscope (and culdoscopy) is derived from the
phrase cul-de-sac, which in French literally means "bottom
of a sac", here referring to a blind pouch or cavity in the
female body that is closed at one end, that is the
rectouterine pouch. As early as the 13th century, a cul-de-
sac was a dead-end street (or a dead-end way), a blind
alley

42
NON-SURGICAL METHDS
Culdoscopy and culpotomy are two types of
vaginal sterilization approaches. The
vaginal method of tubal ligation was once
the preferred technique. However, since it
is associated with higher risks than
laparoscopic surgery, surgeons have been
favoring the abdominal approach to
transvaginal procedures.
These procedures each take about 15 to 30
minutes, and women are able to go home
the
43
NON-SURGICAL
METHODS
Hysteroscopy – an instrument to visualize
uterine cavity thru cervical canal
 Entails ID of cornual opening of tubes &
occluding them either by electro-cautery,
chemicals or mechanical plugs
 In Phil – did not gain ground; reserved for well
staffed & equipped medical centers
 Latest methods –

Essure methods

Adiana’s method

44
NON-SURGICAL
METHODS

45
IMPLANT
A tubal implant is a small
metal spring that is placed in
each of the two fallopian
tubes without using surgery.
It is guided through the
vagina, cervix, and uterus
and lodged in a fallopian
tube. Over time, scar tissue
grows around the two
implants and permanently
blocks the tubes. This stops
eggs from traveling from the
ovaries and down the
fallopian tubes, where eggs
are normally fertilized by
sperm. 46
IMPLANTS
ESSURE METHOD

47
ESSURE METHOD

48
ESSURE METHOD
Essure is a permanent birth control
procedure that works with your body to
create a natural barrier against pregnancy
Advantages:
 No cutting
 No going under general anesthesia
 No slowing down to recover
 No hormones
 No guessing for birth control
 Short procedure time - only takes about 13
minutes to perform
49
ESSURE METHOD
Disadvantages of Hysteroscopic Tubal Ligation
 The need to use an alternative birth control method
for three months until scar tissue forms and blocks
the fallopian tubs.
 Additionally, the Essure hysteroscopic sterilization
procedure is not reversible. Because the fallopian
tube tissue and coil implants grow together to
create a closed passage, the micro-inserts cannot
be surgically removed without damaging the
fallopian tubes.
 A tubal implant can also be difficult to insert, so a
second procedure is sometimes necessary to
completely block both tubes. In clinical studies,
approximately 1 out of every 7 women were not
able to have the coil-implants placed in both
fallopian tubes during the first placement
procedure.
50
ESSURE METHOD
Two years after the Essure procedure
indicate these potential risks:
 The micro-inserts may have been expelled out of the
fallopian tubes.
 The coil implants may have been inserted too far, or
not far enough, into the fallopian tubes.
 The micro-inserts may have been pushed through the
uterus or fallopian tube wall (perforation). Should this
occur, surgery may be needed to repair the situation.
 The coil implants could become damaged during
other medical procedures, such as endometrial
biopsy, dilation and curettage (D&C), or procedures
that require the use of radio frequency
51
ESSURE METHOD
 Additionalcomplications that could
occur during the insertion of the Essure
implants include:
 Mild to moderate pain
 Nausea and/or vomiting

 Fainting following the procedure

 Infection

 Undiagnosed pregnancy

52
ESSURE METHOD
The procedure can be performed in the comfort of
a doctor’s office without general anesthesia, and most
women resume their normal activities within one day.
3 months following the procedure, your body and the
micro-inserts work together to form a natural barrier
that prevents sperm from reaching the egg. During
this period, you must continue using another form of
birth control (other than an IUD or IUS).
Three months after the Essure procedure, a doctor will
perform an Essure Confirmation Test, to confirm that
the tubes are fully blocked and that the women can
rely on Essure for permanent birth control.
Essure does not contain hormones to interfere with
your natural menstrual cycle. Your periods should
more or less continue in their natural state.
53
ESSURE TEST
After insertion Hysterosalpingogram
(HSG) Test
Essure Scar Tissue - 3
Months

54
ADIANA TUBAL
STERILIZATION

55
ADIANA’S METHOD
Adiana is another new hysteroscopic sterilization procedure
Adiana uses radio frequency energy and a polymer microsinsert that
together result in tubal blockage in the interstitial segment of the
fallopian tube that is within the uterine muscle.
With the Adiana procedure, a catheter is positioned immediately
inside the opening of the patient's fallopian tube using a
hysteroscope. The catheter applies low-level radiofrequency (RF)
energy to remove the thin layer of cells that line a 1 cm section of the
inside of the fallopian tube.
A soft polymer matrix implant, that is smaller than a grain of rice, is
then inserted into the tubal opening. As scar tissue grows into the
inplant, tubal blockage occurs. The area of the tube that is affected is
smaller than with the Essure device. The portion of the tube outside
the uterus is not affected.
Similar to Essure, a confirmatory hystero-salpingogram (HSG) is
performed three months later to ensure the fallopian tubes are
completely blocked and that the woman can begin relying on Adiana
for permanent contraception. Adiana reversal is also performed by
the technique of tubouterine implantation.

56
TYPES OF OPERATIONS
Laparotomy:
 A laparotomy procedure (open tubal ligation) is considered to be major
surgery, so it is less commonly used than laparoscopy and mini-
laparotomy. This procedure requires general or regional anesthesia.
Your surgeon will make a larger incision (2 to 5 inches) in the
abdomen. The fallopian tubes will then be pulled up into or out of the
incision, closed off (tied, clipped, or sealed shut) with a device, and put
back into place. The incision will be stitched shut.
 A woman may need to be hospitalized for 2 to 4 days, and it could take
several weeks to fully recover. If the procedure is done after delivery, a
woman's hospital stay may be extended by 1 or 2 days.
 n open tubal ligation is usually performed right before or after some
other type of unrelated abdominal surgery, such as a Cesarean section
. If you are having a c-section delivery, your surgeon can perform the
laparotomy in just a few extra minutes while you are still under
anesthesia and your abdomen is still open.
 In addition to having abdominal surgery for other reasons, an open
tubal ligation may be recommended if you have or have had
pelvic inflammatory disease (PID), endometriosis, or previous
abdominal or pelvic surgery. These conditions can often cause
abdominal tissue and organs to scar or stick together (adhesion).
57
TYPES OF OPERATIONS
Laparotomy:
 A laparotomy procedure (open tubal ligation) is
considered to be In addition to having abdominal
surgery for other reasons, an open tubal ligation may be
recommended if you have or have had
pelvic inflammatory disease (PID), endometriosis, or
previous abdominal or pelvic surgery. These conditions
can often cause abdominal tissue and organs to scar or
stick together (adhesion).
 A laparotomy tubal ligation may also be necessary if a
woman:
 has had prior abdominal surgery
 is significantly overweight
 has had infections that have left adhesions or scar
tissue in the abdomen
 has had certain medical or gynecological problems
58
LAPAROTOMY

59
FEMALE
STERILIZATION
Restoration of fertility – One should be
sterilized believing that her fertility can
be restored either by surgery or
assisted reproductive technic (in-vitro;
ovum transfer)
These procedures are costly, difficult
& uncertain
Success rates vary upon age &
technology used
60
FEMALE
STERILZATION
Tube can be occluded by surgical,
electrical, mechanical or chemical
Electro-coagulation – is applied & tubes
are cut; current is applied to grasping
forceps either by mono-polar or bipolar
system; bipolar is safer
Mechanical – rings or clips are applied
Chemical – Quinacrine is delivered to
tubes via the cervix using the IUD
applicator; 3 monthly use is needed 61
FEMALE STERILZATION
Types of tubal sterilization done –
 Puerperal tubal ligation
 Irving procedure
 Pomeroy procedure
 Parkland procedure
 Madlener procedure
 Fimbriectomy
 Failure of puerperal sterilization – most sterilization
failures were not preventable
 Surgical errors – includes transection of the round
ligament instead of oviduct or partial transection of
oviduct
 Formation of fistula tract bet.severed tubal stumps
or spontaneous re-anastomosis
62
TECHNICS of
FEMALE
STERILZATION
Pomeroy’s method
Irving’s
Aldridge Madlener
Uchida
Parkland’s method
Kroner
Modified Pomeroy’s method
63
64
POMEROY’S TECHNIC
Pomeroy technique.
 A. A loop of the proximal portion of the tubal ampulla is
elevated to reveal the vascular supply of the
mesosalpinx
 B. A strand of absorbable suture material is used to
bilaterally ligate the tube and simultaneously provide
hemostasis.
 C. A hemostat is placed on the suture strands
immediately distal to the knot to prevent the tube from
retracting into the abdomen. The open blade of the
Metzenbaum scissors is used to pierce the mesosalpinx
and approximately 1 cm of the tube is excised.
 D. The end result following dissolution of the
absorbable suture material is return of the proximal and
distal portions of the tube to their normal anatomic
position. 65
66
PARKLAND TECHNIC
Parkland procedure involves
tying two non-absorbable
ligatures around the
fallopian tube in its proximal
to middle segment and then
cutting out the tubal
segment between the
ligatures.
The end result is similar to
the Pomeroy method of
tubal ligation. Two healthy
tubal segments remain that
can be rejoined by tubal
Two-thirds of women with a
Parkland tubal ligation
become pregnant following
tubal reversal surgery.
67
IRVING’S TECHNIC
Placing two ligatures around the
fallopian tube in its proximal to mid-
segment and removing the tubal
segment between the two ligatures.
Then, the tied end of the segment
of fallopian tube attached to the
uterus is sutured into the back side
of the uterus, and the other tied
end is buried in the connective
tissue underlying the fallopian tube.
As with other ligation/resection
methods, the Irving technique
leaves behind two healthy tubal
segments that can be put back
together with tubal reversal
microsurgery. The pregnancy rate
after reversal of an Irving tubal
ligation is 60-70%
68
IRVING’S TECHNIC

69
UCHIDA’S TECHNIC
A saline-epinephrine solution is injected into the
subserosal area of the tube, causing the muscular
tube to separate from the serosa.
The ballooned serosa is incised, and the muscular
tube is withdrawn.
A 5-cm section of the tube is then excised and
the proximal end ligated.
A purse-string suture is applied. The procedure
may be extended so as to include fimbriectomy
and removal of the isthmus and ampulla with
another suture placed around the mesosalpinx.
70
71
MADLENER’S TECHNIC
A. A loop of the ampullary
portion of the tube is
elevated and then both
segments are crushed
with a hemostat.
B. A strand of
nonabsorbable suture
material is used to ligate
the tube over the crushed
area. No tissue is excised.
The devascularized loop
of tube undergoes aseptic
necrosis
72
KROENER FIMBRIECTOMY
Top. A suture is anchored in
the mesosalpinx and placed
around the tube in the distal
ampulla. A second suture
may be placed adjacent to
the first, and the
infundibulum of the tube is
excised.
Bottom. The tube as it
appears following excision of
the distal segment.
73
ALDRIDGE TECHNIC
Top. By blunt dissection, a
pocket is developed within the
substance of the broad ligament.
Traction sutures are placed
within the muscular layer of the
distal tube and are used to draw
the infundibulum into the
peritoneal pocket.
Bottom. Several sutures of
nonabsorbable suture material
are then used to anchor the
infundibulum of the tube into the
new anatomic subperitoneal
location. Care must be taken to
ensure that the entire fimbriated
portion of the tube is firmly held
beneath the peritoneum.
74
REVERSAL OF STERILIZATION
It is restoration of the anatomical &
functional continuity of occluded ducts
 Re-anastomsis pf f. tubes; reconstruction of
abd. ostia; or implantation of healthy segments
into the uterus
 Males – re-anastomsis of vas deferens

Before surgery – considerations:


 Validity of reason for reversal
 Total fertility picture of couple
 Medical & social circumstances at time of
request is made (favorable or not)
 Duration of the sterilized state
75
REVERSAL OF STERILIZATION
Success of reversal is based on anatomical
& functional & proven by –
 Female – tubal insufflation, hysterosalpingo-
graphy or endoscopy; comfirmed when there is
intra-uterine pregnancy
 Male – anatomical success, proven by mere
finding of sperm in the ejaculate
Pregnancy rate ff. tubal anastomosis
depends on
 Method of sterilization
 Site of anastomosis
 Length of resected tube
 Technic employed 76
MALE STERILIZATION
A vasectomy is a surgery to render a man unable to
have children, or sterile. It is one of the most commonly
performed surgeries in America, while surgery to
sterilize women is more popular, the vasectomy surgery
is far less invasive and offers a much quicker recovery.
The vasectomy surgery works by preventing sperm
from exiting the body. This is done by severing or
blocking the vas deferens, the duct through which
sperm travels from the testes and out of the body.
Sperm is produced, but it cannot travel outside the
body when a man ejaculates.
While the surgery is effective at preventing pregnancy,
it does not alter the ability to have/maintain an erection.
There is no change in the quality or quantity of semen,
nor is there a change in the ability to ejaculate.
77
MALE STERILIZATION
Vasectomy considered one of most effective, safe
& simple methods
Why not popular among males –
 Interested in proving their virility than assuming
responsibility
 Afraid that it will affect their sex lives
Reasons for decline –
 Increasing availability of other methods
 Female sterilization – safer & simpler
 Lack of interest among family planners
 Publicity of long-term side effects among monkeys
but not proven in man 78
NORMAL MALE
ANATOMY

79
VASECTOMY

80
VASECTOMY

81
MALE STERILIZATION
Vasectomy – small incision in the scrotum, the
lumen of vas deferens is disrupted to block
passage of sperm from testes
Female sterilization compared to male has:
 20 x increased complication rates
 10 – 37 x failure rate
 3 x higher cost
Disadvantage – sterility in not immediate
 Complete expulsion of stored sperm n the tract –
takes about 3 mos or 20 ejaculations
 Semen check – 2 consecutive (-) count
 Take another form of contraceptive 82
MALE STERILIZATION
Precautions in vasectomy –
 It does not cause instant sterility
 Have to wait 15 – 20 ejaculations before
tract becomes devoid of sperm
Vas deferens cut – permanganate solution is
injected into proximal cut end, so it will flow
to seminal vesicle; violet color in urine –
most sperms are rendered inactive
Very effective – similar to pregnancy rate as
those female sterilization
83
MALE STERILIZATION
Usually done in the surgeon's office using local
anesthesia; scrotum is shaved and cleaned, &
anesthesia is given into this area to numb it.
Small incision in the upper part of the scrotum,
and tie off and cut apart the vas deferens. The
"tubes" are cut and sealed by tying, stitching,
cauterization or otherwise clamped to prevent
sperm from entering the seminal stream.
Then use stitches or a skin glue to close your
incision.
84
MALE STERILIZATION
Types of vasectomy –
 Vasectomy without an incision. This is called
a no-scalpel vasectomy (NSV). The surgeon
will find the vas deferens by feeling the
scrotum and then give you a shot of the
anesthesia into this area to numb it.
 Regular - a tiny hole in the skin of the
scrotum and seal off the vas deferens. Done
by either by pulling the vas deferens through
the tiny hole or insert a clip into the hole to
seal it; no need to stitches.
85
MALE STERILIZATION
New method of vasectomy – no-scalpel
technic pioneered in China
 A special designed fixing clamp encircles &
holds the vas w/o penetrating the skin
 Scrotum & vas sheath – punctured w/ sharp
ended hemostat & spread open
 Vas lifted out of scrotum & cut; then sealed
by ligation or coagulation
 Vas is then put back inside the sheath &
scrotum
86
MALE STERILIZATION
Compare to failure rate in tubal ligation –
10 – 20 x more likely to fail than vasectomy
Restoration after successful vasectomy does not
always succeed
 Odds for success is about 50%
 Risk of regret is due to immaturity at time of sterilization
Concern –
 Possibility that immune response might cause harmful
systemic changes
 No differences in occurrence of MI or stroke
 No convincing evidence of increase in testicular CA
87
MALE STERILIZATION
Vasectomy:
 INDICATIONS -
 A desire to not father a child
 Pregnancy contraindicated
 CONTRAINDICATIONS –
 Bacterial skin infection in the groin/scrotum
 Coagulation disorders or treatment with anticoagulant or antiplatelet
therapy
 Inability to palpate and elevate both vasa
 Hypersensitivity to palpation, precluding mobilization of the vas
 Lack of adequate informed consent
 Depression, psychosexual impairment, or impaired decision making
 Relative Contraindications
 Impending infertility, such as menopause or hysterectomy in wife
 Unresolved conflict or stress
 Inappropriate expectations of vasectomy 88
VASECTOMY:
1. Incisions
2. Spermatic Cord

89
PROCEDURE
The procedure starts with the administration of local
anesthesia, to numb the genitals.
Once the solution dries, the surgery begins with 1 or 2
half-inch long incisions on the underside of the
scrotum. The vas deferens, the cord that carries
sperm, is then located and either cut and tied off or cut
and cauterized. Research shows that the use of
cautery is the most effective, as it prevents the vas
deferens from healing back together.
The incision is then closed with sutures, which can be
removed at the surgeon’s office in a week to ten days.
90
MIDLINE INCISION

91
MIDLINE
INCISION

92
TECHNIC
In a vasectomy, an incision is made in the man's
scrotum. The spermatic cord is pulled out (B) and
incised to expose the vas deferens, which is then
severed (C). The ends may be cauterized or tied off
(D). After the procedure is repeated on the
opposite cord, the scrotal incision is closed (E).
The patient is not sterile immediately after the
procedure is finished.
 Use other methods of contraception until two
consecutive semen analyses confirm that there
are no sperm present in the ejaculate.
 It takes about four to six weeks or 15–20
ejaculations to clear all of the sperm from the
tubes. 93
Existing technique vs.
no needle approach

94
MALE STERILIZATION
Minor Complications –
 Minor complications occur in 5% to 10% of
vasectomy patients.
 Congestive epididymitis
 Sperm granuloma
 Bleeding from the skin incision
 Extensive ecchymosis
 Superficial wound infection
 Suture or clip rejection
 Skin reaction to the surgical antiseptic solution
 Neuroma
 Post-vasectomy pain syndrome 95
VARIATIONS OF
VASECTOMY
The No-Scalpel method (coined Key-Hole), in
which a sharp hemostat, rather than a scalpel, is
used to puncture the scrotum may reduce healing
times as well as lowering the chance of infection
(incision).
An "open-ended" vasectomy obstructs only one
end of the vas deferens, which allows continued
streaming of sperm (by virtue of the un-sealed
vas-deferens) into the scrotum. This method may
avoid build-up of pressure in the epididymis.
Testicular pain (from "backup pressure") may also
be reduced using this method. 96
MALE STERILIZATION
Major Complications –occur in less than 3% of
patients.
 Hematoma
 Scrotal infection
 Post-vasectomy pain -may last for a lifetime, is
estimated to appear in between 5% and 35
The "Vas-Clip" method does not require cutting the Vas
Deferens, but rather uses a clip to squeeze shut the
flow of sperm. This method may facilitate a better
chance/outlook for reversal, as well as reduced pain
(post-procedure).
 Link to dimentia - small number of men with
primary progressive aphasia, a rare speech disorder
 Psychological reactions - depression or anger

97
The Risks of
Vasectomy
Bleeding: A small amount of bleeding should be expected, but serious
bleeding should be reported
Hematoma: A collection of blood similar to a bruise but more
severe, a hematoma after a vasectomy typically results from
blood pooling under the skin at the surgical site.
Epidydimitis:A chronic ache or pain in the testicles, best
known by the slang term “blue balls," this condition can be
resolved with warm compresses in many cases. In severe
cases, surgery may be necessary to remove the epydidimis.
Sexual Problems:While there is no physical reason for sexual
problems, a small minority of men report problems with their
ability to function sexually after surgery. This is typically related
to feelings about the surgery rather than the surgery itself.
Spermatic Granuloma: An abscess that forms at the site of a
vasectomy, caused by sperm leaking from the vas deferens
after surgery.
98
MALE STERILIZATION
Reasons for failures – failure rate is 1% but
dependent on:
 Unprotected coitus before tract is empty
 Spontaneous recanalization of vas deferens
 Division & occlusion of wrong structures
 Rare undiagnosed congenital duplication of vas
Technic of vasectomy –local anesthesia
 Vas can be approach either thru single midline scrotal
incision or bilateral scrotal incision
 Vas is exposed, after cutting its sheath, clamp, cut &
ligated - Ligation of cut ends vary – some fold back the
proximal end onto itself than tied; some overlap the
tied ends while others close the sheath of vas over cut
ends
 Skin is closed w/ one stitch or none at all 99
MALE STERILIZATION
Restoration does not always succeed &
factors in restoring fertility
 Application of meticulous micro-surgical
technic for anastomosis
 Length of time after vasectomy
 Presence of sperm granulomas

No increase in MI or stroke nor cancer


Vasectomy – the safest of all VSC
procedures; does not affect hormonal
balance; does not lessen sexual desire &
enjoyment; & male virility is preserved 100
MALE STERILIZATION
Reversal procedure to reverse vasectomies using
vasovasostomy (a form of microsurgery)
Vasovasostomy is effective at achieving pregnancy in
only 50%-70% of cases. The rate of pregnancy
depends on factors such as: method use & length of
time elapsed
The body often produces antibodies against sperm,
sperm counts are rarely at pre-vasectomy levels.
 There is evidence that men who have had a
vasectomy may produce more abnormal sperm,
which would explain why even a mechanically
successful reversal does not always restore fertility.
 higher rates of aneuploidy and diploidy

101
PROGNOSIS
Vasectomy does not affect a man's ability to
have an erection or orgasm, or ejaculate
semen.
Sperm count gradually decreases after a
vasectomy. After about 3 months, sperm
are no longer present in the semen.
Most men are satisfied with vasectomy.
Most couples enjoy not having to use birth
control.
Alternative Names - Sterilization surgery –
male; No-scalpel vasectomy (NSV)
102
Semen Sample/Sperm
Count After a
Vasectomy
Six to eight weeks after the procedure, a semen sample
will be tested for sperm. This is done to make sure the
procedure was effective and that no sperm is present. In
some cases, it may take longer than 8 weeks for the
semen to have no sperm in it, but by 3 months, the
semen should be completely free of sperm.
When collecting a semen sample, it is important that the
semen not come in contact with spermacide, a type of
birth control that kills sperm. It is often present in
condoms and other types of contraceptives.
Three months after the surgery, the semen should have
no sperm in it. If there is any sperm in the sample, the
man remains fertile and can father children. 103
Ano ang say mo?

104

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