Surgery: Postpartum Sterilization Techniques

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What is a postpartum tubal? 

  • Procedure done after birth of a baby to permanently prevent future pregnancy 

  • Reason for performing it postpartum:

    • Usually done within 1-2 days after vaginal delivery 

    • Highly effective: risk of pregnancy is <1% (though if you want to look at the actual rates depending on type of surgery, please check out the CREST study!

    • Increased access: patients are already in the healthcare setting after delivery of their baby; don’t have to come back to the hospital/healthcare setting for a different procedure

    • Mostly minimally invasive: not laparoscopy, but can be done through a single, mini-lap incision below the belly button as the fundus of the uterus is still high 

Today we will focus on the surgical steps 

  • For pictures, we still like Atlas of Pelvic Surgery:

  • Pre-operative 

    • Surgical consent 

      • Review the way the procedure is done and discuss the different methods that you can provide.

      • Discuss the risks, benefits, and alternatives

        • Benefits: stated above, quick recovery usually 

        • Risks: as with all surgeries, there are risks of bleeding, infection, injury to organs around the uterus and fallopian tubes 

          • Another big risk I tell people: we can’t perform the surgery that they want after delivery 

          • A few major reasons: significant anemia after delivery, infection (ie. chorio/endometritis), inability to palpate the fundus after delivery 

            • Can also be an issue for patients with increased central adiposity 

          • Lastly, it is possible that we enter the abdomen but cannot perform the surgery because we can’t find the tubes, usually due to adhesions 

        • Alternatives: no sterilization procedure or use a different form of birth control until 6 weeks postpartum for a laparoscopic procedure 

        • MA-31 - 30 day consent! For those with state insurance

    • Preoperative work up 

      • History: 

        • Ask specifically about history of abdominal surgeries and pelvic infections (ie. Chlamydia/Gonorrhea) 

        • This can help determine if there will be significant intrabdominal adhesions that may prevent surgery 

        • Not a strict contraindication for surgery, but should go into counseling of patients 

      • Physical 

        • Palpation day of surgery of the fundus 

        • Can decide to proceed or not if fundus is easily palpable 

      • No additional work up usually beyond prenatal care and delivery 

      • Sometimes, if there is significant blood loss with delivery, providers may want to get a CBC 

      • Usually, will have a type and screen on file already as patients are admitted for delivery (but should have this definitely)

    • Anesthesia 

      • Most procedures are done with neuraxial anesthesia 

      • Sometimes, patients can keep their epidural from labor/birth 

      • However, some patients may not want another epidural/spinal 

    • Expectations 

      • Patient will not need to necessarily stay longer than for delivery 

      • May need a small amount of narcotic medication for incisional pain, but usually, I do not prescribe more than 5 tabs of 5 mg oxycodone, and only if needed 

  • During the surgery 

    • Adequate anesthesia and prepped and draped 

    • Positioning: 

      • Dorsal supine 

      • Though during surgery, we can ask the anesthesiologist to airplane the patient to the left or right in order for the uterus to fall to one way or the other and bring the fimbria of the tube into view 

    • Surgical steps 

      • After prepping the abdomen, mark approximately 3-4 cm on the inferior edge of the umbilicus 

      • Some people will inject 1% lidocaine at this time, but I find that it distorts the anatomy 

      • Incise along edge and continue downward dissection until the fascia is reached. Can use Army-Navy or other retractors to hold back the skin 

      • Pick up the fascia with either Kelly, Kocher, or Allis and make a small incision with the Metzenbaum scissors after ensuring no bowel is adhered to the fascia 

      • Incise the fascia after protecting with a finger, and place a Kocher on either end. Some people will also throw a stitch on either end with an 0-vicryl and hold these with hemostats to be able to find your fascia later 

      • Retract the fascia (again, can use army-navies or some people like the small Alexis-O retractor) and pop into peritoneum, then use a finger to feel for the cornua and tube 

      • Can airplane the patient right or left for either tube 

      • Once the tube is found, use a Babcock to hold it up and follow it out to the fimbria. Make sure it is a tube and not a round ligament! 

      • Salpingectomy

        • Use a Ligasure to clamp, seal, and cut the tube along the mesosalpinx 

        • Make sure to hug the tube 

        • Clamp, seal, and cut where the tube meets the cornua to remove the tube 

        • Inspect area of sealing and cutting to ensure no bleeding 

        • Allow the tube to fall back into the abdomen, and proceed with the next tube 

        • If you don’t have a Ligasure, can use a kelly clamp to clamp along the mesosalpinx below the tube. Cut above the Kelly clamp until the end of the clamp is reached 

        • Use a 3-0 synthetic absorbable suture and take a bite with the needle just beneath the level of the clamp and tie this portion down 

        • Do this several more times until the cornua is reached 

        • Use the Kelly clamp to clamp off the end of the tube, cut off the tube, and again, use the 3-0 synthetic absorbable suture to ligate the end of the tube 

        • Send tube to pathology for confirmation of cross section

      • Pomeroy Technique

        • Place the babcock in the middle of the tube so that a small, 1-2 cm portion of tube is elevated 

        • Tie a 3-0 synthetic absorbable around the base of this elevated section. Can tie two for a modified pomeroy 

        • Hold the suture with a hemostat and then excise the knuckle of tube for pathologic confirmation 

        • Use the hemostat to keep the tube out of the abdomen to inspect the area that you have incised for any bleeding. Use a bovie to coagulate any areas of bleeding

        • Once the area is dry, can take off the hemostat and let the tube drop back into the abdomen 

  • Parkland technique

    • Place the babcock in the middle of the tube so that a small, 1-2 cm portion of tube is elevated 

    • Using the Metzenbaum scissors, incise a small, avascular portion of the mesosalpinx beneath the babcock 

    • Pass two ligatures of 3-0 synthetic absorbable suture through the area that was incised and tie down on either end of the tube

  • Hold one end with a hemostat 

  • Use the scissors to incise the knuckle of tube above the ligatures and send to pathology 

  • Inspect the incised portions and ensure no bleeding

  • Allow the tube to fall back into the abdomen 

  • Once you have completed both sides and achieved hemostasis, close the fascia with 0-Vicryl or similar suture 

  • Then close the skin with 4-0 Biosyn/Monocryl 

  • Can inject lidocaine at this time if desired 

  • Bandage the area with small pressure dressing 

  • Post operative 

    • Spinal/epidural should wear off before going to postpartum unit 

      • Can breastfeed immediately if desired 

    • Routine postpartum in the hospital, with small amount of narcotics if needed

    • Remove dressing in 24 hours  

    • Follow up for routine postpartum care 


The CREST Study

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Here’s the RoshReview Question of the Week!

Which of the following methods of sterilization has the highest relative risk for ectopic pregnancy?

Check your answer and get a special deal on RoshReview at the link above!

Background: 

  • Who did the study? 

    • Study was done by the US Collaborative Review of Sterilization Working Group 

    • CREST was part of the CDC and conducted with the NICHD 

    • Conducted with 10 year follow up and was done at multiple medical centers (Baltimore, MD, Buffalo, NY, Chapel Hill, NC, Honolulu, HI, Houston, TX, Memphis, TN, Sacramento CA, St. Louis, MO, San Francisco, CA) 

  • Where was the study published? 

    • AJOG in 1996 

    • Presented at the Annual Meeting of the American Gynecological and Obstetrical Society in Napa, CA in 1995 

  • Why was the study done?

    • Tubal sterilization is the most prevalent form of contraception among married women and formerly married women in the US 

    • While sterilization was common, there was not widespread data about their efficacy, especially over time 

  • Objective: To assess the effectiveness of various methods of tubal occlusion 

Methods: 

  • Who was included? 

    • Prospective study of women undergoing tubal sterilization at the above mentioned medical centers from 1978 -1986 

    • Ages 15-44 years 

    • Patients were approached before their sterilization procedure 

  • How was it done? 

    • If the patient agreed, information about her history was obtained 

      • Characteristics of the surgical procedure, including complications during the surgery and afterward, were recorded 

      • Contacted at 1 month for brief follow-up 

      • Annual follow-up planned for 5 years for all patients 

      • If they were enrolled early enough, patients also had annual followup for 8-14 years after sterilization 

      • If the patient could not be contacted for the follow up then the last completed interview was used in the analysis 

    • At the follow up, all patients were asked: “Since your tubal sterilization, have you had a positive pregnancy test or been told by a physician that you were pregnant?” 

      • If yes, the interviewer then had a separate form with additional info about the pregnancy 

      • Excluded from further follow up if they became pregnant, had a repeat sterilization, a tubal anastomosis, or hysterectomy 

    • Type of tubal occlusion included: (don’t need to say all of these) 

      • Laparoscopic unipolar coagulation - don’t do these anymore! 

      • Laparoscopic bipolar coagulation - I have never seen this 

      • Laparoscopic silicone rubber band application - I think I did a few of these 

      • Laparoscopic spring clip application - Filshie clips? 

      • Partial salpingectomy (including Pomeroy, other types of partial, and total salpingectomy) 

    • If a pregnancy was identified, they were classified into: 

      • True failure (pregnancy conceived after sterilization) 

      • Luteal phase pregnancy (pregnancies conceived before sterilization but ID’ed after) 

      • Pregnancy resulting from tubal anastomosis or IVF 

      • Or pregnancy of unknown status (didn’t get the information) 

Results 

  • Who: 

    • 10,863 women enrolled → 178 were excluded from analysis

      • Some were due to loss to follow up, refusal to be interviewed at 1 month follow up, or refusal for prolonged follow up 

      • Others excluded because of hysterectomy, repeat tubal ligation, or death  

    • Demographics 

      • Median age: 30 (so pretty young!) 

      • Most women were non-Hispanic White (52.7%) and had had at least 2 pregnancies 

      • Most common procedure: silicone band (31.2%), followed by bipolar coagulation (21.2%), postpartum partial salpingectomy (15.3%)

        • For us, that is super different! Since I think what i have done the most is postpartum or interval total salpingectomies 

        • Though for a bit, we also did Pomeroys and Parklands  

  • Follow-up 

    • 89.2% were interviewed at 1 year after sterilization, 81% at 3 years, 73% at 5 years, and 57.7% 8-14 years (so some drop off, but that’s expected) 

    • At each follow up interval, younger women (age 18-27) had lower percentage of follow-up than older women 

    • Black, non Hispanic women also had lower rates of follow up compared to white non-Hispanic women 

  • Sterilization failures

    • Out of 10,685 women in the analysis, only 143 were true sterilization failures = 1.3% failure rate  

      • 21 (14.7%) ended in SAB 

      • 26 (18.2%) were TABs 

      • 41 (28.7%) ended in delivery 

      • 47 (32.9%!!!) ended in ectopic pregnancies 

    • Another 34 women not included in analysis had luteal phase pregnancies  

    • 16 were from tubal anastomosis and IVF, and 5 were “unknown” classification

  • Above table: lifetime accumulation of sterilization failure by method from 1-10 years per 1000 procedures and 95% CI (only showing years 1-4 because all the years made the table huge) 

    • We can see that for clip and interval partial salpingectomy, there seems to be a higher rate of lifetime pregnancies 

    • Lowest risk was postpartum partial salpingectomy 

  • Also looked at 10-year cumulative probability of failure is affected by age at tubal sterilization 

    • Probability for failure in women <28 is greater than for women sterilized at ages >34 (makes sense … if you’re younger, you likely have more “fertile” years ahead of you) 

  • After adjustment for age, race, and study site, interval partial salpingectomy, spring-clip application, and bipolar coagulation were more likely than postpartum partial salpingectomy to result in sterilization failure 

  • After adjustment, black women were at higher risk than white women for sterilization failure 

  • There were also interestingly differences between sites! 

So what did this all mean? 

  • Sterilization failure rates 

    • Higher than previously thought! For all comers it was a little over 1% 

    • HIgher failure rates occurred after longer times (ie. more than 1-2 years, which was what other studies had looked at)

      • Failure rates between 5-10 years after procedure ranged from 1.2-8.3/1000 procedures depending on method 

    • Method failure rate also is affected by age, race, and also institution! (meaning how well or properly you do the procedure could affect effectiveness) 

    • Also, risk of ectopic increases with tubal ligation 

  • What was the follow-up or impact of the CREST study? 

    • There was way more data collected than just this, and way more than just this study that was published from the CREST dataset 

    • Some other studies that were interesting: 

      • Risk of regret after tubal sterilization (1985) - 2% regretted after 1 year, 2.7% did so after 2 years 

        • Characteristics of those that had more regret: age <30 (regardless of parity), concurrent C/S

          • After 5 year follow up, risk of regret in those 20-24 was 4.3%, rate for those 30-34 was 2.4% 

          • Where do we get this 20% risk of regret from??? - different study from 1999 - in women <30 years of age 

            • In that same study for women >30, risk of regret was 5.9% 

            • Also, for women <30 the cumulative probability of regret decreased as time since birth of the youngest child increased

            • Risk of regret was actually lowest for women with no previous births!!

      • Unintended laparotomy associated with laparoscopic tubal sterilization: rate was: 51/5021, so about 1%

        • Increased risk: prior abdominal or pelvic surgeries  

      • Characteristics of those that sought tubal reanastomosis

        • 6.2% sought information for reanastomosis 

        • Women who were <30 were more likely to seek out this information 

        • Of those that actually had anastomosis, they were more likely to be white, have lower gravidity, and be younger, and to have experienced changes in marital status

  • How does this change our practice? 

    • We are performing different procedures from the ones that were studied in the CREST procedure

      • Nevertheless, I still quote the findings from this study for patients when they want them: 

        • Risk of failure depends on method

        • Risk overall of failure is low, but can be as high as 1% overall, and even higher depending on age and type of procedure 

        • Risk of conversion to laparotomy from laparoscopy is overall low but increases with more surgeries in the belly 

        • Risk of regret is as high as 20% – I think I may now qualify this only for certain populations! 

      • We shouldn’t NOT perform sterilization procedures, however, just because of risk of regret 

        • Even if someone is nulliparous, young, and not married, if they are well counseled and still desire sterilization, we can perform it 

Permanent Sterilization with Dr. Aparna Sridhar

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Here’s the RoshReview Question of the Week:

​​A 38-year-old woman presents to your office seeking counseling. She has four children, and she would like to have a tubal sterilization procedure. You explain to your patient the risks and benefits of bilateral salpingectomy compared to tubal ligation. Which of the following is this patient at risk for if she undergoes this procedure?

Check out the correct answer by following the links above!

Today we welcome back Dr. Aparna Sridhar, associate professor at UCLA Health, to talk about permanent sterilization counseling. You may remember her from our previous episode about combined hormonal contraceptives.

Dr. Sridhar gives us an awesome overview of all forms of permanent sterilization, including male permanent sterilization (vasectomy).