Permanent contraception Flashcards
Options for female permanent sterilisation?
- Filshie clip
- Salpingectomy- partial/total
- Essure (hysteroscopic)
Can be done hysteroscopic- Essure, laparoscopically or open (at time of CS)
What is the suggested technique for application of the Filshie clip to the tube?
- Uterine manipulator in position.
- Entry technique for laparoscopy, as per RANZCOG/AGES Consensus Guideline with multiple puncture laparoscopy.
- Identify the ovarian+round ligaments and the fallopian tubes by visualising their fimbrial ends.
- Apply the clip to the tube, ensure the jaws of the clip completely enclose the tube on the isthmic portion of the tube.
- After releasing, ensure the tube hasn’t been transected, the upper arm of the clip is flat
and locked under the nose of the lower jaw, and that the tube is still completely enclosed. - Repeat the procedure on the other side.
- Capture an image of the clip if available.
What are the minimum equipment requirements?
RANZCOG guideline
- either a disposable/ single-use or reusable applicator.
If using a reusable applicator it is strongly recommended that:
• Filshie clip applicators be serviced and recalibrated by their manufacturer or their appointed agent
in line with the manufacturer’s guidelines.
• Prior to using a reusable applicator it is good practice to ensure that the applicator is assembled
correctly and tested with the pressure gauge to ensure correct calibration.
What are the main reasons for legal claims against medical practitioners resulting from a failed
tubal occlusion?
Failure by the medical practitioner to:
• Time the procedure so that the patient is not pregnant, or exclude a pregnancy prior to performing
the procedure;
• Warn of possible sterilisation failure;
• Perform the appropriate technique;
• Diagnose a pregnancy that occurs after a failed sterilisation; and
• Diagnose an ectopic pregnancy.
Another basis for claims has been inadvertent injury at laparoscopy. Therefore, it is vital that practitioners
are skilled in carrying out the procedure.
Good practice points?
Good Practice Points
1. Ensure a detailed history is taken about previous gynaecological procedures.
2. Ensure the appropriate patient consent form/ is correctly completed. It is good practice to include
reference to the various discussions in the patient’s file and in a letter to the referring doctor.
3. Date of LMP should be recorded. It is recommended that the procedure be performed in the early to mid-follicular phase of the cycle unless other contraception
is being used.
4. A pregnancy test should be performed prior to the procedure if necessary.
5. The surgical unit is responsible for ensuring equipment is calibrated and Fellows should be satisfied that this process is adequate.
6. Note any intraoperative difficulties. If initial application is not ideal, a second clip may be applied.
7. If image capture equipment is available take adequate photographs to show that the clip has been
correctly applied.
8. If there is any doubt about either of the clip applications, or if one or both tubes can not be
visualised, discuss the situation with the patient post-operatively.
9. If in doubt, advise the patient to use alternative contraception until tubal occlusion has been
confirmed with hysterosalpingogram or hysterosalpingo contrast sonogram.
Salpingectomy versus tubal Occlusion
Pros:
- Evidence that high-grade serous tumours of the ovary and peritoneal surface epithelium may originate in the fallopian tubes.
- No known benefit for retaining fallopian tubes in the post-reproductive period,
- removal of the fallopian tubes does not appear to impact on ovarian function
- Hence, bilateral salpingectomy should be discussed with the patient during the informed consent process for Filshie clip tubal occlusion.
Cons:
- Removal of the tubes doesn’t increase surgical complications when performed with oophorectomy, there may be an increased risk of other complications when compared to tubal occlusive procedures.
- May also need extra laparoscopy port sites when performing salpingectomy
If filshie clip applicators aren’t serviced, what can happen?
applicators can result in a loss of calibration which can lead to incorrect closure of the Filshie clip and
possible failed tubal occlusion.
Risk of failure for Filshie clip?
1:300
Counselling prior to permanent contraception?
- Other non-permanent contraceptives available
- Discuss salpingectomy vs Filshie
- Risk of failure
- Risk of ectopic in event of failure
- Risk of regret
- Permanent and irreversible
- Give information leaflet (RANZCOG have one)
What features increase a woman’s risk of regret from permanent sterilisation?
- below 30 years of age,
- if the woman is childless,
- if there is conflict between the woman and her partner.
- when sterilisation is undertaken at the time of an abortion.
Male sterilisation vs female
Sterilisation by vasectomy has a lower failure rate in the order of 1 in 2000 and less risk as a procedure.
It is often undertaken under local anaesthesia.
