Sterilisation (male, female) and hysterectomy Flashcards
What are the options for female sterilisation?
-
Laparoscopy - occlusion of the Fallopian tubes
- applying clips – plastic or titanium clamps are closed over the fallopian tubes
- applying rings – a small loop of the fallopian tube is pulled through a silicone ring, then clamped shut
- tying, cutting and removing a small piece of the fallopian tubes
-
Mini-laparotomy
- incision lower abdo
- done under GA
- may also be done at C/S
NB: SEEMS LIKE THIS IS NO LONGER DONE: Hysteroscopy - outpatient procedure where microinserts (expanding springs) are inserted into the tubal ostia and inducing fibrosis of the cornual section.
Define female sterilisation.
Female permanent contraception (aka tubal ligation) that prevents pregnancy by occluding or removing the fallopian tubes.
Define male sterilisation.
Vasectomy.
The most effective mode of permanent male contraception and the only widely available method. It involves interruption/occlusion of each vas deferens and is typically performed in an outpatient setting under local anesthesia.
Describe the process of female sterilisation using filshie clips. How long after is contraception required?
- Done as a laparoscopically or during laparotomy (C-section)
- Effective contraception must be used until next menses (as there is risk of implantation of an early fertilised egg)
- This is irreversible
Describe the process of vasectomy. How long after is additional contraception required?
- Done as an outpatient procedure
- Puncture wound is made in the skin of the scrotum under local anaesthesia
- Vas deferens is accessed, divided and occluded using cautery
- Takes ~15mins and can be done in clinic, hospital or some GPs
- Postvasectomy semen analysis is conducted at 12 weeks to confirm absence of spermatozoa in the ejaculate
- Alternative contraception is required until azoospermia is confirmed
How long after vasectomy does barrier contraception need to be used?
Until semen tests have confirmed effective procedure
Can take 12 weeks
How soon after vasectomy/female sterilisation is intercourse permitted?
Vasectomy - usually days 2-7 if comfortable (with barrier contraception)
Female sterilisation - as soon as comfortable but use contraception until the procedure and 7 days afterwards for effective protection
NB: warn patient that none of these methods protect against STIs
What happens to the eggs released post-sterilisation?
Absorbed by the body
Usually menstruation should not be affected but pattern changes in some
What are the indications for hysertoscopic vs laparoscopic female sterilisation?
Filshie clips may be less suitable for women who pose a high surgical risk e.g. obesity or pervious abdominal surgery
What are the indications for male and female sterilisation?
- Completed family
- Not wishing to have children
- Not wishing to use reversible contraception
What are the contraindications for male and female sterilisation?
Female C/I:
- No absolute contraindications but high surgical risk in:
- Severe obesity
- Intraabdominal adhesions
- Medical morbidity which is significant e.g. cardiac, pulmonary etc.
- Young age (<30yrs) and no children - can still be sterilised but will be referred to discuss before this
Male C/I:
- Scrotal haematoma
- Site infection
- Sperm granuloma
- Local abnormality e.g. varicocele, hydrocele, scrotal mass, cryptorchidism.
What are the complications of female sterilisation?
- Internal bleeding, infection and damage to other organs.
- Failure and subsequent pregnancy which is more likely to be ectopic
- Failure and rejoining of the tubes
- Regret
- Irreversibility (not available on NHS)
What are the advantages and disadvantages of female sterilisation? (counselling)
Advantages:
- >99% effective
- should be effective immediately – but use contraception until your next period
- will not affect libido or sex
- it will not affect hormone levels
Disadvantages:
- it does not protect against STIs
- irreversible usually and reversal operations are rarely funded by the NHS
- failure – the fallopian tubes can rejoin and make you fertile again, although this is rare
- complications of surgery
- an increased risk of an ectopic pregnancy
Advice:
- Will be able to go home once recovered from the anaesthetic, usually same day
- Do not use tampons after procedure
- Use contraception for 3 months after the procedure
What are the complications after vasectomy?
- scrotal haematoma
- sperm granulomas - caused by sperm leaking from the tubes, may form a tender mass but usually asymptomatic
- infection
- epididymitis
- persistent post-vasectomy pain (may need further surgery to reverse vasectomy or complete epididymectomy
- failure
What are the advantages and disadvantages of vasectomy?
Advantages:
- >99% effective
- long-term effects rare
- it doesn’t affect hormone levels,l ibidoor interfere with sex
- simpler and safer alternative to female sterilisation
Disadvantages:
- rarely reversible and reversals are rarely funded by the NHS
- contraception until azoospermia
- surgical complications
- the vas deferens tubes can reconnect, but this is very rare
- vasectomy doesn’t protect against STIs
Is male or female sterilisation more effective?
failure rate: 1 per 2,000
male sterilisation is a more effective method of contraception than female sterilisation
What is the rate of successful reversal of male and female sterilisation?
Male - up to 55%, reversal success, if done within 10 years, and approximately 25% after more than 10 years
Female - likelihood of obtaining reversal for women ≤30 and >30 years of age at the time of permanent contraception was 2.1% and 0.2%, respectively
How high is risk of regret with women who undergo sterilisation? What are the risk factors for regret?
2 to 26% - higher in those who have it done at delivery
Risk factors for this include…
- Age <30
- Nulliparity
- Recent pregnancy (birth, abortion, miscarriage)
- Relationsal issues
(NB: seems like this is no longer done)
Describe the process of female sterilisation hysteroscopically. How long after is contraception require
- Performed as an outpatient procedure without GA
- Microinserts (Essure®) are inserted into the tubal ostia hysteroscopically
- Essure consists of expanding springs of 2mm width x 4cm length, made of titanium, steel and nickel containing Dacron fibres
- The springs induce fibrosis within the cornual section of each Fallopian tube over the next 3 months so contraception is required for 3months after procedure
- Contraception can only be discontinued once correct placement of inserts is confiremd by XR or US
What are the complications of hysterectomy?
Mortality - 1 in 10,000
Immediate - haemorrhage, bladder or ureteric injury
Postoperative - VTE (use LMWH), pain, retentionm infection of urine, wound and chest infections (use prophylactic abx), pelvic haematoma
Long term - prolapse, stress incontinence, premature menopause, pain and psychosexual problems
What are the most common indications for hysterectomy?
- Menstrual disorders
- Fibroids
- Endometriosis
- Chronic PID
- Prolapse
- Pelvic malignancies
- Failure of other methods
What are the types of hysterectomy?
Total abdominal hysterectomy - uterus and cervix through abdominal incision e.g. malignancy
Subtotal hysterectomy - cervix retained and smears in the past need to have been normal
Vaginal hysterectomy - removal of cervix and uterus after incising the vagina from below, usually done for prolapse, faster recovery
Laparoscopic hysterectomy - laparoscopic-assisted vaginal hysterectomy (LAVH) or total laparoscopic hysterectomy (TLH)
Wertheim’s (radical) hysterectomy - removal of parametriumm, upper third of vagina and pelvic lymph nodes. Usually for stage 1a(ii)-2a cervical carcinoma. Rarely done vaginally (‘Schauta’s radical hysterectomy’)
