Enumerate the guidelines for case selection fit for sterilization.
(Self-declaration by the client will suffice as the basis for this information.)
1. Clients should be ever married.
2. Male clients should be at least 22 years old and ideally be below the age of 60 years.
3. Female clients should be below the age of 49 years and above the age of 22 years.
4. The couple should have at least one child whose age is above 1 year unless the sterilization is medically indicated.
5. Clients or their spouses/partners must not have undergone sterilization in the past (not applicable in the cases of failure of previous sterilization).
6. Clients must be in a sound state of mind so as to understand the full implications of sterilization.
7. Mentally ill clients must be certified by a psychiatrist, and a statement should be given by the legal guardian/spouse regarding the soundness of the client's state of mind.
8. A relevant medical history, physical examination and laboratory investigations need to be completed to ascertain eligibility for surgery.
What are the advantages of terminal methods of sterilization?
• Does not require sustained motivation.
• It is the most effective method of contraception.
• Low rate of complications if the surgery is correctly performed.
• Does not require any action at the time of intercourse.
What are the disadvantages of the terminal methods of sterilization?
• Need for a trained doctor for performing the surgery.
• Need for facilities for the surgery.
• Reversibility is difficult.
• Does not protect against STD/HIV.
Which sterilization (male or female) surgery is preferable and why?
Vasectomy is preferable as it is simple, safer, and cheaper than tubectomy.
Under which scheme is a client compensated for a failure of a sterilization surgery?
Compensation is made under Government of India Family Planning Insurance Scheme and the amount is revised from time to time.
VASECTOMY (MALE STERILIZATION)
Steps of the procedure of vasectomy
1. Vas is clamped at two points.
2. A piece of approximately 1 cm is resected from the segment between the two clamps.
3. The cut ends are ligated.
4. The ends are folded onto themselves and sutured in that position.
5. The removed section is gently squeezed onto a glass slide, stained with Wright's stain, and examined under the microscope to confirm that the removed part is the Vas only and not any other structure.
Mention the postoperative advice to be given after vasectomy.
Warn the client that he is not immediately rendered sterile after vasectomy.
• He should use another method of contraception till azoospermia is established. This takes approximately 30 ejaculations.
• Avoid bathing for next 24 hours at least.
• He should wear a T-bandage or scrotal support (Langot) for 15 days after surgery. This bandage should be kept clean and dry.
• Avoid cycling and lifting heavy weight for next 15 days.
• To report back for stitch removal on the 5th postoperative day.
• The client should be warned that there is a small possibility of recanalization of the vas, which may result in failure of contraception. His written consent should include the acknowledgement of having received this information.
• He should report for semen analysis after 3 months.
Mention the failure rate of vasectomy.
Failure rate for vasectomy: 0.15 pregnancies per HWY
Mention some causes of failure of vasectomy.
• Mistaken identity of the vas at the time of surgery
• Spontaneous recanalization of the vas
• Occurrence of more than one vas on one side
• Sexual intercourse before total disappearance of sperms from the reproductive tract
Mention some complications of vasectomy.
Early postoperative
• Pain
• Scrotal hematoma
• Local infection
Late postoperative
• Sperm granules
• Spontaneous recanalization
Psychological
• Decreased sexual performance
• Impotence
• Fatigue
• Headache
Mention some contraindications to male sterilization surgery.
There are no absolute contraindications for performing vasectomy.
However, there are certain relative contraindications where one needs to apply the criteria of ‘caution’, ‘delay’ or ‘special’.
Caution: The procedure is normally conducted in a routine setting, but with extra preparation and precautions.
1. Young age - young men should be counselled about the permanency of sterilization and the availability of alternative, long- term and highly effective methods
2. Depressive disorders
3. Diabetes mellitus – increased risk of post-operative wound infections
4. Previous scrotal injury
5. Large varicocele – The vas may be difficult or impossible to locate; a single procedure to repair varicocele and perform a vasectomy is advocated
6. Large hydrocele – The vas may be difficult or impossible to locate; a single procedure to repair hydrocele and perform a vasectomy is advocated
7. Cryptorchidism – if unilateral; if bilateral along with demonstrated fertility the surgery will be more complicated and will be assigned to ‘special’ category.
Delay: The procedure is delayed until the condition is evaluated and/or corrected. Till then, alternative temporary methods of contraception should be provided.
1. AIDS - The presence of an AIDS-related illness may require a delay in the procedure
2. Local infections - increased risk of post-operative infection
a. Scrotal skin infection
b. Active STI
c. Balanitis
d. Epididymitis or Orchitis
3. Systemic infection or gastroenteritis - increased risk of post-operative infection.
4. Filariasis; Elephantiasis - If elephantiasis involves the scrotum, it may be impossible to palpate the spermatic cord and the testes.
5. Intrascrotal mass - This may indicate an underlying disease
Special: The procedure should be performed by an experienced surgeon and staff, in a setting where equipment for providing general anaesthesia and other back-up medical support is available
1. Coagulation disorders - increased risk of post-operative haematoma
2. Inguinal hernia - Vasectomy can be performed concurrently with hernia repair21
What is No – scalpel vasectomy (NSV)?
No Scalpel Vasectomy is a refined approach for isolating and delivering the vas and uses only vasal-block anaesthesia.
NSV neither requires any scalpel cut on the skin nor any skin stitch after completion of the procedure. Therefore it is much less painful and faster procedure than conventional vasectomy.
In the no-scalpel vasectomy technique, the provider grasps the vas deferens with specially designed forceps and makes a tiny puncture in the skin at the midline of the scrotum with a special surgical instrument
No-scalpel vasectomy is the recommended technique. In March 1992, NSV was officially put into National Family Planning Programme of India
TUBAL LIGATION (FEMALE STERILIZATION)
Name the two surgical procedures which are used for female sterilization.
• Laparoscopy – This involves inserting a laparoscope into the abdomen, through a small incision. The laparoscope enables the doctor to view and occlude the fallopian tubes with Falope rings
• Mini laparotomy (minilap) – which involves making a small incision in the abdomen. In this, a portion of the fallopian tube is ligated and incised
At which stages in the reproductive period of a woman can the surgery be performed?
Sterilization surgery can be performed
• As an interval procedure: This is known as “interval sterilization.” This should be performed within 7 days of the menstrual period (because this is the follicular phase and the ovulation is yet to occur).
• Postpartum sterilization: This is done after 24 hours and within 7 days of the delivery.
• At the time of an MTP: Can be done concurrently with the MTP.
• Following a spontaneous abortion: Provided that the client is medically fit.
• Concurrent with other Surgery: LSCS, Salpingectomy or Ovarian Cystectomy
Which surgery is advocated for postpartum ligation?
• Mini laparotomy
Why Post-Partum Sterilization should not be performed beyond 7 Days?
By seven days after delivery, the uterus descends into the pelvis which makes access to the fallopian tubes more difficult. Bacteria are present more often in the tubes and endometrial cavity which leads to increased chance of infection.
Hence, the procedure should be postponed to 42 days (6 weeks) after delivery when the uterus has involuted and become less vascular and risk of pelvic infection is also reduced.
Who is eligible for performing these surgeries?
Minilap
• An MBBS doctor after training and certification in minilap
Laparoscopic sterilization
• DGO
• MD (Obs & Gyne)
• MS (Surgery) with training in laparoscopic sterilization
• MBBS with experience in minilap followed by training in laparoscopic sterilization
In addition, these doctors should be on the district panel and this panel is to be updated 6 monthly.
In which conditions, laparoscopic sterilization is not indicated?
• For the postpartum sterilization
• When done along with a second-trimester abortion
Minilap is the surgery of choice for tubal ligation under these circumstances.
Where can female sterilization be performed?
If no pre-existing medical conditions require special arrangements:
• Minilap Tubectomy can be provided in basic health facilities such as PHC/CHC/ district hospitals where surgery can be done. These include both permanent and temporary facilities that can refer the woman to a higher level of care in case of emergency.
• Laparoscopy requires a better equipped center where the procedure is performed regularly.
How many follow-ups are advocated under the National program after surgical sterilization of a woman?
1. First follow-up is within 48 hours.
2. The second follow-up is on the 7th day for stitch removal.
3. Third follow-up is done after 1 month or after the first menstrual period after sterilization, whichever is earlier. This follow up is for determining if there are any side effects or complications or dissatisfaction related to the surgery. The client is treated or referred as indicated.
Is the consent of the spouse essential for sterilization surgery?
• The client herself can give the consent.
• The consent of the spouse is not required for sterilization.
Enumerate some postoperative complications after tubal ligation surgery.
• Wound sepsis
• Hematoma in abdominal wall
• Intestinal obstruction
• Peritonitis
• Tetanus
• Failure, resulting in pregnancy and
• Rarely, incisional hernia
Mention the causes of failure of a sterilization surgery.
Failure may be due to
• Technical deficiency in the surgical procedure.
• Spontaneous recanalization of the fallopian tube.
Mention the failure rate of tubal ligation.
Failure rate of tubal ligation ranges from 0.5 pregnancies per HWY in the first year to 1.8 pregnancies per HWY in the subsequent years.
If a woman does become pregnant after tubectomy, she is more likely to have an ectopic pregnancy. All women who have undergone minilap tubectomy and present with symptoms of pregnancy, should be carefully evaluated for ectopic pregnancy
Mention the management of a pregnancy resulting from the failure of tubal ligation surgery.
Rule out ectopic pregnancy (as tubectomy predisposes to this)
If the client does not wish to continue with the pregnancy
• Offer MTP
• Perform repeat sterilization surgery
If the client wishes to continue the pregnancy
• She should be medically supported throughout the pregnancy. Each case of pregnancy due to failure of tubectomy MUST be reported to the District Quality Assurance Committee.
Mention the side effects of tubal ligation.
• The surgery increases the risk of ectopic pregnancy should there be a failure resulting in conception.
• Compared to male sterilization, female sterilization is slightly more risky and often more expensive, if there is a fee.
• Reversal surgery is difficult, expensive, and unavailable in most areas. Successful reversal is not guaranteed.
Mention some contraindications to female sterilization surgery.
No medical conditions prevent a woman from undergoing female sterilization but as explained previously, there are certain relative contraindications where one needs to apply the criteria of ‘caution’, ‘delay’ or ‘special’.
Caution: The procedure is normally conducted in a routine setting, but with extra preparation and precautions. Some examples are:
• Previous abdominal or pelvic surgery
• Obesity
• Controlled BP (140-159/ 90-99)
• Uncomplicated heart disease
• Stroke
• History of cerebro-vascular accident
• History of deep vein thrombosis or pulmonary embolism
• Epilepsy
• Depressive disorders
• Current breast cancer
• Uterine fibroids
• PID without subsequent pregnancy
• Uncomplicated diabetes
• Hypothyroidism
• HIV and others
Delay: The procedure is delayed until the condition is evaluated and/or corrected. Till then, alternative temporary methods of contraception should be provided. Some examples are:
• Severe iron deficiency anaemia (Haemoglobin < 7 gm/dl)
• Current pregnancy
• 8 – 42 days postpartum
• Pregnancy with severe pre-eclampsia or eclampsia
• Post-partum or post abortion complications (infection, haemorrhage and trauma)
• Abdominal skin infections
• Unexplained vaginal bleeding
• Current purulent cervicitis, Chlamydia, Gonorrhea
Special: The procedure should be performed by an experienced surgeon and staff, in a setting where equipment for providing general anaesthesia and other back-up medical support is available. Some examples are:
• Conditions that increase chances of heart disease or stroke i.e. older age, smoking, high BP or diabetes
• Blood Pressure > 160/100
• Complicated heart disease
• Chronic lung diseases (asthma or emphysema)
• Endometriosis
• Pelvic tuberculosis
• Fixed uterus due to previous surgery or infection
• Abdominal wall or umbilical hernia
• Post-partum or post abortion uterine rupture or perforation
• Hyperthyroidism
• AIDS
References:
1. Government of India, October 2013. Reference Manual for Male Sterilization, Family Planning Division, Ministry of Health and Family Welfare, New Delhi
2. Government of India, November 2014. Reference Manual for Female Sterilization, Family Planning Division, Ministry of Health and Family Welfare, New Delhi
3. Park K. Demography and family planning. In: Park K. Park's Textbook of Preventive and Social Medicine, 24th ed. Jabalpur, India: Banarsidas Bhanot Publishers, 2017; pp. 525-52.
4. Chapter 1-contraceptives; In: Mastering Practicals – Community Medicine. 2nd ed. Eds. Tiwari P, Tiwari S. Lippincott Williams & Wilkins; Wolters Kluwer, New Delhi