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Laparoscopic Tubal Ligation

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What are Contraceptives ?

Contraceptives are also called birth control methods which are used to deliberately prevent or reduce the likelihood of a woman becoming pregnant. They are devices or methods or procedures which reduces the likelihood of the fertilization of an ovum by a sperm.

Nowadays, there is a vast number of different contraceptive methods. There are many different contraceptive methods available and different methods suit people at different times of their lives. It is very important for the woman and her partner to decide on the method of contraception most suited to them. There are barrier methods like condoms, cervical diaphragm. Then there are hormonal methods like pills which are very commonly used. Besides, devices like IUCD are placed in the uterus. But all these are temporary methods. That means they are reversible. But for few people, permanent birth control is a more reasonable option.

This option is considered when the couple : -
  • Does not want to have children in the future, no matter how the life may change.
  • Have a partner who also does not want children in the future but does not want to have a vasectomy
  • Have also considered other methods of birth control and do not want the side effects, risks, or costs of those methods.
  • Have health problems that would be made worse by pregnancy.
  • Have a hereditary condition that one does not want to pass on.

What is surgical contraception?

Permanent birth control methods are practically irreversible processes actually require surgical intervention. So they are also called surgical contraceptives. Sterilization is when a man or woman has an operation to prevent pregnancy. It safeguards individual health and rights, preserves our planet's resources, and improves the quality of life for individual women, their partners, and their children.

For females there are two methods:
  • Tubal ligation : - It is often referred to as "having the tubes tied," is a surgical procedure. The fallopian tubes, which carry the eggs from the ovaries to the uterus, are blocked or cut and sealed off so that the eggs can't reach the uterus and be fertilized by sperm. Instead, the eggs are reabsorbed by the body.

  • Tubal implants : - They are small metal springs that are placed in each fallopian tube in a non-surgical procedure (no cutting is involved). Over time, scar tissue grows around each implant and permanently blocks the tubes. Both these methods are considered to be permanent methods of birth control for women. Both procedure stops eggs from travelling from the ovaries into the fallopian tubes, where the egg is normally fertilized by a sperm. Reversing a tubal ligation is possible, but it is not highly successful.

How is it done ?

Tubal ligation and tubal implants are considered to be permanent procedures. They come under surgical procedures. The female must make sure to talk to her gynaecologist openly to understand what is best for her. The choice of birth control depends on factors such as a person's health, frequency of sexual activity, number of sexual partners, and desire to have children in the future.

Before surgery : - A pregnancy test is administered beforehand, because a pregnant woman can't undergo sterilization. After a detailed case history taking, the physician may advice for certain tests, depending upon the clinical indications. The patient will be advised to fast before the surgery. The doctor may choose to give either general anaesthesia or epidural.

The surgery : -

1. Tubal ligation method

There are several different ways of closing the fallopian tubes, including clipping or banding them, shut or cutting and stitching or burning them closed.

The surgeon will probably prefer one of the following methods: Laparoscopic tubal ligation Laparoscopy involves inserting a viewing instrument and surgical tools through small incisions made in the abdomen. Laparoscopy can be done using local anaesthesia just at the site of the incision. However, they are usually done with a regional (epidural) or general anaesthetic.

The doctor injects a harmless gas (carbon dioxide) into the abdomen, which inflates the abdominal cavity, making it easier to see the internal organs. The doctor then makes a tiny incision near the navel and inserts a long, thin instrument (called a laparoscope) that contains a small lens and lighting system to magnify and illuminate the structures inside the lower abdomen. The physician may make a second incision just above the pubic hair to insert an instrument for grasping the fallopian tubes.

The tubes are closed by one of the following means : -
  • Tying and cutting (ligation)
  • Sealing by creating scar tissue
  • Removing a small piece of the tube
  • Applying plastic bands or spring-loaded clips

The tools are then removed and the openings closed with stitches. The procedure can be performed in outpatient surgical clinics. It takes 20 to 30 minutes. Very little scarring occurs. Women often go home the same day. They may have sexual intercourse as soon as they feel comfortable about it. Injury to the bowel or bleeding inside the abdomen occurs in five out of 1,000 cases. Major surgery may be required to resolve such complications.

The Fallopian tubes being tied using laparoscopic instrument

Mini-laparotomy ("mini-lap")
This is done through an incision that is less than 2 inches (5 cm) long. Postpartum tubal ligation is usually done by this method, following 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. Mini-laparotomy can be done using local anaesthetic just at the site of the incision. However, they are usually done with a regional (epidural) or general anaesthetic Laparoscopy can be done using local anaesthesia just at the site of the incision.

For this procedure, there is no gas or laparoscope. It is typically performed soon after childbirth. The doctor makes a small incision just above the pubic hair, or if done within 48 hours of childbirth, below the navel. The tubes are located, and the doctor uses a small tool to tie, clip, or seal off the tubes. Women usually recover in a few days. Doctors will advise as to when sexual intercourse can be resumed.

The mini-lap may be a good choice for women who cannot undergo laparoscopy due to prior

abdominal surgery or disease, and those for whom full laparotomy is too risky because of heart or respiratory conditions. It may not be appropriate for women who are obese or those with damaged fallopian tubes.

This procedure is major surgery. It is less commonly used than mini-laparotomy and laparoscopy. The surgeon makes a two-to-five-inch incision in the abdomen. Laparotomy is usually done under general anaesthesia. This uses the same methods for closing or cutting the fallopian tubes, but the abdomen is opened with a larger incision to give the surgeon a clear view of all of the organs.

The surgeon locates and closes off the tubes. The operation requires general or spinal anaesthesia. A woman may need to be hospitalized for two to four days. It may take several weeks at home to completely recover. If the procedure is done after delivery, the woman's hospital stay may be extended by one or two days. When to resume sexual intercourse depends on the rate of recovery.

It may be preferable for women who need other abdominal procedures at the same time (such as caesarean delivery), and those who have had pelvic inflammatory disease, endometriosis, or prior abdominal surgery.

2. Tubal implant method

Implants are inserted in the fallopian tubes without surgery or general anaesthesia. The procedure is done in an outpatient surgery centre or hospital and does not require an overnight stay. The implant procedure usually takes about 30 minutes. A tubal implant can be difficult to insert. In about 15% of women, a second procedure is needed to completely block both tubes.

Before the procedure, the cervix is first opened (dilated) to reduce the risk of injury to the cervix. The health professional may place a slowly expanding tube or sponge (laminaria or synthetic dilator) in the cervix several hours beforehand. If not, a speculum and a dilating instrument is used to gradually open the cervix just before the procedure. The physician then passes a thin tube (catheter) through the vagina and cervix, into the uterus, and then into a fallopian tube. The catheter is used to place an implant into a fallopian tube. An implant is then placed in the other fallopian tube the same way. One may have some menstrual-like cramping afterwards. After the procedure, an X-ray is taken to make sure the implants are in place.

For the first 3 months after insertion, the patient is adviced to use another method of birth control. At 3 months, dye is injected into the uterus and an X-ray is taken (hysterosalpingography) to make sure that the implants are in place and the tubes are fully blocked by scar tissue. If they are, there is no longer use of another method of birth control.

After Surgery

After the surgery, the patient will be taken to the recovery room, where she will remain until she wake up or gets the feeling back in the numbed area. Depending upon the case, the physician may discharge the patient on the same day. After laparoscopy, the stomach may be swollen (distended) from the gas that was used to lift the skin and muscles away from the abdominal organs so the surgeon could see them better. This should go away within a day or so. One may also have some back or shoulder pain from the gas in abdomen. This will go away as the body absorbs the gas. A follow-up exam in 2 weeks is usually scheduled.

Care at home

She will be advised to take rest for a few days (or at least 24 hours) before beginning to resume normal activities. The patient has to take care as to avoid constipation because straining has to be avoided. The physician will also explain the patient as to when she can resume with her sexual life.

Benefits and drawbacks

Tubal ligation and tubal implants are permanent methods of birth control and allows the female to be sexually active without worrying about becoming pregnant. Although these methods are expensive but it is a one-time cost. These procedures are usually covered by medical insurance, and there are no costs after the surgery is done. The cost of other birth control methods, such as pills or condoms and spermicide, may be greater over time.

Above all, both these methods do not change the biological rhythm of the body. There is no change in monthly menstrual cycle. One will still release an egg each month (ovulate) and have menstrual periods. The female will go through menopause at the same time that she would have if she had not had the surgery. On the sexual front also there is no change. Infact women claim of feeling more relaxed about having sex because she doesn't have to worry about becoming pregnant.

The major disadvantage is that Tubal ligation and tubal implants do not protect against sexually transmitted diseases (STDs), including infection with the human immunodeficiency virus (HIV).

Risks and Complications

Major complications of tubal ligation are uncommon. Minor complications include infection and wound separation. They affect about 11% of women after mini-laparotomy, and 6% of women after laparoscopy. Major complications include heavy blood loss, general anesthesia problems, organ injury during surgery, and need for a larger laparotomy incision during surgery. They affect 1.5% of women after mini-laparotomy, and 0.9% of women after laparoscopy.

Although fewer complications occur with laparoscopy than with other kinds of tubal ligation surgery, these complications can be more serious. For example, on rare occasions, the bowel or bladder is injured when the laparoscope is inserted. But by choosing a skilled laparoscopic surgeon, these risks can be avoided.

The risk of pelvic infection is greater with tubal implants. There is a slight risk of becoming pregnant after tubal ligation. This happens to about 5 per 1,000 women after 1 year. After a total of 10 years following tubal ligation, about 18 per 1,000 women will have become pregnant.
Pregnancy may occur if : -
  • The tubes grow back together or a new passage forms (recanalization) that allows an egg to be fertilized by sperm. The health professional can discuss which method of ligation is more effective for preventing tubes from growing back together.
  • The surgery was not done correctly.
  • One was pregnant at the time of surgery.

If a tubal ligation or implant fails and the female becomes pregnant, she may run into the risk of having ectopic pregnancy. This means that the egg after getting fertilized implants itself into the fallopian tubes instead of uterus.

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