Permanent Sterilization: When you are really sure!

Transcription

1 Permanent Sterilization: When you are really sure! Tony Ogburn MD Department of Ob/Gyn

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3 National Survey of Family Growth 6.1% of women had a sterilized male partner

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8 The History of Female Sterilization 1823 First proposed by James Brundell in London 1880 First published report of procedure by Lungren in Toledo, Ohio 1930 First publication of the Pomeroy Technique, Pomeroy, New York State Journal of Medicine 1936 Bosch performed the first laparoscopic tubal occlusion in Switzerland

9 Sterilization as a method of contraception Prior to 1960, sterilization of females was performed primarily as a result of medical indications Increased interest in family planning coupled with safer and more effective methods allowed sterilization to become a viable method of contraception during the 1960 s. Widespread acceptance of laparoscopy led to the development of several methods Data Quoted From: Hulka J and Stepian A. Laparoscopic sterilization. In: Gordon AG, Hulka JF, Walker DM, and Campana A, eds. Practical Training and Research in Gynecologic Endoscopy Sklar AJ. Tubal Sterilization. emedicine. November 15, Available at

10 Sterilization Mortality & Morbidity Morbidity affected by provider experience < 100 procedures, 14.7/1,000 complications > 100 procedures, 3.8/1,000 complications Complications include vessel injury, bowel burn or perforation, tubal transection Westhoff C, Davis A. Fertil Steril

11 US Tubal Sterilization Regret CREST study Percent of women regretting tubal sterilization 30 or younger: 20% Older than 30: 6% Hillis SD, et al. Obstet Gynecol

12 Who is eligible 18 years of age or older No waiting period No childbirth requirement Federal funding (Medicaid, IHS, Military,Title X) requires 21 years of age or older Sign federal consent days before procedure

13 Counseling/Consent Permanent Procedure Failure rate of ~1% Failures are more likely to be ectopic Effective alternatives available Male sterilization available Menses may change with discontinuation of hormonal contraception

14 Types of Female Sterilization Post Partum Pomeroy Parkland Irving Uchida Filshie Clip

15 Pomeroy Technique Developed in 1930 by Ralph Hayword Pomeroy Benefits Easy Technique Highly effective Relatively inexpensive (excluding Lab costs for Pathology) Complications Infection and Bleeding Potential Ectopic Pregnancy Failure Rate: 7.5/ Pregnancy After Tubal Sterilization with Bi-Polar Electrocoagulation. Obstetrics and GYN. August 1999 Volume 94. Herbert B Petterson et al for the CREST Working Group

16 Tied Pomeroy Procedure Cut Final result

17 Parkland Technique Introduced in the 1900 s Benefits Designed to reduces natural tube reattachment Good Success Rates Few Complications Inexpensive to perform (if no pathology) Complications Ectopic Pregnancies, Infection, Bleeding Time required to perform procedure properly Reported failure rate 7.5/ Pregnancy After Tubal Sterilization with Bi-Polar Electrocoagulation. Obstetrics and GYN. August 1999 Volume 94. Herbert B Petterson et al for the CREST Working Group

18 Parkland Procedure

19 Types of Female Sterilization Interval Laparoscopic Electrocoagulation (Mono and Bi-Polar), Falope Ring, Hulka Clip and Filshie Clip Hysteroscopy Micro Inserts

20 Bipolar Coagulation Failure Rate:24.8/1000 Complications Higher rate of Ectopic Pregnancy Potential for Bowel Burns Reversals are potentially more difficult due to the degree of tube damage 1. Peterson HB, et al. The risk of pregnancy after tubal sterilization: Findings from the U.S. Collaborative Review of Sterilization. Am J obstet. Gynecol. 1996; 174 (4):

21 Monopolar Coagulation Failure Rate:7.5/ Peterson LS Contraceptive use in the United States: Advance Data: From Vital Health Statistics February 1995;

22 Yoon Band Falope Ring

23 Tubal Clip

24 Filshie Clip

25 Filshie Clip

26 Post-Sterilization Pregnancy Risk: CREST Study Years Since Sterilization Method (# ectopic pregnancies) Bipolar coagulation (2267/24) Unipolar coagulation (1432/1) Silicone rubber band application (3329/10) Spring clip application (1595/7) Interval partial salpingectomy (425/3) Postpartum partial salpingectomy (1637/2) All methods (10,685/47) Peterson HB, et al. N Engl J Med. 1997;336:

27 Sylvia: I want my tubes tied 38 y/o G4P4 weighs 260 pounds, history of severe asthma, C/S x 4, prior DVT after last delivery Mirena IUD removed after months of constant bleeding Transcervical sterilization

28 Essure Device Overview Micro-insert device wound down Proprietary device expansion Expanded outer coil PET fibers Distal ball tip & inner coil

29 Essure System Placement Prepare endometrium Hydro-dilation of cervix Preoperative toradol degree hysteroscope

30 Essure System

31 Essure Contraception x 3 months post-procedure HSG at 3 months If patent Continue alternate contraception Repeat at 6 months Effectiveness data Combined data from Phase 2 and 3 trials 99.8% effective at 2 years Long term data not available

32 Essure Reimbursement Medicaid covers it in NM Major insurers also including United Healthcare, Pres, Lovelace, BCBS

33 Micro-Insert: Effectiveness 99.5% Effective Reported Pregnancies

34 Adiana New transcervical sterilization Bi-polar radiofrequency (RF) delivers a thermal dose to tubal lumen Then delivers an implantable, silicone polymer, a "matrix," which remains within the tube. The matrix is smaller than a grain of rice. Tissue grows into the matrix, creating a complete blockage. A confirmatory (HSG) is conducted at three months

35 Adiana, cont

36 Adiana Catheter inserted into fallopian tube Creates superficial lesion Porous non-biodegradable implant inserted

37 Transcervical Sterilization Advantages May perform as outpatient under oral sedation and paracervical block No incisions No catastrophic complications May be less expensive Less pain, shorter recovery

38 Transcervical Sterilization Disadvantages Not immediately effective HSG required Long term effects unknown Need specialized equipment and training Difficult (impossible?) to reverse

39 Tidbits about Sterilization in New Mexico/UNM UNM Cares/EMSA do not cover sterilization NM Family Planning Medicaid does We should strive to get all reproductive aged women on Family Planning Medicaid!!!! IUDs and Implanon are as effective as sterilization and a whole lot cheaper

40 What to do at UNM If a patient is considering sterilization Sign federal consent Not a commitment but provides option Give them a copy Counsel about options Medicaid Information Refer to Center for Reproductive Health! Ad hoc request Eve, Tony, Rameet all perform Essure in office OSIS available for LSC tubal or Essure if patient desires

41 Rabia Balkhi Maternity Hospital Kabul, Afghanistan