1. Session I: Characteristics of Tubal Ligation (Female Sterilization)
Basic Slides—Female Sterilization Session I: Characteristics of Female Sterilization
This first set of slides on the characteristics of female sterilization, when adapted and used appropriately with other resources, will enable participants to:
State what female sterilization is
Describe the characteristics of female sterilization in a manner that clients can understand
Describe the effectiveness of female sterilization
List the side effects and complications of female sterilization

2. Characteristics of Female Sterilization
Session Objectives
By the end of this session, participants will be able to:
State what female sterilization is
Describe the characteristics of female sterilization in a manner that clients can understand
Describe the effectiveness of female sterilization
List the side effects and complications of female sterilization.
Explain that in this first session, you will be reviewing the characteristics of female sterilization. The learning objectives for this session are that by the end of this session, participants will be able to:
State what female sterilization is
Describe the characteristics of female sterilization in a manner that clients can understand
Describe the effectiveness of female sterilization
List the side effects and complications of female sterilization

3. What Is Female Sterilization?
Female sterilization is a family planning method that provides permanent contraception to women and couples who want to limit births or do not want any more children.
The two surgical approaches most often used are minilaparotomy and laparoscopy.
Female sterilization is also referred to as “tubal occlusion,” “tubal sterilization,” “tubal ligation,” “surgical contraception,” “voluntary surgical contraception,” “tubectomy,” “bi-tubal occlusion,” “minilap,” or simply “the operation.”
Display slide and click mouse to display the question.
Ask: What is female sterilization?
Allow responses from 2-4 participants, then click mouse to advance the slide.
Explain:
Female sterilization is a family planning method that provides permanent contraception to women and couples who want to limit births or do not want any more children.
It requires surgery; the two surgical approaches that are most commonly used are:
Minilaparotomy: This procedure involves making a small incision in the abdomen. The fallopian tubes are then brought to the incision and are cut or blocked.
Laparoscopy: This procedure requires insertion of a special instrument called a “laparoscope” (a long, thin tube with a lens and a source of light) into the abdomen through a small incision. The laparoscope enables the surgeon to visualize and block or cut the fallopian tubes in the abdomen.
During this course, you will learn how to do the minilaparotomy procedure.
Female sterilization is also sometimes referred to as tubal sterilization, tubal ligation, surgical contraception, tubectomy, bi-tubal occlusion, minilap, or simply the operation.
The term tubal occlusion is currently the preferred terminology.
Ask if there are any questions, and respond to these as needed.

4. Key Points for Providers and Clients
Female sterilization is a surgical procedure.
The womb is NOT removed. The woman will still have menstrual periods.
It is permanent—for women who will not want more children.
It is very effective.
It is very safe.
There are no long-term side effects.
It does not protect against STIs, including HIV.
Explain:
The key points to remember about female sterilization include:
It requires a physical examination and a surgical procedure conducted by a trained health care provider at a health facility.
The procedure is normally performed while the client is awake, and she receives medication for pain.
The client may experience some discomfort or pain during and after the procedure for a few days.
During the procedure, the uterus is not removed, and the woman will still have menstrual periods.
It is a permanent method of contraception, so there is no need for resupply.
Female sterilization is appropriate for clients who do not want any more children.
It is a method that cannot be reversed.
It is one of the highly effective methods of contraception; however, pregnancy may occur in very rare instances.
It is easy to use, and there is nothing to do or remember.
The contraceptive effect is immediate, and there is no need for back-up methods.
It is safe to use.
Sterilization has no side effects, and serious complications are rare.
It does not protect one from STIs, including HIV.
Ask if there are any questions, and respond to these as needed.
Source: Adapted from: WHO & Johns Hopkins Bloomberg School of Public Health. Center for Communication Programs. Information and Knowledge for Optimal Health (INFO) Decision-making tool for family planning clients and providers. Baltimore, Maryland: INFO; and Geneva: WHO.

5. Effectiveness of Female Sterilization
In this diagram on the progression of effectiveness of FP methods, where would you place female sterilization?
Implant
Male sterilization
Intrauterine device
Progestin-only injectables
Combined oral contraceptives
Male condoms
Standard days method
Female condom
Spermicides
Withdrawal
Female
sterilization
More effective
Inform the participants that you will now focus on the effectiveness of female sterilization as a method of family planning. Display this slide and explain that all methods are displayed on a continuum according to their effectiveness, from most effective to least effective, as they are commonly used. In this list, spermicides are the least effective method (and so they are at the bottom of the chart) and the most effective methods are the contraceptive implant, male sterilization, and the intrauterine device (at the top of the chart).
Ask: “Where would you put female sterilization on this diagram?”
Allow a few responses, then click the mouse twice to display the position.
Explain
Female sterilization is in the group of the most effective contraceptive methods.
Less
effective

6. Relative Effectiveness of Family Planning Methods
No. of unintended pregnancies among
1,000 women in 1st year of typical use
No method use
850
Withdrawal
220
Female condom
210
Male condom
180
Pill 90
Injectable 60
IUD
8 / 2 (Cu-T/LNG-IUS)
Female sterilization 5
Vasectomy
1.5
Implant
0.5
Source: Trussell, J Contraceptive failure in the United States. Contraception 83:397–404.
Explain: Another way of looking at the effectiveness of the different family planning methods is to focus on the number of unintended pregnancies that occur when a specified number of women use a method over a period of time—for example, over the first year of use.
In this slide, we look at how effective family planning methods are as they are commonly used.
The slide shows the number of women who would get pregnant if 1,000 women used each particular method for one year. So, if 1,000 fertile women were having sex but not using any protection from pregnancy, it is estimated that 850 of them would become pregnant by the end of one year.
In contrast, if the same 1,000 women were using female sterilization, five would become pregnant by the end of one year. This means that 995 women of every 1,000 women relying on this method would not become pregnant by the end of the first year.
Inform the participants that there is a small risk of pregnancy after the first year of use until the woman reaches menopause.
Over 10 years of use, for example, about 18–19 pregnancies per 1,000 women have been reported for female sterilization.
The effectiveness of female sterilization also varies slightly with the tubal occlusion method or technique As we shall see later, one of the most effective methods of tubal occlusion is the modified Pomeroy method or technique.
As part of good counseling, it is important to inform clients about how effective each method is and the small chance of method failure with each.
Ask: What if these same women were using a female condom? How many would become pregnant?
Allow a few responses, then share the correct answer, which is 210.

7. Explaining How the Method Works
A segment of the fallopian tube is removed, and then the tube is tied or blocked.
Sperm are blocked from fertilizing the ovum
ovary
Fallopian tube
Ask: “How does the female sterilization method of contraception work?” Allow a few responses, then advance the slide as you explain how the method works.
Explain In female sterilization, contraception is achieved by blocking the fallopian tubes, thus preventing the sperm from reaching and fertilizing the ova.
Fallopian tube
Uterus
Source: Adapted from: Roy Jacobstein and John Pile, Global Technical Brief -Female Sterilization: The Most Popular
Method of Modern Contraception, Engenderhealth and JHUCCP 2004

8. Female Sterilization: Health Benefits
Protects against risks of pregnancy and childbirth
Lower risks of ectopic pregnancy
May lower risks of developing ovarian cancers
Ask: “What are some of the health benefits of female sterilization?”
Allow 2–3 responses, then advance the slide show and present the health benefits.
Explain:
In addition to the benefit of preventing unwanted pregnancy and therefore preventing the risks associated with pregnancy, female sterilization use has some significant noncontraceptive health benefits. Female sterilization is known to reduce the risk of ectopic pregnancy, because of its effectiveness in preventing pregnancy overall.
In the United States, for example, the ectopic pregnancy rate among female sterilization users is only six per 10,000, compared with 65 per 10,000 among women using no contraception.
However, on the rare occasion when female sterilization fails and the woman becomes pregnant, one-third of those pregnancies will be ectopic.
Female sterilization has also been shown to help protect against ovarian cancer.

9. Timing of the Procedure and the Surgical Approaches
Interval
Postabortion
Postpartum
Approaches
Surgical
Nonsurgical
Laparotomy
Minilaparotomy procedure
After delivery of baby and Placenta during C/S
Transcervical
Laparoscopic procedure
Explain
Female sterilization procedures may also be categorized according to the timing of the procedure in in relation to a recent pregnancy. The three main timings of the procedure are interval, postpartum, and postabortion.
An interval sterilization is when the procedure is performed at any time unrelated to a pregnancy or six weeks or more after the last delivery or abortion, when the uterus is normal in size and located in the pelvis.
Postpartum sterilization is when the procedure is performed within the first week after a vaginal delivery or while a cesarean section is being performed.
Postabortion sterilization may also be performed within the first week following a nonseptic spontaneous or induced abortion.
Next, explain:
Female sterilization may also be performed through surgical and nonsurgical approaches.
The most commonly used methods are the surgical methods.
There are two main surgical approaches, through laparotomy and with the use of a laparoscope.
Laparotomy may be performed as a minilaparotomy—that is, through a vey small incision—or following a cesarean section, after delivery of the baby and placenta and closure of the uterine incision, but before closure of the abdominal incision.
Minilaparotomy is the preferred approach for female sterilization in low-resource settings.
The laparoscopic technique involves the use of a laparoscope to visualize and occlude the fallopian tubes. This approach is safer and can be performed in less time than minilaparotomy; however, it can only be performed by highly skilled providers using sophisticated equipment.
The only nonsurgical method of female sterilization is a trans-cervical approach using a special instrument, the hysteroscope. The hysteroscope is introduced through the cervix and an occlusive device (called Essure, which is approved by the U.S. Food and Drug Administration) is introduced into each fallopian tube. The tubes then become occluded over a period of a few months (up to three months); during this waiting period, the client needs to use other effective reversible contraceptive methods to avoid pregnancy.
This approach is costly, requires a high level of skill, and is still under evaluation.

10. Characteristics of Interval, Postabortion, and Postpartum Procedures
Timing
Not associated with a pregnancy
Usually immediately after an abortion
Usually within seven days of delivery
Uterine size
Normal
Small (close to normal) after uncomplicated first-trimester abortion
Enlarged
Location of surgical incision site
Suprapubic
Subumbilical
Scheduling
At any time that pregnancy can be ruled out
Ideally, within the first two weeks of the menstrual cycle
Usually within the first six hours after uterine evacuation
Within seven days of delivery
To allow time to assess the infant’s condition, many providers wait 10–12 hours after delivery.
Explain
The table presents the characteristics of interval, postabortion, and postpartum procedures in relation to timing, uterine size, incision site, and recommended scheduling of the procedure.
In relation to timing, the interval procedure is not associated with any recent pregnancy, while postabortion and postpartum procedures are performed immediately after the delivery or abortion (preferably within seven days of delivery for postpartum clients).
Uterine size is normal in interval clients, while it is slightly enlarged for postabortion clients following a first-trimester abortion but is significantly enlarged after a second-trimester abortion. After delivery, the uterine fundus is at the level of the umbilicus.
The location of the incision is therefore at the suprapubic area for interval and postabortion (first trimester) procedures and in the subumbilical area for postpartum clients. Following a cesarean section, the procedure is performed immediately after delivery of the baby and removal of the placenta and membranes and closure of the uterine incision.
An interval procedure can be performed at any time when the provider can be reasonably sure that the client is not pregnant. Otherwise, it is recommended that the procedure be scheduled during the first half of the menstrual cycle (also referred to as the proliferative phase), which is one to two weeks after menses (for women with menstrual cycle ranging from 21 to 35 days).
Source: EngenderHealth Minilaparotomy for female sterilization: A training course for service providers: Trainer’s manual. New York

11. Characteristics of Interval, Postabortion, and Postpartum Procedures (cont.)
Screening
Standard history
Physical exam
Pelvic exam
Physical exam to screen for abortion or post abortion events that could increase surgical risk
Assessment of uterine size
Physical exam to screen for antenatal or postpartum events that could increase surgical risk
Special instruments
Uterine elevator and tubal hook
Uterine elevator and tubal hook
Tubal hook
Timing of discharge
When stable, usually 2– 4 hours after the procedure
When stable, usually 2–4 hours after the procedure
No additional hospital stay required beyond routine postpartum stay
Explain
Irrespective of the timings of the procedure, all clients require an evaluation, which includes taking a history and performing a physical examination. Interval clients will require a pelvic examination before the procedure; however, after an abortion, or a normal vaginal delivery, a pelvic examination should not be repeated immediately before the procedure. Since it was performed during the evaluation of the client after the treatment for the abortion related problems or after a vaginal delivery and is documented in the client records. The uterine size is assessed by abdominal palpation.
With the minilaparotomy approach, interval and first-trimester postabortion procedures may require use of special instruments (the uterine elevator and the tubal hook), while for second-trimester abortion and postpartum procedures, the provider may only use the tubal hook and cannot use the uterine elevator.
After an interval or postabortion minilaparotomy procedure, a client can be discharged when her vital signs are stable, she feels recovered from the effects of pain management, she is coherent and can walk without support, the wound is not bleeding, and she has no intolerable pain or problems. In the majority of cases, clients are ready for discharge after a period of at least two hours, whereas for postpartum clients, the timing of discharge depends on the allowable period of stay after normal vaginal or cesarean delivery. The procedure does not increase the client’s stay at the hospital beyond the routine postpartum stay.
Source: EngenderHealth Minilaparotomy for female sterilization: A training course for service providers: Trainer’s manual. New York.

12. The Minilaparotomy Procedure
Definition: Minilaparotomy is an abdominal surgical approach to access the fallopian tubes by means of an incision less than 5 cm in length with the intent to occlude the fallopian tubes.
Explain
Minilaparotomy is defined as an abdominal surgical approach to access the fallopian tubes by means of an incision less than 5 cm in length, with the intent to occlude the fallopian tubes.
Other characteristics of minilaparotomy are that it is simpler, safe, and cost-effective. The procedure can also be performed at the interval, postabortion, and postpartum periods, whereas the laparoscopic procedure cannot be performed immediately postpartum.
The tubes can be accessed in two ways—through subumbilical and suprapubic incisions.
EngenderHealth Minilaparotomy for female sterilization: A training course for service providers: Trainer’s manual. New York

13. Techniques for Tubal Occlusion
Removal of part of the tubes
Ligation and excision (aka ligation and cut, or partial salpingectomy): Pomeroy, modified Pomeroy, Parkland, Irving, Uchida
Salpingectomy
Application of a mechanical device
Clips: Filshie clip and Wolf (aka Hulka)
Rings: Fallope ring
Micro-inserts (Trans-cervical)
Essure
Electrocoagulation
Explain
Several methods can be used to occlude the fallopian tubes. The following are the four main methods;
Excision and ligation, or removal of part of the tube, is the most commonly practiced method of tubal occlusion; several methods have been described, documented, and used. These include the Pomeroy technique, the modified Pomeroy technique, the Parkland procedure, the Irving procedure, and the Uchida technique. Excision and ligation is performed through laparotomy (minilaparotomy, or postcesarean). All of these methods involve excision (from the word “to excise” or “cut off”) of a section of the fallopian tube, also known as partial salpingectomy and ligation or closure of the distal and proximal ends of the remaining tube. The modified Pomeroy technique of tubal occlusion is the most commonly used and is preferred because it is easier to perform, requires minimal manipulation of viscera, and is effective.
The application of mechanical devices to occlude the tubes requires the aid of the laparoscope. While many different types of mechanical devices have been used in the past, the most commonly used mechanical devices include clips (Filshie, Hulka) and rings (Fallope). Mechanical devices are the second most widely used method.
Another mechanical method of occlusion is the use of micro-inserts. These are devices inserted into the fallopian tube through the cervix with the aid of the hysteroscope. The only device that can be used is known as Essure. No incision is made on the abdominal wall or excision and ligation of any part of the fallopian tube. This approach is still under evaluation, as mentioned earlier.
Electrocoagulation is also an effective method for occluding the fallopian tubes.

14. Modified Pomeroy Technique for Tubal Occlusion
The modified Pomeroy is the preferred method.
After transfixing a suture in an avascular area of the mesosalpinx, one side (proximal) of the tube is tied, then the other (distal) side of the looped tube is secured with a square knot, and the tube is excised.
Explain
The modified Pomeroy technique is preferred because:
It minimizes handling of and trauma to the tubes and pelvic structures.
It also requires minimal suture material and instruments, and specialized equipment is not needed.
The method requires that a section of the tube be identified and drawn or positioned to form a loop; a suture is then transfixed in an avascular area of the mesosalpinx, one side of the tube is then tied, the other side of the looped tube is then secured with a square knot, and the tube is excised.
Illustration a) shows a loop of the fallopian tube with the suture being transfixed.
In Illustration b), the proximal side of the tube is tied with a square knot before the distal end of the tube is also tied.
Finally, illustration c) shows the section of the tube above the ligature excised.
A section of tube has been identified and a suture transfixed.
One side of the tube is ligated or tied
Both ends of the tube are tied and a section of the loop above the ligature has been excised.
Source : EngenderHealth, 2003, Minilaparotomy for female sterilization : an illustrated guide for service providers.

15. Closure of the Surgical Wound, Recovery, and Discharge
After occlusion of both tubes, the surgical wound is closed.
The client is transferred to a separate recovery area/ward/room to recover from the effects of pain management drugs and for observation.
The client is discharged in stable condition, with postprocedure instructions.
Explain
After the tubal occlusion, the surgical team inspects the stump and surrounding viscera to confirm that there is no trauma or bleeding. The surgical wound is closed by suturing the fascia and the skin and a dressing is applied. If the uterine elevator  was used, it is removed.
A member of the surgical team escorts the client to the recovery area for observation as she recuperates from the pain management drugs and surgery. Once her vital signs return to preprocedure rates and the client has recovered and can walk without support, the provider gives the client postprocedure instructions on what she should do immediately after the procedure, what to do about common problems, danger signs to look for, and when to come back to the clinic for follow-up.
The client is discharged with pain relief medication. Antibiotics should not be routinely prescribed after the minlaparotomy procedure.

16. Female sterilization is a safe method of contraception.
Client Safety
Female sterilization is a safe method of contraception.
The incidence of complications is low, estimated at between 9 and 16 per 1,000 procedures.
The risk of death is also very low, estimated at 1–4 deaths per 100,000 procedures in the United States (most associated with general anesthesia) and at 5 per 100,000 procedures globally.
Explain:
Female sterilization is a safe method of contraception.
The complication rate is low, at between 9 and 16 per 1,000 procedures.
The risk of mortality associated with female sterilization is very low, at about 5 per globally. Some of the factors that predispose clients to this complication include use of general anesthesia, poor surgical technique (leading to unintended injury to other viscera), and poor infection prevention practices.

17. Side Effects and Complications
Complications of female sterilization are rare.
Immediate side effects of minilaparotomy are transient and include nausea, vomiting, and minor abdominal discomfort.
Complications may be:
Surgical
Injuries to other viscera
Bleeding or hemorrhage/ hematoma formation
Infection
Small risk of failure leading to pregnancy(ectopic or intrauterine)
Anesthesia-related
Respiratory depression
Drug overdose
Explain:
Complications of female sterilization are rare.
The immediate side effects of minilaparotomy are transient and include nausea, vomiting, and minor abdominal discomfort.
There are no long-term side effects.
Complications can be classified as surgical (such as injuries to other viscera - bladder and bowel injury, uterine perforation, tubal and mesosalphinx injuries or bleeding and hematoma formation, and infections, there is also a small risk of failure leading to pregnancy (this could be an ectopic pregnancy or a normal intrauterine pregnancy). The other class are the anesthesia-related complications including respiratory depression and hypotension as a result of drug overdose.
Complications and their management will be addressed in more detail later in the training.

18. Long-Term Effects of Female Sterilization
Long-term effects are rare.
Risk of ectopic pregnancy
Potential for regret
Explain
Long-term side effects of female sterilization are very rare. They include:
Ectopic pregnancy. The risk of ectopic pregnancy is much lower than that among women not using female sterilization (in the United States, 6 per 10,000 women per year vs. 65 per 10,000 women per year).
Regret Overall, fewer than 6% of women obtaining sterilization express regret over the decision. Studies have identified a profile among women who experience poststerilization regret. Such women often seek sterilization at a young age, have inadequate information about the procedure, and give a history of not having used contraceptives before or not knowing many contraceptive methods before sterilization. Regret is also more likely among clients who make the decision while under stress—for example, in the immediate postabortion or postpartum period, or when suffering from a chronic or debilitating disease.  
Regret can also occur if the client is coerced or if she makes a rushed decision to have sterilization.