1. Permanent Family Planning
Zenebe Wolde, MD Assistant Professor, Hawassa University Department of Obstetrics and Gynecology

2. Outline Objectives Introduction Male sterilization
Female sterilization
Summary

3. Objectives Define permanent family planning methods
Identify male and female permanent family planning methods
Describe benefits and risks of permanent family planning methods
Explain the techniques of vasectomy and female sterilization

4. Introduction to Permanent Family Planning
Surgical procedure to permanently and intentionally terminate male and female reproductive function
Appropriate for men and women who made a fully informed and well considered decision
Most are not reversible
Vasectomy for men
Tubal ligation in women
Permanent
Family Planning
Permanent methods are procedures whereby the reproductive function of a man or a woman is intentionally and permanently terminate
As these methods are irreversible it needs fully informed and well considered decision, counseling should focus on method reversibility, benefits and risks

5. Vasectomy For men who do not want more children
Transection and occlusion of the vas deferens
Also called male sterilization, male surgical contraception
No interference with sexual performance
Outpatient procedure by local anesthesia
Procedure involves transection and occlusion of the vas deferens
Terminologies used interchangeably include male sterilization and male surgical sterilization

6. Techniques of Vasectomy
Scalpel and Non-scalpel
Palpate the vas through the scrotum
Grasp the vas with fingers or forceps
Pull loop of vas and remove segment
Ligate one or both ends of the vas
Bury the proximal stump

7. Vasectomy (cont’d)

8. Short video on vasectomy

9. Indications for Delaying Vasectomy
Active STIs
Swollen and tender testes
Scrotal skin infection
Bilateral undescended testes

10. Benefits of Vasectomy Failure is less than 1%
Reason for failure can be:
Unprotected intercourse soon
Failure to occlude the vas
Recanalization
Safer and more effective than tubal ligation
0.5 deaths per 100,000 vasectomies

11. Complications of Vasectomy
Side effects are uncommon to very rare
Testicular and scrotal pain lasting for months
Surgical site infection
Hematoma

12. Female Sterilization
For women who do not want more children and/or with medical problem
Also called tubal sterilization, tubal ligation, voluntary surgical contraception
Most widely used globally million couples and 28% in the US
Not popular in Ethiopia – only 0.1%
Occlusion of the tubes in some form
Also called tubal sterilization, tubal ligation, voluntary surgical contraception, tubectomy, bi-tubal ligation, tying the tubes, and minilap,

13. Pomeroy Method

14. Timing of Female Sterilization
At the time of Caesarian Section
Postpartum minilaparotomy
Interval minilaparotomy
Concurrent with pregnancy termination
At the time of CS, no additional risk, slight prolongation of the procedure
Any time with in 7 days of LMP
R/O pregnancy with certainty
Within 7 days after child birth, 6 weeks after child birth
With in 48 hours after uncomplicated abortion

15. Methods of Female Sterilization
Abdominal (laparotomy/Minilaparotomy)
Vaginal
Laparoscopic
Hysteroscopic
Different surgical approaches
Any time with in 7 days of LMP
R/O pregnancy with certainty
Within 7 days after child birth, 6 weeks after child birth
With in 48 hours after uncomplicated abortion

16. Minilaparotomy for Tubal Ligation
Ligation of the fallopian tubes through 3-4cm incision on the abdomen, can be done:
As an outpatient procedure
By local anesthesia and sedation
Minilaparotomy following vaginal delivery:
Enlarged uterus, tubes in the mid abdomen, 3-4 cm sub umbilical incision
Interval minilaparotomy:
Short transverse suprapubic incision
Uterine elevator used through the vagina
Ligation of the fallopian tubes through 3-4cm incision on the abdomen
Can be done as an outpatient procedure

17. Video on minilap

18. Indications to Delaying Tubal Ligation
Current pregnancy
Less than 6 weeks postpartum
Severe postpartum or post abortion complications
Unexplained vaginal bleeding
Pelvic inflammatory disease and STIs
Pelvic malignancies
Postpartum and postabortion complications include infections, severe bleeding, and injury
Pelvic malignancies including Cervical, endometrial, ovarian cancers and malignant trophoblastic diseases
Treatment for pelvic malignancies can serve as sterilization

19. Benefits of Female Sterilization
No known side effect
Helps to protect against unwanted pregnancy
Nothing to remember and no worries about contraceptives again
Prevents against pelvic inflammatory disease (PID)
May protect against ovarian tumor
Complications are extremely rare and often related to surgery and anesthesia
Complications may include hemorrhage, infection, incision abscess,
Ovarian tumor protection persists for 20 years after surgery

20. Risks of Female Sterilization
Few complications
Related with surgery, anesthesia, previous surgery, PID, Obesity, and DM
1-2 deaths /100,000 cases
2 pregnancies per 100 women over 10 years
Possibility of future regret
Young age
Lost a child
Few or no children
Not married/ Marital problems
Related with surgery, anesthesia, previous surgery, PID, Obesity, and DM

21. Counseling on Female Sterilization
Counseling is critical:
Potential risks
Benefits
Possibility of later regret
Possibility of pregnancy (mostly ectopic)
Medical or surgical conditions that are considered contraindication for pregnancy

22. Summary Permanent methods are irreversible
Non-scalpel vasectomy in men and minilaparatomy for women are preferred
Permanent methods are less popular in Ethiopia
Detailed counseling is essential
Rare complications - not related to method

23. Case study 20 year old woman come to your clinic for family planning
She and her husband decided that tubal ligation is best for them. The couple has one child.
What important issue would you like to raise during the counseling?
Take 3 minutes to reflect

24. Considerations in the Case
Check if it is well thought through
Discuss the possibility of future regret as the method is irreversible
Mention other alternative family planning methods