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Sterilization has become a popular choice of contraceptive for millions of men and women in the United States as well as in many countries worldwide. This procedure is indicated in those requesting sterilization and who clearly understand its permanence and its difficult and often unsuccessful reversal. A woman should be counseled regarding alternative contraceptive choices (American College of Obstetricians and Gynecologists, 2007).

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Female sterilization is the contraceptive method selected by 28 percent of couples in the United States (American College of Obstetricians and Gynecologists, 2003). And for women aged 35 to 44 years, surgical sterilization was their most commonly reported form of contraception (Bensyl and associates, 2005; Huber and Huber, 2009).

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Sterilization is usually accomplished by occlusion or division of the fallopian tubes. This can be performed at any time, but at least half are performed in conjunction with cesarean or vaginal delivery and are termed puerperal (MacKay and associates, 2001). Nonpuerperal surgical tubal sterilization is usually accomplished via laparoscopy in an outpatient surgical center. Hysteroscopic or minilaparotomy approaches to occlusion are also available.

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Puerperal Tubal Sterilization

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For several days after delivery, the fallopian tubes are accessible at the umbilicus directly beneath the abdominal wall. Wall laxity allows easy repositioning of the abdominal incision over each uterine cornu. Thus, puerperal sterilization is technically simple, and hospitalization need not be prolonged. Some prefer to perform sterilization immediately following delivery, although others wait for 12 to 24 hours (Bucklin and Smith, 1999). At Parkland and the University of Alabama Hospitals, puerperal tubal ligation is performed in the obstetrical surgical suite the morning after delivery. This minimizes hospital stays but allows the likelihood of postpartum hemorrhage to diminish. In addition, the status of the newborn can be better ascertained.

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Various techniques are now used to disrupt tubal patency. In general, a midtubal segment of fallopian tube is excised, and the severed ends seal by fibrosis and reperitonealization. Commonly used methods of interval sterilization include the Parkland, Pomeroy, and modified Pomeroy techniques (American College of Obstetricians and Gynecologists, 2003). Irving and Uchida techniques or Kroener fimbriectomy are rarely used because they involve increased dissection, operative time, and chance of mesosalpingeal injury. With fimbriectomy, unfavorably high failure rates stem from recanalization of the proximal tubal portion (Pati and Cullins, 2000).

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Surgical Technique

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A small infraumbilical incision is made. The fallopian tube is identified by grasping its midportion with a Babcock clamp, and the distal fimbria is identified. This prevents confusing the round ligament with the midportion of the tube. A common reason for sterilization failure is ligation of the wrong structure, typically the round ligament. Therefore, identification and isolation of the distal tube prior to ligation is required. Whenever the tube is inadvertently dropped, it is mandatory to repeat this identification procedure. Surgical steps are outlined for each method in Figures ...

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