Tubal sterilisation and reversal — structured SAQ (15 marks)

(a) Counselling before caesarean sterilisation (4 marks)

One mark each for voluntariness/timing, permanence and failure, alternatives, and age-related regret. ^[2]

• Voluntariness and timing: speak privately with the patient, assess capacity, ask whether she feels pressured, and ensure she can change her mind. Consent obtained during labour or a high-emotion event must be scrutinised; defer if she is uncertain. ^[2]
• Permanence and failure: explain that the operation is intended to be permanent, can fail years later and is not guaranteed to be reversible; pregnancy after failure needs early ectopic assessment. ^[1]
• Alternatives: offer LARC (copper or levonorgestrel IUD, implant), partner vasectomy and reversible contraception; the patient should understand why sterilisation rather than LARC fits her goals. ^[2]
• Age-related regret: at age 29, she is in the group with greater poststerilisation regret; discuss future relationship change and the possibility that her wishes may change. This is not a reason to refuse but is a reason for a careful, separate consent conversation. ^[2][6]

(b) Method comparison (4 marks)

One mark for comparing the three surgical methods; one mark for Essure and current status. ^[1]

• Filshie clip: interval laparoscopic, short mechanical occlusion, low long-term failure and relatively favourable residual tube for reversal. ^[1]
• Pomeroy/partial salpingectomy: common postpartum or at caesarean; a loop is ligated and excised; effective, but success of reversal depends on residual length and luminal alignment. ^[1]
• Bipolar coagulation: destroys a longer segment; more diathermy lowers reversal success and failure is higher in younger women. ^[1]
• Essure: historical hysteroscopic micro-inserts required a three-month confirmation test; withdrawn in Australia and globally after pain, migration, perforation and reoperation concerns; not an option for new patients. ^[3]

(c) Workup and reversal versus IVF (4 marks)

One mark for the workup; one mark for reversal; one mark for IVF; one mark for matching the route to the patient. ^[4][5]

• Workup: obtain the operative report and histology; semen analysis; AMH and antral follicle count; pelvic ultrasound; assess uterine factors and any remaining tubal anatomy. ^[4]
• Tubal re-anastomosis: microsurgical or robotic excision of scarred ends with mucosal alignment and fine sutures; reasonable at age 33 if both tubes retain adequate healthy proximal and distal segments. ^[4]
• IVF: bypasses the tube; more efficient if the residual tube is too short, male factor is present or reserve is poor; no need to reverse the sterilisation first. ^[5]
• Choice: at 33 with modified Pomeroy, the decision is shared; a tubal surgeon should review operative details and local audited outcomes before recommending reversal versus IVF. ^[4][5]

(d) Success determinants and early complication (3 marks)

One mark for age, one for tube/method and one for ectopic risk. ^[4]

• Age and ovarian reserve are the strongest patient determinants; success falls with advancing age, especially after 40. ^[4]
• Method and residual tube matter: clips leave more reconstructable tube than extensive coagulation; length, site and final luminal diameter after re-anastomosis determine outcome. ^[4]
• Ectopic pregnancy must be excluded early in any pregnancy after re-anastomosis or sterilisation failure: arrange prompt transvaginal ultrasound and serial hCG until location is confirmed. ^[1]

Common errors that lose marks

• Accepting the caesarean-section request as automatic consent without asking whether the patient is uncertain.
• Saying reversal is "usually successful" without reviewing the operative report, age and remaining tube.
• Offering Essure as a current option in ANZ.
• Forgetting partner semen analysis and ovarian reserve before tubal surgery.
• Treating a positive pregnancy test after sterilisation as a routine intrauterine pregnancy.

Examiner notes

The candidate who scores well recognises that her age and timing are the key regret risks, offers LARC without judgement, describes Pomeroy as effective but potentially less reconstructable than clips, and gives a balanced reversal-versus-IVF pathway. ^[2][4][5]