Introduction

Tubal sterilisation is the method of contraception practised most widely all over the world (1, 2, 3). It is highly effective in protection against pregnancy and eliminates the requirement of long-term contraceptive use. Thus, it is a safe, easy, and highly effective birth control method for the long term. Furthermore, tubal ligation is the best option for developing countries like India where most of the patients do not come for a return visit, as it can be done during hospital stay for either normal delivery or caesarean section and allows a single recovery period for the surgical procedure and the delivery. As per National Family Health Survey (NFHS) -3 (2005–2006), female sterilisation is responsible for 37.3% of all methods of family planning used in the nation (4). Many patients prefer tubectomy because of the provision of monetary payment to patients under the national family planning programme. According to survey data, 64% of women stated that they would like to go in for tubal sterilisation at some point of time in future (5). Even though tubal ligation is performed as a permanent method of sterilisation, due to unanticipated circumstances, 1%–3% of women who have undergone the procedure later insist on the reversal of sterilisation (6). The most common causes for seeking reversal are the death or disability of their child, followed by a second marriage (7, 8). The laparoscopic approach is the favoured technique in many centres as it potentially involves less manipulation of the intraperitoneal organs and causes less bleeding (9, 10). These advantages may result in fewer adhesions, enhancing the pregnancy rate.

In counseling for family planning, the right of clients to receive accurate information and make their own decisions, ie their right to make an informed choice, is considered fundamental. The counselling often involves a written statement that the client signs to verify his/her understanding of the method, medical procedure and risks. Another important purpose of obtaining informed consent is to protect the service provider from lawsuits alleging malpractice. Thus, it is important from the perspectives of both the patient and the doctor.

Case report

A woman in her twenties visited the out-patient department of Pt BD Sharma PGIMS, Rohtak, with the complaint that she had been married for the past three years and had been unable to conceive. At first glance, it looked like a case of primary infertility. Her personal and family history was not significant. Her menstrual history was also normal. She said that she was consulting some private practitioner for her problem and had gone through many investigations. She had also been prescribed certain drugs for the problem, but despite all these efforts, she was still unable to conceive. Finally, she came to PGIMS, Rohtak for treatment. The patient showed us the private doctor’s documents of her case. According to her, the doctor had informed her that the results of all her investigations were normal. The private practitioner had put her on ovulation induction drugs. She also had hysterosalpingography (HSG) films, which showed that there was no free peritoneal spill and the fallopian tubes were not delineated till the fimbrial ends. Further, there was a suspect radio-opaque structure in both fallopian tubes. This was an important finding missed by the doctor whom she had been consulting before coming to PGIMS, Rohtak.

The patient’s detailed past history was elicited. She informed us that around three years before her marriage, she had undergone an abdominal surgery for abdominal pain. She said that before her marriage, she was living with her relatives and was operated on in a private hospital for the pain. She did not have the records of that surgery and did not know anything about the nature of the surgery. After the history-taking, the patient was examined. On general physical examination, she was found to be afebrile. Her pulse rate and blood pressure were within the normal range. The abdominal examination revealed a laparoscopy scar mark.

The patient was admitted for a laparoscopic examination. She was assessed by the anaesthetist and was found fit for the laparoscopy. The laparoscopic examination revealed the presence of Falope rings in both her tubes. Recanalisation surgery was performed and she was discharged from the hospital in a stable condition.

Discussion

It is clear that the doctor needed to obtain informed consent from the patient before doing the tubal ligation. As explained above, tubal ligation is a sterilisation operative procedure that renders the patient unable to conceive children. It is a procedure that is not without risks both during and after the operation. This is an unusual and rare case reported in our OPD where the young unmarried girl was tubectomised without her consent. This is a case of forced tubectomy or forced sterilisation. Forced sterilisation is illegal and unethical, and the erring doctor may be punished by the law-enforcing agencies. The informed consent has legal sanctity and the doctor may be sued in a court of law if informed consent is not taken before performing a tubectomy. Further, the Medical Council of India or the State Medical Council, as the case may be, can also initiate disciplinary action against errant doctors. In this case, the reason for performing a bilateral tubectomy in a young unmarried girl was not clear. However, it was clear that in all probability, it was not performed as per the medical indications and the doctors or the patient’s relatives had some ulterior motive. As the patient was not from a very poor family, the possibility of opting for a tubectomy due to the prospect of receiving incentive money was a remote possibility. In some instances, young girls are tubectomised and forced into sex work, but this was also a remote possibility in this case. The girl could conceive after recanalisation, but the chances were lower than normal. Also, there were greater chances of complications such as ectopic pregnancy. It is also important to note here that every surgeon should follow the WHO surgical safety checklist to prevent any chance of wrong patient selection, operating on the wrong patient and other such errors. The doctor should have obtained an explicit informed consent from the patient before performing any procedure on him/her.

Conclusion

Doctors should always take informed written consent from patients before performing any procedure; otherwise they can be charged with negligence or malpractice. Further, the patient may also file a claim for compensation against the doctor under the Consumer Protection Act 1986. The Medical Council of India or the State Medical Council concerned may also initiate disciplinary action against the erring doctor for violating medical ethics.