INTRODUCTION — Surgical sterilization is a safe, highly effective, permanent, and convenient form of contraception. The most common surgical sterilization procedure for women is called a tubal ligation or having the "tubes tied". The fallopian tubes are attached to the uterus and adjacent to the ovaries (show figure 1). The fallopian tubes are the site where the egg becomes fertilized by the male's sperm prior to traveling to the uterus. In tubal sterilization, the fallopian tubes are separated or sealed shut, thus preventing the egg and sperm from meeting.
A tubal sterilization is usually performed by laparoscopic surgery, in which a flexible tube (laparoscope) is inserted through a small incision and used to view and operate inside a woman's abdomen. It can also be performed by a laparotomy, where an incision is made in the abdomen. This is most often performed in women who have recently given birth, during the postpartum period.
DECIDING TO HAVE A TUBAL LIGATION — Sterilization is a major decision; it means that a woman and her partner do not want children at any time in the future. A woman's decision to undergo sterilization must be voluntary and not forced by her family, partner, or health care provider. In the United States, a woman's husband or partner is not required to give consent for the procedure, though both partners should have an understanding of the procedure as well as tubal sterilization's benefits, alternatives, and potential risks. The woman and her partner should review the risks and benefits of all methods of contraception, including male sterilization (vasectomy). (See "Patient information: Vasectomy").
The physician should provide an explanation of the details of the procedure, including anesthesia (general, spinal, local), and the possibility of pregnancy following the procedure (see "Outcomes" below), including the chance of ectopic pregnancy (when a pregnancy begins to grow outside the uterus, usually in the fallopian tubes). A woman may change her mind at anytime before the procedure.
Tubal sterilization should be considered permanent; reversing the procedure involves major surgery, is not always successful, and is rarely covered by most insurance plans.
ALTERNATIVES — Alternatives to permanent female sterilization include male sterilization (vasectomy) and reversible types of contraception (birth control pills/patch/vaginal ring, condoms, diaphragm, cervical cap, intrauterine device, or hormone injections).
REGRET AFTER STERILIZATION — Regret after tubal sterilization occurs in 3 to 25 percent of women. However, only about 1 to 2 percent of all women who have undergone sterilization seek a reversal of the procedure [1-3]. The most common factor associated with regret is a change in marital status. Other factors include marital problems at the time of procedure, stress due to recent pregnancy complications, and young age (less than age 30) at the time of sterilization.
For these reasons, women who are younger than 30, have recently given birth and had significant complications (eg, premature birth, death of an infant), or who are having difficulty with their marriage or relationship should initially consider other birth control options. A healthcare provider may recommend that sterilization be delayed until a woman is sure of her decision, aware of the risks and benefits, and aware of the alternatives to permanent sterilization.
TIMING OF STERILIZATION — Sterilization can be performed at any time during a woman's menstrual cycle, though another form of birth control is recommended for one month before the procedure to reduce the risk of pregnancy (see below).
Sterilization can also be performed postpartum, after an abortion, or in conjunction with another surgical procedure (eg, gallbladder removal). Ideally, postpartum procedures are performed immediately after delivery or within 24 hours, but may be done up to seven days later. Further delay increases the difficulty of the procedure and the risk of infection.
Contraception before and after sterilization — Some form of contraception (condom, diaphragm, birth control pill) should be used before sterilization to decrease the risk of pregnancy. A woman can become pregnant if fertilization occurs just prior to the tubal ligation. Performing the tubal ligation procedure immediately postpartum or during a woman's menstrual period reduces the chance of becoming pregnant at the time of the procedure.
Although contraception is not necessary after the procedure, condoms should be used for protection against sexually transmitted diseases (eg, chlamydia, HIV) if the woman has multiple sex partners or a partner with other partners.
STERILIZATION PROCEDURES
Minilaparotomy — A minilaparotomy is commonly used postpartum; a small cut (one to three inches) is made in the abdomen, through which the procedure is performed on the fallopian tubes. General, regional, or local anesthesia can all be used for this procedure. In postpartum women, having the procedure does not lengthen the hospital stay.
There are three common surgical methods for the minilaparotomy that correspond to three different techniques of sealing the fallopian tubes: the Pomeroy technique (show figure 2-5), the Irving technique (show figure 6-9), or the Uchida method (show figure 10). Each has advantages and disadvantages.
One advantage of minilaparotomy is that a tissue specimen can be removed to prove the fallopian tubes have been completely cut. Disadvantages of minilaparotomy include a greater need for pain medication, slightly longer recovery time, and a larger surgical incision than with a laparoscopic procedure [4].
Laparoscopic sterilization — Laparoscopic sterilization is the most common surgical method for interval (at a time unrelated to pregnancy) sterilization. In laparoscopic surgery, a small incision is cut near the belly button and in the lower abdomen and a flexible tube (laparoscope) is used to view the fallopian tubes and pelvis. The physician uses rings or clips to close the fallopian tubes or seals them shut using electrocoagulation (a procedure in which the fallopian tubes are cauterized) (show figure 11).
Severe heart or lung disease, a bleeding tendency, intraabdominal scarring, and obesity make laparoscopic procedures more dangerous and may prevent a woman from undergoing a laparoscopic sterilization.
Vaginal sterilization — The vaginal route for tubal sterilization is uncommon because it is more difficult to see the fallopian tubes than with the laparoscopic approach. In the vaginal sterilization technique, an incision is made through the vagina to reach the fallopian tubes, which are then cauterized, banded, or clipped.
Hysteroscopic sterilization — A minimally invasive hysteroscopic technique for tubal sterilization is also available. The Essure® permanent birth control procedure is a minimally invasive hysteroscopic technique for permanent tubal blockage whereby a tiny coil mechanism is inserted into the fallopian tube hysteroscopically under local anesthesia. Patients must use contraception until a procedure (called hysterosalpingogram) is performed three months after coil placement confirms tubal blockage. Some patients will require a second procedure if the tubes are not completely blocked.
OUTCOMES
Complications — The risk of surgical complications is approximately 1 in every 1000 procedures, but depend on the type of procedure. These complications include infection, bowel or bladder injury, internal bleeding, and problems related to anesthesia. Burns may occur if electrocautery is used. Blood clots and death are very rare.
Menstrual periods — There is no evidence that bleeding or uterine cramping is increased after tubal sterilization [5-7]. In fact, women who undergo sterilization are more likely to have fewer days of bleeding during menstruation, a lower amount of blood loss, and less menstrual pain. However, sterilized women have described more cycle irregularity than women who were not sterilized.
Sex — Tubal sterilization does not affect sexual desire or performance.
Pregnancy — Sterilization failure resulting in pregnancy is uncommon. In a study of 10,685 women who underwent tubal sterilization and were followed for 8 to 14 years, 143 women became pregnant (approximately 1 percent) [8,9] (show table 1A-1B) . The risk of pregnancy was highest among women sterilized at a young age (under age 30). When pregnancy occurs, it is more likely to be an ectopic pregnancy. (See "Patient information: Ectopic (tubal) pregnancy").
Other — Women who have undergone tubal sterilization have a slightly lower risk of developing ovarian cancer.
AFTER SURGERY — Patients may go home a few hours after an outpatient procedure, but someone should be available to drive and help as needed. There will be some discomfort at the incision site and menstrual-type cramping; this can be treated with pain medication such ibuprofen. Depending upon the type of procedure and anesthesia, patients may have a sore throat (from a tube placed to help with breathing during general anesthesia), neck or shoulder pain, or vaginal discharge/slight bleeding. Most patients should be able to return to a normal routine within a couple of days.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Planned Parenthood
(www.plannedparenthood.org)
Society of Obstetricians and Gynaecologists of Canada (SOGC)
(www.sogc.org/health)
Managing Contraception
(www.managingcontraception.com/cmanager/publish/choices.shtml)
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Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Grubb, GS, Peterson, HB, Layde, PM, Rubin, GL. Regret after decision to have a tubal sterilization. Fertil Steril 1985; 44:248.
2. Allyn, DP, Leton, DA, Westcott, NA, Hale, RW. Presterilization counseling and women's regret about having been sterilized. J Reprod Med 1986; 31:1027.
3. Wilcox, LS, Chu, SY, Eaker, ED, et al. Risk factors for regret after tubal sterilization: 5 years of follow-up in a prospective study. Fertil Steril 1991; 55:927.
4. American Coleege of Obstetricians and Gynecologists. Sterilization. ACOG technical Bulletin No. 222. ACOG, Washington, DC 1996.
5. DeStefano, F, Huezo, CM, Peterson, HB, et al. Menstrual changes after tubal sterilization. Obstet Gynecol 1983; 62:673.
6. Bhiwandiwala, PP, Mumford, SD, Feldblum, PJ. Menstrual pattern changes following laparoscopic sterilization with different occlusion techniques: a review of 10,004 cases. Am J Obstet Gynecol 1983; 145:684.
7. Bhiwandiwala, PP, Mumford, SD, Feldblum, PJ. Menstrual pattern changes following laparoscopic sterilization: a comparative study of electrocoagulation and the tubal ring in 1,025 cases. J Reprod Med 1982; 27:249.
8. Peterson, HB, Xia, Z, Hughes, JM, et al. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996; 174:1161.
9. Peterson, HB, Xia, Z, Hughes, JM, et al. The risk of ectopic pregnancy after tubal sterilization. N Engl J Med 1997; 336:762.
10. Miesfeld, RR, Giarratano, RC, Moyers, TG. Vaginal tubal ligation--is infection a significant risk? Am J Obstet Gynecol 1980; 137:183.
11. Lipscomb, GH, Stovall, TG, Summitt, RL, Ling, FW. Chromopertubation at laparoscopic tubal occlusion. Obstet Gynecol 1994; 83:725.
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