Tubal ligation

Template:Short description Template:Redirect Template:Infobox Birth control Tubal ligation (commonly known as having one's "tubes tied") is a surgical procedure for female sterilization in which the fallopian tubes are permanently blocked, clipped or removed. This prevents the fertilization of eggs by sperm and thus the implantation of a fertilized egg. Tubal ligation is considered a permanent method of sterilization and birth control by the FDA. Bilateral tubal ligation is not considered a sterilization method by the MHRA.

Medical uses

Female sterilization through tubal ligation is primarily used to permanently prevent a patient from having a spontaneous pregnancy (as opposed to pregnancy via in vitro fertilization) in the future. While both hysterectomy (the removal of the uterus) or bilateral oophorectomy (the removal of both ovaries) can also accomplish this goal, these surgeries carry generally greater health risks than tubal ligation procedures.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>

Less commonly, tubal ligation procedures may also be performed for patients who are known to be carriers of mutations in genes that increase the risk of ovarian and fallopian tube cancer, such as BRCA1 and BRCA2. While the procedure for these patients still results in sterilization, the procedure is chosen preferentially among these patients who have completed childbearing, with or without a simultaneous oophorectomy.<ref>Template:Cite journal</ref>

Benefits and advantages for use as contraception

High effectiveness

Template:Further Most methods of female sterilization are approximately 99% effective or greater in preventing pregnancy.<ref name=":02">Template:Cite journal</ref> These rates are roughly equivalent to the effectiveness of long-acting reversible contraceptives such as intrauterine devices and contraceptive implants, and slightly less effective than permanent male sterilization through vasectomy.<ref name=":02" /> These rates are significantly higher than other forms of modern contraception that require regular active engagement by the user, such as oral contraceptive pills or male condoms.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Avoidance of hormonal medications

Many forms of female-controlled contraception rely on suppression of the menstrual cycle using progesterones and/or estrogens.<ref>Template:Cite journal</ref> For patients who wish to avoid hormonal medications because of personal medical contraindications such as breast cancer, unacceptable side effects, or personal preference, tubal ligation offers highly effective birth control without the use of hormones.<ref>Template:Cite journal</ref>

Reduction of pelvic inflammatory disease risk

Occluding or removing both fallopian tubes decreases the likelihood that a sexually transmitted infection can ascend from the vagina to the abdominal cavity, causing pelvic inflammatory disease (PID) or a tubo-ovarian abscess.<ref name=":02" /> Tubal ligation does not eliminate the risk of PID, and does not offer protection against sexually transmitted infections.<ref name=":02" />

Reduction of ovarian and fallopian tube cancer risk

Partial tubal ligation or full salpingectomy (a tubal ligation method that relies upon the physical removal of the fallopian tube) reduces the lifetime risk of developing ovarian or fallopian tube cancer later in life. This is true both for patients who are already known to be at high risk for ovarian or fallopian tube cancer secondary to genetic mutations, as well as females who have the baseline population risk.<ref name=":02" /><ref>Template:Cite journal</ref>

Risks and complications

Risks associated with surgery and anesthesia

Most tubal ligation procedures involve accessing the abdominal cavity through incisions in the abdominal wall and require some form of anesthesia. Major complications from laparoscopic surgery may include need for blood transfusion, infection, conversion to open surgery, or unplanned additional major surgery, while complications from anesthesia itself may include hypoventilation and cardiac arrest.<ref name=":02" /> Major complications during female sterilization are uncommon, occurring in an estimated 0.1–3.5% of laparoscopic procedures, with mortality rates in the United States estimated at 1–2 patient deaths per 100,000 procedures.<ref name=":02" /> These complications are more common for patients with a history of previous abdominal or pelvic surgery, obesity, and/or diabetes.<ref name=":02" />

Failure

While female sterilization procedures are highly effective at preventing pregnancy, there is a small continuing risk of unintended pregnancy after tubal ligation.<ref>Template:Cite journal</ref> Several factors influence the likelihood of failure: increased time since sterilization, younger age at the time of sterilization, and certain methods of sterilization are all associated with increased risk of failure.<ref name=":02" /> Pregnancy rates at 10 years after sterilization vary depending on the type of procedure used, documented as low as 7.5 per 1,000 procedures to as high as 36.5 per 1,000 procedures.<ref name=":02" />

Ectopic pregnancy

Overall, all pregnancies, including ectopic pregnancies, are less common among patients who have had a female sterilization procedure than among patients who have not.<ref name=":02" /><ref>Template:Cite journal</ref> However, if patients do have a pregnancy after tubal ligation, a greater percentage of these will be ectopic; approximately one third of pregnancies that occur after a tubal ligation will be ectopic pregnancies.<ref name=":02" /> The likelihood of ectopic pregnancy is higher among patients sterilized before age 30 and differs depending on the type of sterilization procedure used.Template:Citation needed

Emotional after effects

The majority of patients who undergo female sterilization procedures do not regret their decisions. However, regret appears to be more common among patients who undergo sterilization at a young age (often defined as younger than 30 years old),<ref>Template:Cite journal</ref> patients who are unmarried at the time of sterilization, non-white patients, patients with public insurance such as Medicaid, or patients who undergo sterilization soon after the birth of a child.<ref name=":02" /><ref>Template:Cite journal</ref> Regret has not been found to be associated with the number of children a person has at the time of sterilization.<ref name=":02" />

Side effects

Menstrual changes

Patients who have undergone female sterilization procedures have minimal or no changes in their menstrual patterns. They were more likely to have perceived improvements in their menstrual cycle, including decreases in the amount of bleeding, in the number of days of bleeding, and in menstrual pain.<ref name=":02" />

Ovarian reserve

Studies of hormone levels and ovarian reserve have demonstrated no significant changes after female sterilization, or inconsistent effects.<ref>Template:Cite journal</ref> Evidence does not indicate a strong association between tubal ligation and earlier onset of menopause.<ref>Template:Multiref2</ref>

Sexual function

Sexual function appears unchanged or improved after female sterilization compared with non-sterilized females.<ref>Template:Cite journal</ref>

Hysterectomy

Patients who had tubal occlusion surgeries have been found to be four to five times more likely to undergo hysterectomy later in life than those whose partners underwent vasectomy.<ref name=":02" /> There is no known biologic mechanism to support a causal relationship between tubal ligation and subsequent hysterectomy, but there is an association across all methods of tubal ligation.<ref name=":02" />

Postablation tubal sterilization syndrome

{{#invoke:Labelled list hatnote|labelledList|Main article|Main articles|Main page|Main pages}} Some females who have undergone tubal ligation prior to an endometrial ablation procedure experience cyclic or intermittent pelvic pain; this may happen in up to 10% of women who have undergone both surgeries.<ref>Template:Cite journal</ref>

Contraindications

Given its permanent nature, tubal ligation is contraindicated in patients who desire future pregnancy or who want to have the option of future pregnancy. In such cases, reversible methods of contraception are recommended.<ref name=":02" />

Since most forms of tubal ligation require abdominal surgery under regional or general anesthesia, tubal ligation is also relatively contraindicated in patients for whom the risks of surgery and/or anesthesia are unacceptably high considering their other medical issues.<ref name=":02" />

Procedure technique

Tubal ligation through blocking or removing the tubes may be accomplished through an open abdominal surgery, a laparoscopic approach, or a hysteroscopic approach.<ref name=":3">Template:Cite journal</ref> Depending on the approach chosen, the patient will need to undergo local, general, or spinal (regional) anesthesia. The procedure may be performed either immediately after the end of a pregnancy, termed a "postpartum" or "postabortion tubal ligation", or more than six weeks after the end of a pregnancy, termed an "interval tubal ligation".<ref name=":02" /> The steps of the sterilization procedure will depend on the type of procedure being used.Template:Citation needed (See Tubal ligation methods below.)

If the patient chooses a postpartum tubal ligation, the procedure will further depend on the delivery method. If the patient delivers via Cesarean section, the surgeon will remove part or all of the fallopian tubes after the infant has been delivered and the uterus has been closed.<ref name=":3" /> Anesthesia for the tubal ligation will be the same as that being used for the Cesarean section itself, usually regional or general anesthesia. If the patient delivers vaginally and desires a postpartum tubal ligation, the surgeon will remove part or all of the fallopian tubes usually one or two days after the birth, during the same hospitalization.<ref name=":3" />

If the patient chooses an interval tubal ligation, the procedure will typically be performed under general anesthesia in a hospital setting. Most tubal ligations are accomplished laparoscopically, with an incision at the umbilicus and zero, one, or two smaller incisions in the lower sides of the abdomen. It is also possible to perform the surgery without a laparoscope, using larger abdominal incisions.<ref name=":3" /> It is also possible to perform an interval tubal ligation hysteroscopically, which may be performed under local anesthesia, moderate sedation, or full general anesthesia.<ref name=":3" /> While no methods of hysteroscopic sterilization are currently on the market in the United States as of 2019, the Essure<ref name=":0">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> and Adiana systems were previously used for hysteroscopic sterilization, and research trials are investigating new hysteroscopic approaches.

Tubal ligation methods

There are a number of methods of removing or occluding the fallopian tubes, some of which rely on medical implants and devices.

Postpartum tubal ligation

Performed immediately after a delivery, this method removes a segment, or all, of both fallopian tubes. The most common techniques for partial bilateral salpingectomy are the Pomeroy<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> or Parkland<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> procedures. The ten year pregnancy rate is estimated at 7.5 pregnancies per 1000 procedures performed, and the ectopic pregnancy rate is estimated at 1.5 per 1000 procedures performed.<ref name=":02" />

Interval tubal ligation

Bilateral salpingectomy

This method removes both tubes entirely, from the uterine cornuae out to the tubal fimbriae. This method has recently become more popular for female sterilization, given evidence to support the fallopian tube as the potential site of origin of some ovarian cancers.<ref>Template:Cite journal</ref> Some large medical systems such as Kaiser Permanente Northern California <ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> have endorsed complete bilateral salpingectomy as the preferred means of female sterilization and professional medical societies such as the Society of Gynecologic Oncology <ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> and the American College of Obstetricians and Gynecologists (ACOG) recommend discussing the benefits of salpingectomy during counseling for sterilization.<ref>Template:Cite journal</ref> While complete bilateral salpingectomy theoretically should have an efficacy rate that approaches 100 percent and eliminates the risk of tubal ectopic pregnancy, there is not high quality data available comparing this method to older methods.Template:Citation needed

Bipolar coagulation

This method uses electric current to cauterize sections of the fallopian tube, with or without subsequent division of the tube.<ref name=":4">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> The ten year pregnancy rate is estimated at 6.3 to 24.8 pregnancies per 1000 procedures performed, and the ectopic pregnancy rate is estimated at 17.1 per 1000 procedures performed.<ref name=":02" />

Monopolar coagulation

This method uses electric current to cauterize the tube, but also allows radiating current to further damage the tubes as it spreads from the coagulation site. The tubes may also be transected after cauterization.<ref name=":4" /> The ten year pregnancy rate is estimated at 7.5 pregnancies per 1000 procedures performed.<ref name=":02" />

Tubal clip

This method uses a tubal clip (Filshie clip or Hulka clip) to permanently clip the fallopian tubes shut. Once applied and fastened, the clip blocks movement of eggs from the ovary to the uterus.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> The ten year pregnancy rate is estimated at 36.5 pregnancies per 1000 procedures performed, and the ectopic pregnancy rate is estimated at 8.5 per 1000 procedures performed.<ref name=":02" />

Tubal ring (Falope ring)

This method involves a doubling over of the fallopian tubes and application of a silastic band to the tube.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> The ten year pregnancy rate is estimated at 17.7 pregnancies per 1000 procedures performed, and the ectopic pregnancy rate is estimated at 8.5 per 1000 procedures performed.<ref name=":02" />

Less commonly used or no longer used procedures

Irving's procedure

This method places two ligatures (sutures) around the fallopian tube and removing the segment of tube between the ligatures. The medial ends of the fallopian tubes on the side closer to the uterus are then connected to the back of the uterus itself.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Uchida tubal ligation

This method involves dissecting the fallopian tube from the overlying connective tissue (serosa), placing two ligatures and excising a segment of the tube, then buries the end of the fallopian tube closest to the uterus underneath the serosa.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Dr. Uchida reported no failures among 20,000 procedures.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>

Essure tubal ligation

This method closed the fallopian tubes through a hysteroscopic approach by placing two small metal and fiber coils in the fallopian tubes through the fallopian ostia. After insertion, scar tissue forms around the coils, blocking off the fallopian tubes and preventing sperm from reaching the egg.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> It was removed from the US market in 2019.<ref name=":0" />

Adiana tubal ligation

This method closed the fallopian tubes through a hysteroscopic approach by placing two small silicone pieces in the fallopian tubes. During the procedure, the health care provider heated a small portion of each fallopian tube and then inserts a tiny piece of silicone into each tube. After the procedure, scar tissue formed around the silicone inserts, blocking off the fallopian tubes and preventing sperm from reaching the egg.<ref>Template:Cite press release</ref> It was removed from the US market in 2012.

Reversal or in vitro fertilization after tubal ligation

{{#invoke:Labelled list hatnote|labelledList|Main article|Main articles|Main page|Main pages}} All tubal ligation procedures are considered permanent and are not reliably reversible forms of birth control. Patients who wish to have the option of future pregnancy should ideally be directed towards effective but reversible forms of birth control, rather than sterilization procedures.<ref name=":02" /><ref>Template:Cite journal</ref> Examples of this include intrauterine devices. However, patients who desire pregnancy after having undergone a female sterilization procedure have two options.

Tubal reversal is a type of microsurgery to repair the fallopian tube after a tubal ligation procedure. Successful pregnancy rates after reversal surgery are 42-69%, depending on the sterilization technique that was used.<ref>Template:Cite journal</ref>

Alternatively, in vitro fertilization (IVF) may allow patients with absent or occluded fallopian tubes to successfully carry a pregnancy. The choice of whether to attempt tubal reversal or move straight to IVF depends on individual patient factors, including the likelihood of successful tubal reversal surgery and the age of the patient.<ref>Template:Cite journal</ref>

Recovery and rehabilitation

Most laparoscopic methods of interval tubal ligation are outpatient surgeries and do not require hospitalization overnight. Patients are counseled to expect some soreness but to expect to be ready to perform daily activities 1–2 days after surgery.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Patients undergoing postpartum tubal ligations will not be delayed in their discharge from the hospital after birth, and recovery is not significantly different from normal postpartum recovery.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

History

The first modern female sterilization procedure was performed in 1880 by Dr. Samuel Lungren of Toledo, Ohio, in the United States.<ref name=":5">Template:Cite journal</ref> Hysteroscopic tubal ligation was developed later by Mikulicz-Radecki and Freund.<ref name=":5" />

Since its development, female sterilization has been periodically performed on patients without their informed consent, often specifically targeting marginalized populations.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Given this history of human rights abuses, current sterilization policy in the United States requires a mandatory waiting period for tubal sterilization on Medicaid beneficiaries. This waiting period is not required for private insurance beneficiaries, which has the effect of selectively restricting low-income women's access to tubal sterilization.<ref>Template:Cite journal</ref>

Society and culture

Prevalence

Of the 64% of married or in-union women worldwide using some form of contraception, approximately one fifth (19% of all women) used female sterilization as their contraception, making it the most common contraceptive method globally.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> The percentage of women using female sterilization varies significantly between different regions of the world. Rates are highest in Asia, Latin America and the Caribbean, North America, Oceania, and selected countries in Western Europe, where rates of sterilization are often greater than 40%; rates in Africa, the Middle East, and parts of Eastern Europe, however, are significantly lower, sometimes less than 2%.<ref name=":1">Template:Cite book</ref> An estimated 180 million women worldwide have undergone surgical sterilization, compared to approximately 42.5 million men who have undergone vasectomy.<ref name=":1" />

In the United States, female sterilization is used by 30% of married couples<ref name=":02" /> and 22% of women who use any form of contraception, making it the second-most popular contraceptive after the birth control pill.<ref name=":2">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Slightly more than 8.2 million women in the US use tubal ligation as their main form of contraception,<ref name=":2" /> and approximately 643,000 female sterilization procedures are performed each year in the United States.<ref name=":02" /> A September 2024 study found that states which enacted abortion bans following the ruling in Dobbs v. Jackson Women's Health Organization saw a 39% increase in tubal ligation rates by December 2022.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

See also

• Compulsory sterilization

External links

• Birth Control Comparison Chart 2008