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Tubal ligation

Definition

Tubal ligation is a permanent voluntary form of birth control (contraception) in which a woman's fallopian tubes are surgically cut or blocked off to prevent pregnancy.

Purpose

Tubal ligation is performed in women who want to prevent future pregnancies. It is frequently chosen by women who do not want more children, but who are still sexually active and potentially fertile, and want to be free of the limitations of other types of birth control. Women who should not become pregnant for health concerns or other reasons may also choose this birth control method.

Demographics

Tubal ligation is one of the leading methods of contraception, having been chosen by over 10 million women in the United States—about 15% of women of reproductive age. The typical tubal ligation patient is over age 30, is married, and has had two or three children.

Description

Tubal ligation, or getting one's "tubes tied," refers to female sterilization, the surgery that ends a woman's ability to conceive. The operation is performed on the patient's fallopian tubes. These tubes, which are about 4 in (10 cm) long and 0.2 in (0.5 cm) in diameter, are found on the upper outer sides of the uterus. They open into the uterus through small channels. It is within the fallopian tube that fertilization, the joining of the egg and the sperm, takes place. During tubal ligation, the tubes are cut or blocked in order to close off the sperm's access to the egg.

Normally, tubal ligation takes about 20–30 minutes, and is performed under general anesthesia, spinal anesthesia, or local anesthesia with sedation. The surgery can be performed on either hospitalized patients within 24 hours after childbirth or on outpatients. The woman can usually leave the hospital the same day.

Tubal ligation should be postponed if the woman is unsure about her decision. While the procedure is sometimes reversible, it should be considered permanent and irreversible. As many as 10% of sterilized women regret having had the surgery, and about 1% seek treatment to restore their fertility.

The most common surgical approaches to tubal ligation include laparoscopy and mini-laparotomy. In a laparoscopic tubal ligation, a long, thin telescope-like surgical instrument called a laparoscope is inserted into the pelvis through a small cut about 0.5 inches (1 cm) long near the navel. Carbon dioxide gas is pumped in to help move the abdominal wall to give the surgeon easier access to the tubes. Often the surgical instruments are inserted through a second incision near the pubic hair line. An instrument may be placed through the vagina to hold the uterus in place.

In a mini-laparotomy, a 1.2–1.6 in (3–4 cm) incision is made just above the pubic bone or under the navel. A larger incision, or laparotomy, is rarely used today. Tubal ligation can also be performed at the time of a cesarean section.

The tubal ligation itself is performed in several ways:

• Electrocoagulation. A heated needle connected to an electrical device is used to cauterize or burn the tubes. Electrocoagulation is the most common method of tubal ligation.
• Falope ring. In this technique, an applicator is inserted through an incision above the bladder and a plastic ring is placed around a loop of the tube.
• Hulka clip. The surgeon places a plastic clip across a tube held in place by a steel spring.
• Silicone rubber bands. A band placed over a tube forms a mechanical block to sperm.

Tubal ligation costs about $2,000 when performed by a private physician, but is less expensive when performed at a family planning clinic. Most insurance plans cover treatment costs.

Diagnosis/Preparation

Preparation for tubal ligation includes patient education and counseling. Before surgery, it is important that the woman understand the permanent nature of tubal ligation as well as the risks of anesthesia and surgery. Her medical history is reviewed, and a physical examination and laboratory testing are performed. The patient is not allowed to eat or drink for several hours before surgery.

Aftercare

After surgery, the patient is monitored for several hours before she is allowed to go home. She is instructed on care of the surgical wound, and what signs to watch for, such as fever, nausea, vomiting, faintness, or pain. These signs could indicate that complications have occurred.

Risks

While major complications are uncommon after tubal ligation, there are risks with any surgical procedure. Possible side effects include infection and bleeding. After laparoscopy, the patient may experience pain in the shoulder area from the carbon dioxide used during surgery, but the technique is associated with less pain than mini-laparotomy, as well as a faster recovery period. Mini-laparotomy results in a higher incidence of pain, bleeding, bladder injury, and infection compared with laparoscopy. Patients normally feel better after three to four days of rest, and are able to resume sexual activity at that time.

The possibility for treatment failure is very low—fewer than one in 200 women (0.4%) will become pregnant during the first year after sterilization. Failure can happen if the cut ends of the tubes grow back together; if the tube was not completely cut or blocked off; if a plastic clip or rubber band has loosened or come off; or if the woman was already pregnant at the time of surgery.

Normal results

After having her tubes tied, a woman does not need to use any form of birth control to avoid pregnancy. Tubal ligation is almost 100% effective for the prevention of conception.

Morbidity and mortality rates

About 1–4% of patients experience complications following tubal ligation. There is a low risk (less than 1%, or seven per 1,000 procedures) of a later ectopic pregnancy. Ectopic pregnancy is a condition in which the fertilized egg implants in a place other than the uterus, usually in one of the fallopian tubes. Ectopic pregnancies are more likely to happen in younger women, and in women whose tubes were closed off by electrocoagulation.

Rarely, death may occur as a complication of general anesthesia if a major blood vessel is cut. The mortality rate of tubal ligation is about four in 100,000 sterilizations.

Alternatives

There are numerous options available to women who wish to prevent pregnancy. Oral contraceptives are the second most common form of contraception—the first being female sterilization—and have a success rate of 95–99.5%. Other methods of preventing pregnancy include vasectomy (99.9% effective) for the male partner; the male condom (86–97% effective); the diaphragm or cervical cap (80–94% effective); the female condom (80–95% effective); and abstinence.

See also Vasectomy.

Resources

BOOKS

"Family Planning: Sterilization." Section 18, Chapter 246 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

PERIODICALS

Baill, I. C., V. E. Cullins, and S. Pati. "Counseling Issues in Tubal Sterilization." American Family Physician 67 (March 15, 2003): 1287-1294.

Kariminia, A., D. M. Saunders, and M. Chamberlain. "Risk Factors for Strong Regret and Subsequent IVF Request After Having Tubal Ligation." Australian and New Zealand Journal of Obstetrics and Gynaecology 42 (November 2002): 526-529.

ORGANIZATIONS

American College of Obstetricians and Gynecologists. 409 12th St., SW, P. O. Box 96920, Washington, DC 20090-6920. <www.acog.org>.

Planned Parenthood Federation of America, Inc. 810 Seventh Ave., New York, NY, 10019. (800) 669-0156. <www.plannedparenthood.org>

OTHER

Centers for Disease Control and Prevention. Fact Sheet: Risk of Ectopic Pregnancy after Tubal Sterilization, August 6, 2002 [cited March 1, 2003]. <www.cdc.gov/nccdphp/drh/mh_ectopic.htm>.

Planned Parenthood Federation of America. All About Tubal Sterilization. [cited March 1, 2003]. <www.plannedparenthood.org/bc/allabouttubal.htm>.

Planned Parenthood Federation of America. Facts About Birth Control, January 2001 [cited March 1, 2003]. <www.plannedparenthood.org/bc/bcfacts1.html>.

Mercedes McLaughlin Stephanie Dionne Sherk

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

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Tubal ligation is generally performed by an obstetrician/gynecologist, a medical doctor who has completed specialized training in the areas of women's general health, pregnancy, labor and childbirth, prenatal testing, and genetics. The procedure is performed in a hospital or family planning clinic, and usually as an outpatient procedure.

QUESTIONS TO ASK THE DOCTOR

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• How many tubal ligations do you perform each year?
• What method of ligation will you use?
• What form of anesthesia will be used?
• How long will the procedure take?
• What side effects or complications might I expect?
• What is your failure rate?