Overview of Tubal Sterilization
Tubal sterilization is a medical procedure that partially or fully blocks or removes a woman’s fallopian tubes. This is done to permanently prevent pregnancy and is the most widely used birth control method around the globe. This procedure is performed when a woman desires a permanent form of birth control. It can be performed at any time, including during a woman’s menstrual cycle, after childbirth, or after an abortion.
A significant number of these procedures occur right after childbirth, with almost half of all sterilization procedures in the US performed at this time. Procedures that are performed outside of these periods are known as interval procedures. Nowadays, tubal sterilization is performed either using a small camera that is inserted through the belly button (laparoscopically) or through a small cut in the belly (mini-laparotomy).
In the past, doctors would often place clips or bands on the tubes, or use a technique called electrocautery to burn and seal them. When sterilization was done just after childbirth, a piece of the fallopian tube would be removed through a small incision in the belly. However, these days, doctors prefer to remove both fallopian tubes completely since this method decreases the risk of ovarian cancer and unexpected pregnancy, without increasing the risk of complications during surgery.
It’s very important for doctors to let women know that this procedure is meant to be permanent and reversing it may not always be possible. Women who undergo sterilization at a younger age, particularly those under 30, are most likely to regret the decision later, with about 12 to 20% expressing regret. Thus, doctors should explain all the other birth control options that are available, such as long-acting reversible contraceptives (LARCs), like intrauterine devices (IUDs) and contraceptive implants, which are just as effective as traditional tubal sterilization. For women who have a single male partner, a vasectomy (male sterilization) might also be a better option as it has fewer risks.
Though it is rare, pregnancy can still occur after tubal sterilization. This can happen in 7.5 to 54.3 out of every 1000 cases, depending on the specific technique and the age of the woman, with younger women having higher rates of failure. If a woman does become pregnant after sterilization, there’s a high chance the pregnancy could be outside the womb (known as an ectopic pregnancy). Like any surgery, tubal sterilization can also carry risks like bleeding, infection, injury to nearby organs, problems with the wound, and issues with anesthesia. That’s why it’s vital for healthcare professionals to fully understand the benefits, risks, techniques, and circumstances in which tubal sterilization should and should not be performed.
Anatomy and Physiology of Tubal Sterilization
The typical female body has two fallopian tubes, one on each side of the uterus. These are structures that grow from the top sides of the uterus and spread out towards your ovaries. They act as pathways, allowing the egg to journey from the ovary to the uterus and are roughly about 10 to 12 cm long. Each fallopian tube is divided into four distinct areas:
1.
Infundibulum: The farthest part of the tube, which is flared and triangular. It has soft, brush-like extensions called fimbriae. These reach out towards the ovary and catch the egg when it is released.
2.
Ampulla: This is located next to the infundibulum and its walls are thinner. It contains folds called plicae. This is typically the location where an egg is fertilized (where a sperm meets the egg).
Isthmus: This is the narrowest part of the tube that lies between the ampulla and the uterus. This segment is often blocked or removed when someone decides to have their tubes tied.
Interstitial Segment: This is the part of the tube that goes into the uterus and lays inside the uterine muscle. It is the connection between the interior of the uterus and the parts of the fallopian tube outside the uterus. The tube opening inside the uterus can be seen during certain medical procedures and it’s called the ostia.
The fallopian tube is made up of three layers, the innermost is called the endosalpinx, containing cilia (small hair-like structures) and cells that produce fluid. The muscular middle layer is called the myosalpinx. The movement of the cilia and muscular contraction in the myosalpinx help the egg move towards the uterus. The external layer of the tube is called the serosa.
The broad ligament, which is like a drapery over the uterus and tubes, houses the fallopian tube in its fold known as the mesosalpinx. The ovarian artery, which originates from the main body artery (aorta), and the branch of uterine artery supply blood to the fallopian tubes. They join near the fallopian tubes within the mesosalpinx.
The chief purpose of the fallopian tube is to escort sperm towards the egg and then allow the fertilized egg to travel back to the uterus to implant and grow. Therefore, blocking or removing the fallopian tubes prevents an egg from becoming fertilized, which can prevent pregnancy.
Why do People Need Tubal Sterilization
Tubal sterilization is a voluntary procedure that permanently prevents a woman from getting pregnant. Various medical institutions like the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists (RCOG), and the International Federation of Gynecology and Obstetrics (FIGO), say that the only time tubal sterilization is performed is when a patient, who fully understands all their birth control options, desires to permanently avoid future pregnancies.
An “informed patient” means someone who knows about all the alternative birth control methods, how effective these methods are, and is fully aware of the risks and benefits. They also understand that sterilization is a permanent method of contraception.
In the case of women who face serious health risks during pregnancy, like pulmonary hypertension or cardiomyopathy, tubal sterilization should not be performed solely due to these conditions. While sterilization can be discussed as one way to avoid pregnancy for these patients, the decision for sterilization must be made by the patient and only when they are ready and without any pressure from others.
When a Person Should Avoid Tubal Sterilization
The only time a doctor shouldn’t perform tubal sterilization, a procedure that permanently prevents pregnancy, is when the patient hasn’t given informed consent. Informed consent means the patient understands what the procedure involves and agrees to it. So, if a person isn’t sure about being sterilized or might want children in the future, the doctor should explain other birth control options. If the person still isn’t sure, the procedure should be delayed until they’re confident in their decision. It’s also important to note that it’s unethical to force or pressure someone into sterilization.
Because of this, sterilization should rarely be done on people in prison. This is because they might feel pressured to agree to the procedure. For example, between 2006 and 2010, over 140 women in California prisons agreed to sterilization, but some later said they’d felt pressured into it. The American College of Obstetricians and Gynecologists (ACOG) advises that sterilization should only be considered if the person really wants it and has refused other methods of birth control.
There aren’t any medical reasons that mean someone can’t have tubal sterilization. However, some people might find other methods more suitable. For example, long-acting reversible contraception (LARCs, such as intrauterine devices or implants) or vasectomy (male sterilization) might be preferred because they don’t involve surgery in the abdomen. Additionally, the sterilization procedure might be riskier for people who are significantly overweight, have serious health conditions, or have had issues in the past that make surgery in the abdomen difficult.
Being young or not having had many (or any) children shouldn’t stop someone getting sterilized if that’s what they want. However, the doctor should talk through the possibility of regret. Research shows that 12% to 20% of women under 30 who get sterilized regret it later, and it could be as high as 40% in women under 24. For women over 30, the regret rate drops to about 6%. Even though young people are more likely to regret sterilization, it’s important that doctors respect their decisions. The ACOG advises that it’s better to let a patient make a choice they might regret than to limit their freedom to choose. They also highlight the importance of making sure everyone knows that sterilization is permanent and that other, non-permanent methods are just as good at preventing pregnancy.
Equipment used for Tubal Sterilization
Tubal sterilization, a procedure to prevent pregnancy, can be done in several ways. The method often depends on what the surgeon is most comfortable with. The patient’s preference and personal health factors, like having lots of scar tissue in the pelvic area that limits movement of the tubes, can also affect the choice of procedure and techniques used.
Postpartum salpingectomy, which is removing all or part of your fallopian tubes after childbirth, is usually done using regular surgical tools and stitches or more increasingly, a device that uses electricity for surgery. However, separate bilateral salpingectomy (removal of both tubes) is typically done using laparoscopic surgery. This involves using a small camera on a flexible tube to see inside the abdomen and using electrical instruments that can both burn (coagulate) and cut tissue. Despite this, salpingectomy can also be done through a small incision, known as a minilaparotomy, especially in places where there are limited resources for laparoscopic surgery.
Tubal occlusion, another type of sterilization that involves blocking the fallopian tubes, can also be done laparoscopically or through a minilaparotomy. The options for doing so include:
- Titanium clips
- Spring-loaded clips
- Silicone bands
- Electrosurgical forceps, which use electricity to desiccate (dry out) the tube
From 2002 to 2018, two devices that can be used through the hysteroscope, a device for looking inside the womb, were also available for sterilization procedures in the US. However, one was removed from the market in 2012 due to a successful patent violation lawsuit, and the other was voluntarily discontinued in 2018 due to decreasing sales following legal cases about long-term complications. As of now, there are no hysteroscopic devices available for carrying out sterilization procedures.
Who is needed to perform Tubal Sterilization?
The surgery is conducted by a skilled group of medical professionals working together. This group includes:
* The main doctor performing the surgery
* An anesthesiologist or nurse trained to put patients to sleep for surgery
* A surgical technician, who assists the surgeon
* A circulating nurse, who helps around the operating room
* A nurse who helps prepare you for surgery
* A nurse who looks after you once the anesthetic wears off and you wake up from surgery
Preparing for Tubal Sterilization
Sterilization, a permanent form of birth control, can be performed at different times:
- Postpartum: After giving birth, either during a cesarean section (surgery where the baby is taken from the mother’s womb) or vaginal delivery before the mother is discharged from the hospital.
- Postabortal: Right after a miscarriage (when a pregnancy ends on its own) or an abortion (when a pregnancy is ended on purpose).
- Interval: At any time that has nothing to do with a pregnancy. It can be done at any point in the woman’s menstrual cycle.
In the U.S., different local laws may apply when it comes to when you can be sterilized. For people under federal health insurance, you need to sign a form agreeing to the sterilization between 30 and 180 days before the surgery. You also need to be at least 21 years old. The exact rules may differ in each state.
Before a doctor can perform sterilization, they need to have a detailed discussion with the patient. This talk involves explaining what the procedure is, why it’s being done, what to expect, possible side effects, and other choices for birth control. The main points include:
- The procedure is permanent and can’t always be reversed.
- It does not prevent sexually transmitted infections (STIs).
- It’s an effective method of birth control that doesn’t rely on hormones and doesn’t require repeated attention from the patient.
- It even seems to lower the risk of ovarian cancer, which is one of the deadliest cancers for women.
Despite these benefits, sterilization carries certain risks, which should be discussed as well:
- Regret or failure of the procedure. Younger patients or those on hormonal contraception may face a higher risk of these outcomes.
- Medical complications, like injury to organs near the sterilization site, bleeding, infection, or problems related to anesthesia.
Before surgery, patients should be checked to ensure they’re healthy enough for the procedure. This includes a physical examination and, if deemed necessary, an ultrasound of the pelvic organs to identify any conditions that could affect surgery. Patients may also need a pregnancy test on the day of their procedure to rule out any current pregnancies.
For those deciding to get sterilized during a cesarean delivery, they will receive the standard antibiotics given before any surgical operation. However, antibiotics aren’t necessary for standalone sterilization procedures. Patients are advised to keep clean before surgery to prevent infection, using soap or an antiseptic agent for a shower or bath. The doctor will also apply an antiseptic solution to the abdominal skin and vaginal area if needed.
How is Tubal Sterilization performed
Laparoscopy, a minimally invasive procedure involving the use of specialized instruments and a tiny camera, serves as the principal method for temporary blocking of the fallopian tubes, known as tubal sterilization. It doesn’t have to be done the same way for both tubes, but each one must be fully or partially removed or completely blocked.
Laparoscopic bilateral salpingectomy, which entails the removal of both fallopian tubes, is gaining popularity as a sterilization method. It has been linked to lower ovarian cancer rates and does not increase the risk associated with the surgical procedure. Moreover, if the fallopian tubes appear abnormal (filled with fluid for instance), removing them might be recommended.
As a patient, you will lie flat on your back under general anesthesia, while the surgeon takes all the usual steps to make sure everything is clean beforehand. This involves emptying the bladder and conducting a pelvic exam (which helps the surgeon ‘map out’ the surgery). However, whether the surgeon operates on one or two areas (port sites) may vary. The surgeon will check your abdomen and the fallopian tubes to make sure they are identified correctly. If any adhesions or abnormal anatomy are found, the surgeon will take steps to protect your ureters (the tubes that carry urine from your kidneys to your bladder) to prevent any damage. The tubes are then removed using specific surgical tools.
Another approach is tubal occlusion. This procedure is similar to laparoscopic salpingectomy, but instead of removing the tubes, the surgeon focuses on occlusion or blocking the tubes. The area where the tube is thinnest is generally targeted for blocking as this is the easiest and most effective section to occlude.
To conduct this procedure, a specific type of forceps is used to apply radiofrequency energy to the tube, causing it to dry out and the tube’s inner passage to get blocked. Alternatively, a ‘blocking’ device like a clip or silicone band can be used. However, the surgeon needs to follow the manufacturer’s instructions to use the device and ensure the correct placing.
Tube sterilization can also be performed via an ‘open’ approach. If the patient is undergoing a cesarean delivery, this surgery is performed immediately following the closure of the uterus and before doing the abdominal incision. After a vaginal delivery, tubal sterilization is usually conducted through a mini-laparotomy (a small incision) under regional anesthesia. This approach can also be used when there’s a high risk for the laparoscopic procedure or where there’s a lack of resources for it.
Mini-laparotomies involve making an abdominal incision that’s about 2 to 3 cm long. For this procedure, it’s typically placed in the infraumbilical fold for postpartum procedures and in the suprapubic region for other procedures. The tubes are transected or cut near the uterus, and the tube-supporting structure is cut along the length of the tube, enabling the complete removal of the tube. To expedite the surgery and improve the surgeon-reported outcomes, handheld bipolar electrosurgical devices are preferred over traditional suture-ligation techniques.
Possible Complications of Tubal Sterilization
Tubal sterilization, a procedure for permanent birth control, can sometimes have unique complications like the birth control method not working as it should and some patients regretting having the procedure. The best data we have on sterilization outcomes comes from a study known as the CREST study which tracked over 10,000 patients, but it is important to remember that this study is outdated and so may not reflect current medical practices or societal norms.
Based on that study, out of every 1,000 tubal sterilization procedures, about 18.5 failed to properly prevent pregnancy over a 10-year period. Those who were sterilized via postpartum partial salpingectomy or bipolar coagulation had the lowest risk of contraceptive failure. Procedures using spring-loaded clips had the highest failure rates. It’s also noted that younger women had higher failure rates, probably due to their natural fertility rates being higher and having more years where they could potentially get pregnant. A 2016 review confirmed that the failure rate of these procedures in the first year were quite low, with less than five failings per 1,000 procedures. This review also noted that major health issues as a result of these procedures were rare, and deaths were not reported.
There’s also a risk of ectopic pregnancy, where the pregnancy occurs outside of the womb, after tubal sterilization. This risk is highest for women sterilized by bipolar coagulation before the age of 30, so these women should seek medical attention promptly if they suspect they might be pregnant.
The patient’s age at the time of sterilization can have a big impact on the likelihood of them regretting the procedure. The younger the person is when sterilized, the higher the risk of them later regretting the decision. People sterilized before the age of 30 have about a 12%-20% chance of regret, with those sterilized between the ages of 18 and 24 having regret rates as high as 40%. If sterilized after the age of 30, the risk of regret drops to around 6%. The risk also seems to decrease the more time passes between the birth of a person’s youngest child and the sterilization procedure. However, getting sterilized right after childbirth seems to increase the risk of regret, while getting sterilized right after an abortion doesn’t. The number of children a person already has does not seem to increase the risk of regret. To minimize the risk of regret, patients should be fully informed about the procedure, alternative birth control methods, and not feel pressured into making the decision.
In some cases, those who have had a sterilization procedure can also have periodic or constant pelvic pain, especially if they also had an endometrial ablation procedure — the incidence of this is estimated to be about 10% to 20%.
Other potential surgical complications include: damage to internal organs, internal bleeding, the need for blood transfusion, infection, long term pain, needing to switch from a minimally invasive to an open surgery, issues related to anaesthesia, and very rarely, death.
What Else Should I Know About Tubal Sterilization?
Tubal sterilization, a method of closing or blocking a woman’s fallopian tubes, is the most popular form of birth control worldwide. It’s very safe, highly reliable, doesn’t require hormones and doesn’t need regular upkeep, providing a great choice for those who don’t wish to have any future pregnancy.
This surgery only goes ahead if a patient really wants it. However, it’s essential that those thinking about it understand it’s a permanent decision. They also need to know about the procedure’s risks, benefits, and how it stacks up against other forms of birth control. As a result, doctors must be skilled in properly explaining the procedure and its implications to their patients, and also in carrying out the surgery successfully.