Tubal Sterilization (women)

Tubal sterilization is intended to be a permanent method of birth control. More and more women today choose sterilization. They know that this single procedure can provide highly effective protection against pregnancy for the remainder of their reproductive years. They also know that there is an increased chance of failure with many temporary methods, that some temporary methods have bothersome side effects, and that some may be inconvenient. Sterilization does not decrease a woman's sexual pleasure. It is often the answer for women who have completed their families and for women who do not want children.

How Tubal Sterilization Works

Tubal sterilization closes off the fallopian tubes, where an egg is fertilized by a sperm. When the tubes are closed, sperm cannot reach the egg, and pregnancy cannot happen.

Sterilization does not affect femininity. It is very unlikely that sterilization will affect your sex organs, or your sexuality. No glands or organs will be removed or changed. All of your hormones will still be produced. Your ovaries will release eggs. Your menstrual cycles will most likely follow their regular pattern.

Effectiveness

Sterilization is more than 99 percent effective in the first year. In following years, there is a limited possibility that tubes may reconnect by themselves. Up to one out of 100 women become pregnant each year after sterilization. About one out of three of these pregnancies are ectopic (develop in a fallopian tube) and may require emergency surgery. Tubal sterilization provides no protection against sexually transmitted infections. Latex or female condoms can reduce the risk of infection.

You must consider the operation permanent. You and your partner will need no other birth control method after a successful tubal sterilization. It is possible to reverse it in some cases, but your decision not to have a child in the future must be firm. You must be absolutely sure you will never change your mind or regret your choice ? no matter how your life changes. Sterilization will not cause symptoms of menopause (change of life) or make menopause happen earlier.

Reasons for Considering Sterilization

You want to enjoy having sex without causing pregnancy.
You don't want to have a child in the future.
You and your partner agree that your family is complete, and no more children are wanted.
You and your partner have concerns about the side effects of other methods.
Other methods are unacceptable.
Your health would be threatened by a future pregnancy.
You don't want to pass on a hereditary illness or disability.
You and your partner decide tubal sterilization is better for you than vasectomy is for him.

Reasons Against Considering Sterilization

You may want to have a child in the future.
You are being pressured by your partner, friends, or family. (You must want the procedure. You may want to involve others for advice or opinions, but the decision is ultimately yours ? only you can determine what is right for you.)
You have problems that may be temporary ? marriage or sexual problems, short-term mental or physical illnesses, financial worries, or being out of work. Sterilization is not a good solution for problems such as these.
You have not considered possible changes in your life, such as divorce, remarriage, or death of children.
You have not discussed having a tubal sterilization with your partner or anyone else you would like to have as part of your decision-making process.

Thinking It Over

Consider all other methods before you choose sterilization. Birth control pills, the shot, the ring, the patch, and IUDs (intrauterine devices) can be similarly effective. Most women can use them with little risk of serious complications. Other methods, such as diaphragms, caps, shields, fertility awareness-based methods, withdrawal, latex or female condoms, spermicide foams, creams, jellies, and suppositories, are not as effective as sterilization. But they have very few
serious side effects, if any.

Discussing the operation with one's partner beforehand is usually helpful for most relationships. Your partner may consider sterilization for himself instead of you. Sterilization for men is called vasectomy. Vasectomy is simpler, costs less, and has fewer risks than tubal sterilization. But vasectomy must also be considered permanent. So, think carefully about what sterilization will mean for you and your relationship before you make your decision.

Sterilization Methods

Sterilizations are done in hospitals or in clinics. They are done with conscious sedation (awake, relaxed, and drowsy), deep sedation (asleep), or under anesthesia: local (patient is awake), regional (body is numb from the navel to the feet), or general (patient is asleep).

Closing the tubes for sterilization can be done in several ways. Sometimes, small microinserts are used to stimulate blocking of the tubes. This method requires no incision. Sometimes the tubes are closed off by tying and cutting (tubal ligation), sealing (electrocautery), or applying clips, clamps, or rings. Sometimes, a small piece of the tube is removed. These methods require incision.

A woman's health condition may indicate which procedure is better suited for her. Previous surgery and body weight are two factors to consider when choosing the best and safest method. Women who have had certain types of abdominal surgery may require specialized procedures. Consult your health care provider if you have any questions.

More than half of all sterilizations are performed shortly after childbirth or abortion. (The decision to combine sterilization with other procedures needs to be made in advance.) The no-incision method of sterilization cannot be performed until at least six weeks after a woman has delivered a baby, had a miscarriage, or had an abortion.

No-Incision Method ? Hysteroscopic Tubal Sterilization

A no-incision method for tubal sterilization is now available. With Essure, a clinician inserts two small, soft metallic coils ? microinserts ? through the vagina, cervix, and uterus into the fallopian tubes. Once in place, the coils cause scar tissue to grow, blocking the tubes. After two years of follow-up, Essure was found to be 99.8 percent effective at preventing pregnancy.

During the procedure, the clinician uses local anesthesia to numb the cervix. You may be offered other medication to help you relax and reduce your discomfort. A small, rigid, tube-like instrument called a scope is inserted into the vagina and through the cervix. Fluid moving through the scope helps the clinician see the opening of the tubes. The microinserts are positioned in the opening of the tubes.

Three months after insertion, a test called a hysterosalpingogram (HSG) is performed to make sure the tubes are permanently blocked. HSG is an x-ray test that takes pictures of the uterus and fallopian tubes after a dye has been inserted through the cervix. Until the HSG shows that the inserts are in the correct position and the tubes are blocked, another method of birth control must be used.

Essure offers some advantages over traditional methods of tubal sterilization:

It is safer.
General anesthesia is unnecessary.
A surgical or hospital setting is unnecessary.
Recovery is faster.
No incisions are necessary ? there is no visible scarring.

Risks

Essure was approved by the U.S. Food and Drug Administration in 2002. Long-term side-effects are not known. Women who have any type of sterilization procedure have a slight chance of ectopic pregnancy. Studies of women using Essure found the following additional potential risks after two years of follow-up:

Microinserts may not be put in place during the first procedure or are placed incorrectly. It may be necessary to have a second procedure if both are not placed, or if they are not placed correctly.
Microinserts may be expelled.
The uterus may be perforated. This rare complication may require surgery to repair.
Microinserts may be damaged during other medical procedures, such as dilation and curettage (D&C), endometrial biopsy, or procedures that require the use of radio frequency.
Other rare complications include over-absorption of fluids, a broken microinsert, changes in the menstrual cycle, infection, and pelvic or back pain.

Incision Methods ? Transabdominal Tubal Sterilization

Laparoscopy

Laparoscopy is one of the two most common methods of sterilization. First the abdomen is inflated with an injection of harmless gas (carbon dioxide). This allows the organs to be seen clearly. Then the surgeon makes a small incision near the navel and inserts a laparoscope (a rod-like instrument with a light and a viewing lens) to locate the tubes. The surgeon also may insert an instrument for closing the tubes, usually through a second small opening. Sometimes only one incision and one instrument are used.

The procedure can be performed in outpatient surgical clinics. It usually takes 20 to 30 minutes. Very little scarring occurs. Women often go home the same day.

Mini-laparotomy

Mini-laparotomy is another common method of sterilization. It is often performed after childbirth. No gas or visualizing instrument is used in mini-laparotomy. A small incision is made in the lower abdomen, just above the pubic hair. (If the operation takes place within 48 hours of delivery, the incision is made just below the navel.) The surgeon locates the tubes, then ties, clips, or uses electrocautery to block them off. The incision is then closed. Women usually recover in a few days.

Laparotomy

Laparotomy is major surgery. It is less commonly used than mini-laparotomy and laparoscopy. The surgeon makes a two-to-five-inch incision in the abdomen. The surgeon locates and closes off the tubes. The operation requires general or regional anesthesia. A woman may need to be hospitalized for two to four days. It may take several weeks at home to completely recover. If the procedure is done after delivery, the woman's hospital stay may be extended by one or two days.

Risks

Complications can occur with any kind of surgery. Laparoscopy, mini-laparotomy, and laparotomy are considered low-risk surgeries. The complications that can occur during or after these incision methods include

bleeding
infection
reaction to the anesthetic

Infection is rare, and it is treated with antibiotics. Very rarely, the bowel, bladder, uterus, or blood vessels are injured. You may need additional surgery to repair this. Complications may develop in one to four percent of sterilizations performed through the abdomen. Deaths resulting from tubal sterilization are extremely rare and are usually caused by a reaction to general anesthesia. The rate is about two deaths per 100,000 women who have a sterilization procedure performed. This rate is substantially lower than the death rate from pregnancy and childbirth ? 7.3 per 100,000 women.

Higher Risk Surgery ? Hysterectomy

Hysterectomy is the removal of the uterus. It is major surgery and is not usually used for sterilization. It is used to correct significant medical conditions. Hysterectomy ends menstruation as well as the possibility of pregnancy. It does not necessarily affect the fallopian tubes. However, some medical conditions also call for the removal of a tube and/or ovary, on one side or both.

Hysterectomy is performed through the abdomen or vagina. Sometimes a combined approach is used. Women need to spend several days in the hospital. They usually spend several weeks at home recuperating. They should abstain from sexual intercourse for four to six weeks, until the health care provider advises it is all right.

Complications after hysterectomy occur in 10 to 20 percent of cases. Because hysterectomy is usually performed in conjunction with a significant medical condition, the risk of death is much greater than it is for tubal sterilization ? 300 to 500 per 100,000 cases. The cost is also considerably greater.