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Tubal Ligation

Tubal ligation (female sterilization or "band-aid surgery" is currently the most effective method of birth control available, newt to abstinence. It is a method widely chosen by women who want no or no more children. For women who choose it, it offers freedom from fear of pregnancy and therefore increased sexual enjoyment and spontaneity.

Couple considering tubal ligation should know that it is a major surgical procedure with significantly higher risks of complication, and higher cost, than male sterilization (vasectomy). Tubal ligation should also be considered a permanent, irreversible method. Therefore, we advise thorough counseling on both methods before a final decision is made. Current costs for the procedure run between $800-$3,000. However, it is a one-time expense.

Tubal ligation surgery interrupts or blocks the Fallopian tubes, preventing pregnancy by separating the egg from the sperm. Women having the surgery continue to ovulate (release eggs) and menstruate. With the exception of serum progesterone levels which are slightly reduced after sterilization, hormone levels remain within normal limits.

This document will attempt to describe the various surgeries used for sterilization, but it should be kept in mind that research on this method is continuing and everything is not yet known about it.

Types of Tubal Ligation
Tubal ligation can be done by either vaginal or abdominal surgery. Hysterectomy (removal of the uterus) for sterilization purposes alone is an inappropriate procedure and should not be done.

The two most widely used abdominal surgeries are the laparoscopy and the minilaparotomy.
Laparoscopy is also referred to as "band-aid surgery" because the small abdominal incision is covered by one or two band-aids after completion. This description is deceptive, however as it implies that this is less than a major surgical procedure. After anesthesia is given, a tiny incision is made at the bottom of the navel and carbon dioxide or nitrous oxide gas is injected into the abdominal cavity in order to move the intestines out of the way making it easier to view the pelvic organs and close off the tubes without injuring other tissues. The laparoscope, or light source, is then inserted through the incision to locate the tubes. Another incision is made lower in the abdomen for insertion of a forceps device to grasp and close off the tubes. This may be done by cauterization (burning) or by means of rings, bands, cutting and tying, or clips. Incisions are then closed with absorbable suture and covered.

Minilaparotomy involves inserting an instrument through the cervix into the uterus to push the uterus up against the abdomen. An abdominal incision is then made directly overt the top of the elevated uterus. The tubes are brought into view and cut, tied, burned or clipped. Both laparoscopy and minilaparotomy procedures take about one half hour and may be done either on an in-patient or outpatient basis depending on what type of anesthesia is used.

In a colpotomy an incision is made in the vagina just behind the cervix. Once this is done, the tubes may be brought out through the incision and tied (Pomeroy technique) or clipped. This procedure takes about one half hour and can be done on an outpatient basis. It is easier to do on women who have previously had children. This procedure is inappropriate for some clients who have had previous abdominal surgery, a history of pelvic inflammatory disease or sexually transmitted diseases because too much scar tissue may be present to do it safely. It is also inappropriate for women less than six weeks after childbirth because the tubes are usually too far away to be reached through a vaginal incision.The complication rate associated with vaginal approaches is about twice as high as with abdominal tubal ligations, and post-operative pregnancy rates are slightly higher. If a vaginal approach is suggested, ask why and get a second opinion if your question is not answered satisfactorily.

Methods of Closing the Fallopian Tubes
Cauterization carries a danger of accidental burning of other internal organs, which is a serious complication. Unipolar cautery techniques carry greater risks than bipolar cautery techniques. Doctors have more recently used rings, bands or clips to close off the tubes. These methods are still experimental and may not be as effective in preventing pregnancies. Another experimantal technique involves insertion of silicone rubber into the tubes to act as a plug. Little research exists as to this method's effectiveness or complication rate.

The technique of cutting and tying the tubes is still shown to carry the least risks and to be the most effective method. Caution should be used in choosing a method tubal closure considering such factors as the length of time the technique has been used, information available on its effectiveness, health risks, and the expertise of the physician performing the surgery.

Complications
Complications which have been reported with tubal ligations include:

  • Possibly longer or heavier menstrual bleeding and more cramping, which may be dependent upon previous bleeding and menstrual cycle patterns, and birth control methods used.
  • Menstrual irregularities and prolonged bleeding. It is not fully understood why there are bleeding disorders, but two theories are:
  • Reduced levels of serum progesterone or
  • Interruption of the blood supply from the uterus to the ovaries due to scar tissue formation.
  • Increased risk of ectopic (tubal) pregnancy. Chances of pregnancy after tubal ligation are about 2.5 in 1,000 women after four years post-surgery. Out of these, approximately one half will result in ectopic pregnancy. Therefore, pregnancies occurring after tubal ligation must be carefully evaluated to determine if they are intrauterine or ectopic pregnancies.
  • Failure to close the tubes that can result in a pregnancy. A round ligament, for example, may be mistaken for the tube. Also, crushed or severed tubes may heal themselves over time and grow back together naturally.
  • In rare cases, premature menopause.
  • Increased need for surgeries to control excessive bleeding.
  • Injuries to other internal organs from cauterization.
  • Regret over loss of fertility.

Reversibility
Although there have been some cases in which the tubes were repaired after sterilization, reversal operations involve risk, are very costly, and are not successful in most cases. A woman should never have a sterilization done with the idea of reversing it later on. Medicaid-eligible women should know, that while tubal ligations are paid for by government funs, reversals are not.

Sterilization Abuse
Sterilization without informed consent is a controversial issue which directly affects low-income and minority women. Sterilization abuse occurs when women have been pressured to sign consent forms during labor, while under general anesthesia, in the mistaken belief that the procedure is temporary, when the documents are not in the woman's language or when her welfare payments are being threatened. (12) The consent must be informed and it must reside with the woman having the tubal ligation. For more information on sterilization abuse write:
Committee to End Sterilization Abuse (CESA), Box A244, Cooper Station, New York, NY 10003.

On the other hand, any woman wishing to have a tubal ligation and who is having trouble finding a doctor to perform the surgery can contact a local family planning agency for referral information. It is not necessary to have a spousal consent, nor should age, number of children or the fact that a woman has no children interfere with her right to have a tubal ligation.

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