|Tubal ligation / BTL surgery|
|Failure rates (first year)|
|Advantages and disadvantages|
|Risks||Operative and postoperative complications|
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 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.
Tubal ligation through blocking or removing the tubes may be accomplished through an open abdominal surgery, a laparoscopic approach, or a hysteroscopic approach. 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 tubal ligation, or more than six weeks after the end of a pregnancy, termed an interval tubal ligation.
After the anesthesia takes effect, a surgeon will make a small incision at each side of, but just below the navel in order to gain access to each of the two fallopian tubes. With traditional tubal ligation, the surgeon severs the tubes, and then ties (ligates) them off thereby preventing the travel of eggs to the uterus. Other methods include using clips or rings to clamp them shut, or severing and cauterizing them. Tubal ligation is usually done in a hospital operating-room setting.
Most methods of female sterilization are approximately 99% effective in preventing pregnancy. Effectiveness may decrease with increased time since sterilization, leading to unintended pregnancy, depending on the method of sterilization chosen. Method failure is difficult to detect, except by subsequent pregnancy, unlike with vasectomy or IUD.
Of those failures, 15–20% are likely to be ectopic pregnancies. 84% of those failures occurred a year or more after sterilization. According to one study, approximately 5% of women who have had tubal ligation will have a failure due to ectopic pregnancy. Time seems to be a factor as the risk of failure increases after 1 or more years post-surgery. The risk of ectopic pregnancy is 12.5% for women who have had tubal ligation, which is a greater risk than for those who have not had the surgery. Recanalization or formation of tuboperitoneal fistulas occur, the openings of which are large enough for passage of sperm but too small to allow an ovum to push through, resulting in fertilization/implantation in the distal tubal segment.
Two economic studies suggest that laparoscopic bilateral tubal ligation could be less cost-effective than the Essure procedure, which uses a special type of fiber to induce a benign fibrotic reaction.
Tubal ligation methods
Bipolar coagulation The most popular method of laparoscopic female sterilization, this method uses electric current to cauterize sections of the fallopian tube.
Monopolar coagulation Less common than bipolar coagulation, monopolar coagulation uses electric current to cauterize the tube together, but also allows radiating current to further damage the tubes as it spreads from the coagulation site. Many cases involve a cutting of the tubes after the procedure.
Fimbriectomy By removing a portion of the fallopian tube closest to the ovary, fimbriectomy eliminates the fallopian tube's ability to capture eggs and transfer them to the uterus.
Irving's procedure This procedure calls for placing two ligatures (sutures) around the fallopian tube and removing the segment of tubing between the ligatures. Then to complete the procedure, the ends of the fallopian tubes are connected to the back of the uterus and the connective tissue respectively. This method was pioneered by the American Obstetrician-Surgeon, Frederick Carpenter Irving (1883–1957) in 1924.
Tubal clip The tubal clip (Filshie clip or Hulka clip) technique involves the application of a permanent clip onto the fallopian tube. Once applied and fastened, the clip disallows movement of eggs from the ovary to the uterus.
Tubal ring The silastic band or tubal ring method involves a doubling over of the fallopian tubes and application of a silastic band to the tube.
Pomeroy tubal ligation In this method of tubal ligation, a loop of tube is “strangled” with a suture. Usually, the loop is cut and the ends cauterized or “burned“. This type of tubal ligation is often referred to as cut, tied, and burned. This method was develop by the American Gynecologist and Surgeon, Ralph Hayward Pomeroy.
Essure tubal ligation In this method of tubal ligation, two small metal and fiber coils are placed in the fallopian tubes. After insertion, scar tissue forms around the coils, blocking off the fallopian tubes and preventing sperm from reaching the egg.
Adiana tubal ligation In this method of tubal ligation, two small silicone pieces are placed in the fallopian tubes. During the procedure, the health care provider heats a small portion of each fallopian tube and then inserts a tiny piece of silicone into each tube. After the procedure, scar tissue forms around the silicone inserts, blocking off the fallopian tubes and preventing sperm from reaching the egg. This procedure can no longer be performed due to a lawsuit and judgment brought by the company responsible for Essure.
Tubal ligation procedures are done to be permanent and are not considered a temporary form of birth control. Tubal reversal is microsurgery to repair the fallopian tube after a tubal ligation procedure.
Usually there are two remaining fallopian tube segments—the proximal tubal segment that emerges from the uterus and the distal tubal segment that ends with the fimbria next to the ovary. The procedure that connects these separated parts of the fallopian tube is called tubal reversal or microsurgical tubotubal anastomosis.
In a small percentage of cases, a tubal ligation procedure leaves only the distal portion of the fallopian tube and no proximal tubal opening into the uterus. This may occur when monopolar tubal coagulation has been applied to the isthmic segment of the fallopian tube as it emerges from the uterus. In this situation, a new opening can be created through the uterine muscle and the remaining tubal segment inserted into the uterine cavity. This microsurgical procedure is called tubal implantation, tubouterine implantation, or uterotubal implantation.
In vitro fertilization may overcome fertility problems in patients not suited to a tubal reversal.
A 1998 review of over 200 articles in the English literature showed that evidence of a post-tubal sterilization syndrome (abnormal bleeding and/or pain, changes in sexual behavior and emotional health, increased premenstrual distress) aka post tubal syndrome, inconclusive for women over 30 years of age. The risk for women 20–29 years of age with pre-existing histories of menstrual dysfunction may be increased, "although they do not appear to undergo significant hormonal changes". A 1993 study done in Japan found the symptoms of post-tubal ligation syndrome to be mild, and simple symptomatic treatment to be sufficient in most cases. Discontinuing hormonal birth control has its own side effects, many of which are also commonly attributed to post-tubal sterilization syndrome.
Worldwide, female sterilization is used by 33% of married women using contraception, making it the most common contraceptive method. As of June 2010, there is a recent decline of tubal ligation procedures in the United States after two decades of stable rates, possibly explained by an improved access to a wide range of highly effective reversible contraceptives.
Advantages and disadvantages
Tubal ligation is an abdominal surgery. One study found that postoperative complications from tubal ligation are more likely than with vasectomy and more costly. In industrialized nations, mortality is 4 per 100,000 tubal ligations, versus 0.1 per 100,000 vasectomies.
Tubal ligation has a larger initial cost than other contraceptive methods. It may take more than a decade of use for tubal ligation to become as cost-effective as other highly effective, long term methods like IUD or implant. Continued method costs or costs from unintended pregnancies make many other methods as or more costly than tubal ligation if used for several years. The cost of tubal ligation is reduced if it is performed during a cesarean section, since the tubes are already exposed during the laparotomy.
Current tubal ligation (sterilization) policy in the United States imposes a mandatory waiting period for elective tubal sterilization on Medicaid beneficiaries. In the absence of such period for private beneficiaries, some physicians and scientists believe that "this decades-old mandatory delay policy was well intentioned but has now come to have the effect of restricting women's access to elective tubal sterilization and injustice".
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