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Patient information: Permanent sterilization procedures for women (Beyond the Basics)

INTRODUCTION

Surgical sterilization is a safe, highly effective, permanent, and convenient form of contraception. The most common surgical sterilization procedure for women is called a tubal ligation or having the "tubes tied." The fallopian tubes are the passageway for the egg to travel from the ovary to the uterus (figure 1). This is where the egg becomes fertilized by the male's sperm prior to traveling to the uterus. In tubal sterilization, the fallopian tubes are either cut and separated or they are sealed shut. This prevents the egg and sperm from meeting and thus prevents pregnancy.

Sterilization may be performed in one of several ways, depending upon where the procedure is done (office versus operating room) and when it is done (after childbirth or at another time).

Laparoscopic sterilization is done in the operating room any time other than after childbirth. It requires general anesthesia. (See 'Laparoscopic sterilization' below.)

Minilaparotomy is performed in an operating room, using general or regional anesthesia, often one to two days after a woman gives birth. (See 'Minilaparotomy' below.)

Hysteroscopic sterilization may be done in the office or operating room and is done at a time other than after childbirth. Hysteroscopic sterilization is often done with only local anesthesia, though sometimes sedation is also given. (See 'Hysteroscopic sterilization' below.)

Other methods of birth control are discussed separately. (See "Patient information: Barrier methods of birth control (Beyond the Basics)" and "Patient information: Birth control; which method is right for me? (Beyond the Basics)" and "Patient information: Hormonal methods of birth control (Beyond the Basics)" and "Patient information: Long-term methods of birth control (Beyond the Basics)".)

DECIDING TO HAVE A TUBAL LIGATION

Sterilization is a major decision; it means that a woman and her partner do not want children at any time in the future. A woman's decision to undergo sterilization must be voluntary and not forced by her family, partner, or healthcare provider.

In the United States, a woman's husband or partner is not required to give consent for the procedure, although both partners should have an understanding of the procedure as well as tubal sterilization's benefits, alternatives, and potential risks. The woman and her partner should review the risks and benefits of all methods of contraception, including male sterilization (vasectomy). (See "Patient information: Vasectomy (Beyond the Basics)".)

The physician should provide an explanation of the details of the procedure, including the options for anesthesia (general, spinal, local), and the possibility of pregnancy following the procedure (see 'Permanent sterilization outcomes' below), including the chance of ectopic pregnancy (when a pregnancy begins to grow outside the uterus, usually in the fallopian tubes). A woman may change her mind at any time before the procedure.

Tubal sterilization should be considered permanent; reversing the procedure involves major surgery, is not always successful, and is rarely covered by insurance plans.

Alternatives — Alternatives to permanent female sterilization include permanent male sterilization (vasectomy), long-acting reversible contraception or long-acting reversible contraception (LARC), intrauterine devices and contraceptive implants (in the skin of the arm), and short-acting reversible types of contraception (birth control pills/patch/vaginal ring, condoms, diaphragm, cervical cap, or the contraceptive injection).

These methods are discussed in detail in separate topic review. (See "Patient information: Barrier methods of birth control (Beyond the Basics)" and "Patient information: Hormonal methods of birth control (Beyond the Basics)" and "Patient information: Long-term methods of birth control (Beyond the Basics)" and "Patient information: Vasectomy (Beyond the Basics)".)

Regret after sterilization — Between 2 and 20 percent of women regret their decision to undergo sterilization [1-3]. The factor most strongly associated with regret is being less than 30 years old at the time of sterilization. The younger a woman is when she has a sterilization procedure, the more likely she is to regret that decision [4]. Other factors include relationship problems at the time of the procedure, stress due to recent pregnancy complications, and being in a new relationship after sterilization.

For these reasons, women who are younger than 30, have recently given birth and had significant complications (eg, premature birth, death of an infant), or who are having difficulty with their relationship may want to consider other birth control options. A healthcare provider may recommend that sterilization be delayed until the woman is sure of her decision, is aware of the risks and benefits, and is aware of the alternatives to permanent sterilization. In these situations, a woman might be better off with a long-acting reversible method of contraception (eg, intrauterine devices or the contraceptive implant), which are equally as effective as sterilization at preventing pregnancy, but can be removed if the woman decides she would like to have another child.

Timing of sterilization — Sterilization can be performed at any time during a woman's menstrual cycle, although having the procedure just after the menstrual period reduces the risk that the woman will be pregnant at the time of the surgery.

Sterilization can also be performed after childbirth (postpartum), after an abortion, or in conjunction with another surgical procedure (eg, gallbladder removal). Ideally, postpartum procedures are performed immediately after childbirth or within 24 hours, although the procedure may be done up to seven days later. Delaying the procedure for more than 7 days increases the difficulty of the procedure and the risk of infection.

Preventing pregnancy before and after sterilization — Some form of birth control (condom, diaphragm, birth control pill, etc) should be used before sterilization to decrease the risk of pregnancy. A woman can become pregnant if fertilization occurs just prior to the procedure. Performing the procedure immediately postpartum, at the time of an abortion, or during a woman's menstrual period reduces the chance of becoming pregnant at the time of the procedure.

Although sterilization procedures provide very effective birth control, they do not prevent sexually transmitted infections. Condoms are the only birth control method that is known to reduce the risk of sexually transmitted infections, and should be used by anyone who might be at risk. Condoms are recommended to reduce the risk of becoming infected with a sexually transmitted disease (eg, chlamydia, HIV), especially if the woman has multiple sex partners or has a partner with other partners. (See "Patient information: Barrier methods of birth control (Beyond the Basics)".)

PERMANENT STERILIZATION PROCEDURES

Laparoscopic sterilization — Laparoscopic sterilization is a surgical procedure that is done in an operating room at a time other than after childbirth. General anesthesia is required. During the procedure, a small incision is made near the belly button and in the lower abdomen and a thin camera device (a laparoscope) is used to view the fallopian tubes. The physician either uses heat to seal the tubes shut, or uses rings or clips to close the fallopian tubes.

Minilaparotomy — A minilaparotomy is a surgical procedure done one to two days after childbirth. It is done in an operating room using general or regional (eg, spinal) anesthesia. The physician makes a small incision (one to three inches) in the abdomen, then removes a section of the fallopian tubes on each side. In the postpartum period, the procedure does not lengthen the hospital stay.

One advantage of minilaparotomy is that a tissue specimen is removed to ensure that the fallopian tubes have been completely cut. Disadvantages of minilaparotomy include a greater need for pain medication, a slightly longer recovery time, and a larger surgical incision than with a laparoscopic procedure [5].

Hysteroscopic sterilization — Hysteroscopic sterilization is a procedure that may be done in the office or operating room using local anesthesia or sedation. The Essure permanent birth control procedure uses very small coils, which are inserted through the cervix and uterus into the fallopian tubes (picture 1).

After the coils are placed, scar tissue develops around them, causing the tubes to become sealed shut. This process happens gradually over time, and the woman must therefore use another form of birth control for three months after the coils are placed. At this time, an x-ray test called a hysterosalpingogram (HSG) is performed to confirm that the tubes are blocked. If the tubes are not completely blocked after three months, the patient is asked to continue to use another form of birth control for another three months and the HSG is repeated six months from when the coils were placed. It is very rare (<1/1000) that the tubes are not blocked after six months. It is important that women return for the HSG test to confirm that the procedure has been successful and that they are no longer at risk for pregnancy.

The placement of the coils during a hysteroscopic sterilization may be made easier by the use of hormonal contraception (birth control pills, Depo Provera injection, contraceptive implant or hormonal IUD) prior to the procedure. If a woman is using one of these methods, the procedure can be done any time in the menstrual cycle that there is not significant bleeding. If a woman is not using hormonal contraception, it is best to do the procedure 5 to 10 days after the start of a woman's menstrual period.

The advantages of hysteroscopic sterilization are that it can be done without sedation or general anesthesia (eg, the woman is not sleepy and may drive herself home), and there are no incisions. Compared to other forms of surgical sterilization, hysteroscopic sterilization costs less, allows the woman to spend less time in the hospital, is well tolerated, and causes less severe post-operative pain.

The disadvantages of hysteroscopic sterilization include the possibility that the coils cannot be successfully placed in both tubes (<2 percent), need for another method of birth control for three months after the coils are placed, and the need for a test to confirm that the procedure has been successful. In addition, some women may report persistent pelvic pain following correct coil placement, although the exact cause of this pain is not known and this is uncommon.  

PERMANENT STERILIZATION OUTCOMES

Complications — Complications of laparoscopic and minilaparotomy procedures occur in approximately 1 of every 1000 procedures. The most common complications include infection, bowel or bladder injury, internal bleeding, and problems related to anesthesia.

The complication rate with hysteroscopic sterilization is approximately 0.02 per 1000 procedures. The most common complication is perforation of the uterus (when an instrument creates a small tear through the uterine wall). This usually does not require treatment and rarely has any long-term consequences.

Menstrual periods — There is no evidence that bleeding or uterine cramping increase after sterilization. In fact, women who undergo sterilization are more likely to have fewer days of bleeding during menstruation, a lower amount of blood loss, and less menstrual pain. However, sterilized women have described more irregularity in their menstrual cycle than women who were not sterilized.

Sexual desire — Sterilization does not affect sexual desire or performance.

Pregnancy — It is uncommon for sterilization to fail and for a woman to become pregnant after a sterilization procedure. In one study of women who had laparoscopic or minilaparotomy sterilization and were followed for 8 to 14 years, approximately 1 percent of women became pregnant [6] (table 1). The risk of pregnancy was highest among women who underwent sterilization at a young age (under age 30) and among women who had clips placed on the tubes.

The failure rate for hysteroscopic sterilization is also quite low, estimated to be less than 1 percent [7].

When pregnancy occurs after a sterilization procedure, it is more likely to be an ectopic pregnancy than if the woman had not had a sterilization procedure. An ectopic pregnancy is a pregnancy that grows outside of the uterus, usually in the fallopian tube, which can be life-threatening if not promptly treated. For this reason, any woman who has had undergone sterilization and then misses or is late for a menstrual period, or is otherwise concerned that she might be pregnant, should consult her healthcare provider as soon as possible. (See "Patient information: Ectopic (tubal) pregnancy (Beyond the Basics)".)

AFTER PERMANENT STERILIZATION SURGERY

Laparoscopy and minilaparotomy — A few hours after laparoscopic or minilaparotomy sterilization, most women are able to go home. Someone should be available to drive and help as needed. There will be some discomfort at the incision site and menstrual-type cramping; this can be treated with pain medication such acetaminophen (Tylenol) or ibuprofen (Advil, Motrin). Some women will have a sore throat (from a tube placed to help with breathing during general anesthesia), neck or shoulder pain, vaginal discharge, or light bleeding.

Most women are able to return to a normal routine within a couple of days. The woman is usually instructed not place anything in the vagina (eg, tampons, douches) and to avoid sexual intercourse sex for approximately two weeks. (See "Patient information: Care after gynecologic surgery (Beyond the Basics)".)

Hysteroscopy — Following hysteroscopic sterilization, most women are able to drive themselves home or back to work/school. If a sedative was used, the woman should have someone else drive her home. Most women experience mild cramping, which can be treated with an over-the-counter pain medication such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin). A small amount of vaginal bleeding or discharge may occur for a few days after the procedure; no treatment is required. Most women are able to return to normal activities the same day.

The woman should be sure to use an additional form of birth control (eg, pills, injection, implant, condoms) until the HSG test is done, usually three months later, to confirm that both tubes are completely blocked.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Choosing birth control (The Basics)
Patient information: Vasectomy (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Barrier methods of birth control (Beyond the Basics)
Patient information: Birth control; which method is right for me? (Beyond the Basics)
Patient information: Hormonal methods of birth control (Beyond the Basics)
Patient information: Long-term methods of birth control (Beyond the Basics)
Patient information: Vasectomy (Beyond the Basics)
Patient information: Ectopic (tubal) pregnancy (Beyond the Basics)
Patient information: Care after gynecologic surgery (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Intrauterine contraception (IUD): Overview
Contraception: Overview of issues specific to adolescents
Depot medroxyprogesterone acetate for contraception
Emergency contraception
Female condoms
Fertility awareness-based methods of pregnancy prevention
Hormonal contraception for suppression of menstruation
Barrier contraception: Diaphragm
Male condoms
Overview of contraception
Overview of the use of estrogen-progestin contraceptives
Overview of vasectomy
Progestin-only pills (POPs) for contraception
Risks and side effects associated with estrogen-progestin contraceptives
Surgical sterilization of women

The following organizations also provide reliable health information.

National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

Planned Parenthood

      (www.plannedparenthood.org)

Society of Obstetricians and Gynaecologists of Canada (SOGC)

     (http://sogc.org/)

Managing Contraception

    (www.managingcontraception.com/index.php?go=choices)

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Literature review current through: Jul 2014. | This topic last updated: Dec 16, 2013.
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All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.