Patient information: Permanent sterilization procedures for women

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 attached to the uterus and adjacent to the ovaries (picture 1). The fallopian tubes are the site where the egg becomes fertilized by the male's sperm prior to traveling to the uterus. In tubal sterilization, the fallopian tubes are separated or sealed shut, thus preventing the egg and sperm from meeting.

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 or regional (eg, spinal) 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, requires only local anesthesia, and is done at a time other than after childbirth. (See 'Hysteroscopic sterilization' below.)

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

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 health care 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".)

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 anytime 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) and reversible types of contraception (birth control pills/patch/vaginal ring, condoms, diaphragm, cervical cap, intrauterine device, or injection).

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

Regret after sterilization — Between 3 and 25 percent of women regret their decision to undergo sterilization. However, only about 1 to 2 percent of women undergo a reversal of the procedure [1-3]. The most common factor associated with regret is a change in marital status. Other factors include marital problems at the time of procedure, stress due to recent pregnancy complications, and young age (less than age 30) at the time of 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 marriage or relationship should initially 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.

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 or during a woman's menstrual period reduces the chance of becoming pregnant at the time of the procedure. However, it is possible to have a sensitive urine or blood pregnancy test on the day of the procedure to reduce the chances of having the procedure while pregnant.

Although birth control is not necessary after the procedure, 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".)

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 or reginal (eg, spinal) anesthesia is usually recommended. During the procedure, a small incision is made near the belly button and in the lower abdomen and a telescope-like device (a laparoscope) is used to view the fallopian tubes. The physician uses rings or clips to close the fallopian tubes; alternately, the physician seals the tubes shut using electrocoagulation (the fallopian tubes are burned and become permanently sealed) (figure 1).

Minilaparotomy — A minilaparotomy is a surgical procedure done one to two days after childbirth. It is done in an operating room using general, regional, or local 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 [4].

Hysteroscopic sterilization — Hysteroscopic sterilization is a procedure that may be done in the office or operating room using local anesthesia. The Essure® permanent birth control procedure uses a tiny coil mechanism, which is inserted through the cervix and uterus into the fallopian tubes (picture 2).

After the coil is placed, scar tissue develops, causing the tubes to become sealed shut. The woman must use another form of birth control for three months after the coil is placed. At this time, a procedure called hysterosalpingogram is performed to confirm that the tubes are blocked. If the tubes are not completely blocked, the procedure may be repeated.

Hysteroscopic sterilization is best done seven to ten days after the start of a woman's menstrual period. In some cases, the provider will recommended an injectable birth control treatment (medroxyprogesterone acetate/Depo Provera®) two to three weeks before the procedure to make it easier to place the coils (and eliminate the risk of pregnancy before/after the procedure).

The advantages of hysteroscopic sterilization are that no sedation or general anesthesia are required (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 need for an alternate form of birth control for three months after the coil is placed and the potential need to repeat the procedure. In one study, approximately 15 percent of women did not have complete blockage of one or both tubes after three months [4].

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 does not usually require treatment and does not have any long-term consequences.

Menstrual periods — There is no evidence that bleeding or uterine cramping increases 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 cycle irregularity than women who were not sterilized.

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

Pregnancy — It is uncommon for sterilization to fail, allowing a woman to become pregnant. 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 [5] (table 1A-B). 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 [6]. Between 1997 and 2005, approximately 50,000 procedures were performed and 64 pregnancies were reported to the manufacturer [7]. Most pregnancies occurred in women who did not have appropriate follow-up (eg, testing to confirm that the tubes were blocked).

When pregnancy occurs after a sterilization procedure, it is more likely to be an ectopic pregnancy. For this reason, any woman who has had undergone sterilization and then misses or is late for a menstrual period should consult her healthcare provider for advice about the need for a pregnancy test. (See "Patient information: Ectopic (tubal) pregnancy".)

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".)

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, condoms, diaphragm) until a 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. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: A guide to birth control (contraception)
Patient information: Barrier methods of birth control
Patient information: Birth control; which method is right for me?
Patient information: Hormonal methods of birth control
Patient information: Long-term methods of birth control
Patient information: Vasectomy
Patient information: Ectopic (tubal) pregnancy
Patient information: Care after gynecologic surgery

Professional Level Information:
Approach to intrauterine contraception
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
How to fit and use a diaphragm for contraception
Male condoms
Overview of contraception
Overview of the use of estrogen-progestin contraceptives
Overview of vasectomy
Progestin-only pills (minipills) for contraception
Risks and side effects associated with estrogen-progestin contraceptives
Surgical sterilization of women
Patient information: A guide to birth control (contraception)

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

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

• Planned Parenthood

       (www.plannedparenthood.org)

• Society of Obstetricians and Gynaecologists of Canada (SOGC)

      (www.sogc.org/health)

• Managing Contraception

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

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