When discussing sterilization, a couple has the choice of “him or her”. In order to make a properly informed decision, it’s advisable to know about both procedures.
It’s likely that women will look at web pages for women on female sterilization, and they will also look at vasectomy sites. We feel that whilst men will look at vasectomy sites, they are rather less likely to go Googling for female sterilization sites. Just to illustrate that point, this page came out of the fact that three of the senior posters at alt.support.vasectomy, and chatroom administrators on this site, our sum knowledge on female sterilization could be written on the back of a corn flakes packet! We don’t feel that we are alone in our lack of knowledge, so we have put together this page that is intended to be an general overview of female sterilization that will hopefully help all of us!
Table of Contents
Like vasectomy, there are different procedures performed, but in the case of tubal occlusion the procedure is often chosen for specific medical reasons. Unlike vasectomy, it will normally involve a general anaesthetic, and maybe a short stay in hospital. However, in most cases it’s usual to have the procedure done in the morning and go home later in the day.
As with all methods of birth control, there is a failure rate, and pregnancy can occur several years after the procedure. The UK guidelines1 estimate the lifetime risk of failure to be 1 in 200. The guideline covers both male and female sterilization, and quotes the failure rate for vasectomy as being approximately 1 in 2000 where the man has semen samples analysed, and clearance has been given. Whilst men should be tested before being given the “All clear”, women are not usually tested. The advice given is to continue using birth control up the first period after the operation.
Technical failure of the procedure can be down to several causes: Recanalization, incomplete occlusion of the tube, the occlusion device can slip, the occlusion device might be in the wrong place or on the wrong anatomical structure. In addition, each occlusion device has it’s own failure rate. Hulka clips and bipolar diathermy seem to have higher failure rates than other devices / methods. Age is a factor in overall reliability, with younger women being more at risk from failure. Young women are more fertile and have more fertile years remaining, therefore overall risk of failure is increased.1
Before the operation, birth control must be practiced to avoid the possibility of being pregnant, and after the operation birth control should be used up until the first period after the operation. It’s normal to have a pregnancy test before the operation, but if the pregnancy is in the very early stages this may not show up. In one study, 2.6% of women had a positive pregnancy test on the day of their planned sterilization.
The RCOG1 recommends that male and female sterilization should be discussed with anyone requesting sterilization. It also recommends that women requesting sterilization should be informed that vasectomy has a lower failure rate in terms of post-procedure pregnancies, and that there are less risks related to the vasectomy procedure.
Tubal Occlusion and Vasectomy share one thing in common – the same groups have a higher risk of regret, and subsequently requesting reversal surgery. Like vasectomy, the studies that look at regret have varying results. As a general guideline, the studies tend to range between 3% and 10% of women regret being sterilized. Also, like vasectomy good counselling lowers the incidence of regret. In the developed world, the main reason for regret is wanting to start a new family with a new partner, and in the emerging world, it’s often because of the death of a child – particularly a male one.
Men and women most likely to regret being sterilized:
- Men and women who were sterilized under 30
- Couples who don’t have children at the time they request sterilization*.
- Men or women not in a relationship, or not in a mutual faithful relationship
- If there is a crisis in the relationship
- Where psychological or phsycosexual issues exist
- Where there is coercion into being sterilized by partner or medical practitioner
- Where there was a lack of information on the procedure, it’s failure rates, reversibility and alternatives during the decision making process.
- Although tubal occlusion can be carried out during a Caesarian section, during an abortion or after giving birth, there is an increased risk of regret, and a possible increase in failure rate.
This isn’t to say that men or women requesting sterilization under 30, or without children should be refused sterilization, but that whoever is doing the counselling should exercise additional care.
Differences between vasectomy and tubal ligation
The surgeon has to gain access to the Fallopian tubes. There are two procedures in general use to do this – Laporoscopy and Mini-Laporotomy. With Laporoscopy, two small cuts are made just below the navel and lower down, or alternatively to one side, or just above bikini line. Mini-Laporotomy involves a slightly larger opening. Mini-Laporotomy is mainly used if Laporoscopy is unsuccessful, the patient is very over-weight or has had previous abdominal surgery. It may necessitate a longer stay in hospital. Laporoscopy has less chance of causing complications, and is therefore usually the preferred method.
With vasectomy, the tubes are cut. In Tubal Occlusion they are not necessarily cut. It depends upon the procedure and method of incision. If Laporoscopy is used, then the Fallopian tubes may simply be “crushed”. Typically this will be by using a Filshie clip made of titanium and soft rubber. Like vasectomy, tubal occlusion should be regarded as permanent sterilization, but it is felt that as the Filshie clip destroys less of the Fallopian tube it may be easier to reverse. If a pregnancy occurs, it’s less likely to be ectopic if mechanical occlusion (clips or rings) has been used. However, for mechanical occlusion to be successful, the clip has to be applied to the right part of the tube in the correct manner. There are a variety of clips and rings available, but according to the UK guidelines, Filshie clips are the recommended device due to lower failure rate, and less technical difficulty than rings when performing the procedure. The failure rate of the Filshie clip is roughly 2-3/1000 pregnancies in women ten years post procedure.
If the surgery is being performed using Mini-Laparotomy incisions, then there are a variety of procedures available. All of them tie off the tubes and remove a small segment. Reversibility is more difficult with all of the techniques. Methods include the Pomeroy technique, the Parkland or Pritchard technique – also known as the Modified Pomeroy procedure or Partial Salpingectomy.
The Pomeroy technique is the most used in the UK. It’s simple and effective. A loop of tube is made, and tied with dissolvable sutures with a cut being made at the top of the loop. After the sutures dissolve the ends of the tubes pull apart. The advantage is that because the sutures are rapidly absorbed, inflammation and formation of fistulae in the tubes are decreased. The disadvantage is that 3-4cm of tube are destroyed making reversal more difficult.
The Parkland technique is more common in the USA. In this version, the tubes are tied off in two places, and a small segment removed. It’s common to perform this procedure when the patient is being sterilized whilst having a Caesarian section. Some research suggests that in this situation it has a lower failure rate than clips.
Other methods such as the Irving and Cooke technique that bury a severed end in neighbouring tissue are more difficult to perform, and not designed to be reversed.
Like the Marie Stopes method of vasectomy, Diathermy (cautery) can be used to seal the tubes. However, the UK guideline advises against this method, as it increases the risk of subsequent ectopic pregnancy and is less easy to reverse than clips or rings.
Provided that the clinician is confident the patient has used effective contraception up to the day of the operation and is not pregnant, Tubal Occlusion can be done at any time of the menstrual cycle. Although Tubal Occlusion can be performed following birth, or at the same time as a Caesarian Section or abortion, there is an increased regret rate, and a possible increased failure rate. In one study that compared the regret of women who were sterilized at the time of abortion, and women who were booked in to have the sterilization some 6 weeks later found that 32.8% of these women did not return to have the sterilization procedure. Another study finds that women who are sterilized at the time of a Caesarian regretted the procedure twice as often as those who had the procedure away from emotional stress.
Risks of tubal ligation
Tubal occlusion carries a risk of ectopic pregnancy if the procedure fails. The incidence of ectopic pregnancy varies widely between studies and procedure methods, but start at 4.3% of women getting pregnant after being sterilized. The rate is higher when bipolar diathermy is used.
There is an association with subsequent hysterectomy rates, although there is no evidence that Tubal Occlusion leads to problems requiring hysterectomy.
The risks of complications are higher if the patient has had previous abdominal surgery, or is very overweight. Some studies found that women who were sterilized young had a greater risk of hysterectomy than women who had it done later in life.1
Complications can happen during the surgery, but most are minor and can be treated at the time. However, if there is any injury to the bowel, bladder or blood vessels then the surgeon may have to perform a Laporotomy (bikini line incision or midline cut) to affect any repairs. Bowel injuries can happen during the procedure. They are rare, but can be serious.
Most of the complications of Laporoscopic sterilization arise as a result of development of air within the peritoneal cavity, or from the blind insertion of the first trocar1. Also, bowel injuries from trocar perforation happen – whatever occlusion method is used.
Bowel perforations caused by diathermy burns can present some days or up to two weeks after the procedure. If left untreated, peritonitis and septicaemia can occur. Deaths have been reported from unrecognised bowel burns after unipolar cautery.
Major complications are injuries to bowel, bladder or blood vessels that require laporotomy or lead to death. The risk of laporotomy being required varies between studies from 1.4 – 3.1/1000. The risk of death with laporoscopy is 1/12,000.
There is no evidence that having a tubal occlusion affects your sex drive.
There is little to no evidence linked to getting heavier or more irregular periods.
Reversibility of tubal ligation
Reversal statistics vary between 31% to 91% of women will manage to get pregnant after tubal reanastomosis. If the patient was sterilised with clips or rings, they are statistically likely to be at the higher end of the scale. Microsurgical reversal techniques have the best success rate. With reversal there is a risk that between 0% – 7% of pregnancies will be ectopic. The pregnancy rate post reversal decreases with age. One study found that no women over 43 in the study group achieved getting pregnant.
Although there are various sites on the web devoted to this topic, there is no agreement within the research community that the syndrome exists. Literature reviews find that many studies into post-tubal syndrome have serious methodological problems – recall bias, inappropriate control groups, failure to check on past history of gynaecological problems, psychological problems, and failure to account for the use of oral contraceptives and IUCD’s1.
Essure, also known as Hysteroscopic Sterilization had just been introduced into the UK whilst the guidelines were in the final stages of formulation. They do mention that it cannot be reversed. They also mention that with this method, birth control must be practiced for at least three months after the operation, when a test called a Hysterosalpingogram (HSG for short!) is performed to see if the tubes have been successfully blocked.