Tubal ligation

Tubal ligation
Right Fallopian tube prior to ligation
Background
Birth control type	Sterilization
First use	1930
Failure rates (first year)
Perfect use	0.5%
Typical use	0.5%
Usage
Duration effect	Permanent
Reversibility	Sometimes
User reminders	None
Clinic review	None
Advantages and disadvantages
STD protection	No
Risks	Operative and postoperative complications.

Tubal ligation (informally known as getting one's "tubes tied") is a form of female sterilization, in which the fallopian tubes are severed and sealed or "pinched shut", in order to prevent fertilization.

Procedure

There are mainly four occlusion methods for tubal ligation, typically carried out on the isthmic portion of the fallopian tube, that is, the thin portion of the tube closest to the uterus.

• Partial salpingectomy, being the most common occlusion method. The fallopian tubes are cut and realigned by suture in a way not allowing free passage. The Pomeroy technique, is a widely used version of partial salpingectomy, involving tying a small loop of the tube by suture and cutting off the top segment of the loop. It can easily be applied via laparoscopy. Partial salpingectomy is considered safe, effective and easy to learn. It does not require any special equipment to perform; it can be done with only scissors and suture. Partial salpingectomy is not generally used with laparoscopy.^[1]

• Clips: Clips clamp the tubes and inhibits blood flow to the portion, causing a small amount of scarring or fibrosis, in turn, preventing fertilization. The most commonly used clips are the Filshie clip, made of titanium, and the Wolf clip (or "Hulka clip"), made of plastic. Clips are simple to insert, but require a special tool to put in place.^[1]

• Silicone rings: Tubal rings, similarly to clips, block the tubes mechanically. It encircles a small loop of the fallopian tube, blocking blood supply to that small loop, resulting in scarring that blocks passage of the sperm or egg. A commonly used type of ring is the Yoon Ring, made of silicone.^[1]

• Electrocoagulation or cauterization: Electric current coagulates or burns a small portion of each fallopian tube. It mostly uses bipolar coagulation, where electric current enters and leaves through two ends of a forceps applied to the tubes. Bipolar coagulation is safer, but slightly less effective than unipolar coagulation, which involves the current leaving through an electrode placed under the thigh.^[1] It is usually done via laparoscopy.

Interval tubal ligation is not done after a recent delivery., in contrast to postpartum tubal ligation.

In addition, a bilateral salpingectomy is effective as a tubal ligation procedure. A tubal ligation can be performed as a secondary procedure when a laparotomy is done; i.e. a cesarean section. Any of these procedures may be referred to as having one's "tubes tied."

Tubal ligation can be performed under either general anesthesia or local anesthesia (spinal or epidural, often supplemented with a tranquilizer to calm the patient during the procedure). The default in tubal ligations following on from cesarean birth is usually spinal/epidural, while the default in non-childbirth related situations may be general anesthesia as a matter of doctor preference. However, tubal ligations under local anesthesia, either inpatient or outpatient, may be performed under patient request.

Entry to the site of tubal ligation can be done in many forms; through a vaginal approach, through laparoscopy, a minilaparotomy ("minilap"), or through regular laparotomy.

Another form of permanent birth control is the non-surgical Essure procedure that has been in use since 2002. In this procedure an Essure trained doctor inserts soft, flexible inserts through the body’s natural pathways (vagina, cervix, and uterus) and into your fallopian tubes using a hysteroscope and the Essure placement tool. The micro-inserts produce eventual occlusion of the fallopian tubes by causing the in-growth of tissue.

Effectiveness

A tubal ligation is approximately 99% effective in the first year following the procedure. In the following years the effectiveness may be reduced slightly since the fallopian tubes can, in some cases, reform or reconnect which can cause unwanted pregnancy. Method failure is difficult to detect, except by subsequent pregnancy, unlike with vasectomy or IUD. If pregnancy does occur it carries a 33% chance of being an ectopic pregnancy.

Reversal

Generally tubal ligation procedures are done with the intention to be permanent, and most patients are satisfied with their sterilizations. 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 separateds 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.

Tubal reversal, if done by a specialist microsurgeon, has a high success rate and few complications. Successful repair of the fallopian tubes is now possible in 98% of women who have had a tubal ligation, regardless of the type of sterilization procedure.

IVF in vitro fertilization may overcome fertility problems in patients not suited to a tubal reversal.

Prevalence

Worldwide, female sterilization is used by 33% of married women using contraception,^[2] making it the most common contraceptive method.^[3] 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.^[4]

Access

In developing countries, tubal ligation is generally a popular form of birth control, and is widely available, although some Muslim countries (e.g. Egypt and Indonesia) do not permit it.^[5] Faith-based medical institutions in developed countries will sometimes refuse to perform tubal ligations,^[6] and where long waiting times persist, there is a worrying risk of pregnancy or complications due to alternative contraception.^[7] Because of the permanent nature of the operation, women under 30 without children are often denied access to tubal ligation, even if they express a determined desire not to have children.^[8]

Advantages and disadvantages

Tubal ligation is a more major surgery than vasectomy, and carries greater risks. Postoperative complications are more likely than with vasectomy, and more costly.^[9] For instance, in industrialized nations, mortality is 4 per 100,000 tubal ligations, versus 0.1 per 100,000 vasectomies.^[10]

Tubal ligation has a larger initial cost than other contraceptive methods. Typically vasectomies are more cost-effective than tubal ligation because they are less expensive. 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.^[9] The cost of tubal ligation is reduced if it is performed during a cesarean section since the tubes are already exposed during the laparotomy.

Tubal ligation may reduce risk of ovarian cancer.^[11][12]

In other animals

References