Surgical Sterilization

Surgical sterilization is a safe, highly effective and permanent form of contraception. Numerous methods of tubal sterilization are available, many of which reduce postoperative pain and length of hospital stay. Laparoscopic techniques are preferred for most patients, as they are effective, are performed on an outpatient basis and result in rapid patient recovery.

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There are virtually no absolute contraindications, although a patient's gynecologic disease may require sterilization by hysterectomy and bilateral oophorectomy (removing the ovaries). Women with pre-existing gynecologic conditions that are treated hormonally, such as menorrhagia, or irregular menses, may be better served by hormonal contraception.

It's important to note that tubal sterilization is elective; regret after sterilization is possible, and can be related to young age, conflicted feelings at the time of surgery or a subsequent change in marital status. However, the procedure should be considered permanent. Reversal may be successful, but the rate of success is low. Reversal also requires major surgery, is costly and may not be covered by your insurance.

Women who have undergone tubal ligation are less likely to develop ovarian cancer and pelvic inflammatory disease, but may have a slightly higher rate of future hysterectomy. Tubal sterilization is highly effective; however; pregnancies occurring after tubal ligation are more likely to be ectopic.
 

Types Minilaparotomy Sterilization

A minilaparotomy is most commonly employed for postpartum sterilization. An incision is made just under the navel, and the fallopian tubes are "tied off." General, regional or local anesthesia all provide adequate anesthesia. Minilaparotomy may be useful if the surgeon is not trained in laparoscopy, when the patient is morbidly obese or when severe tubal adhesive disease is present. Disadvantages of minilaparotomy include a higher complication rate, greater need for postoperative analgesia, longer recovery time and a larger surgical incision.

Laparoscopic Sterilization

Laparoscopic sterilization is the most common surgical method for interval sterilization. A small incision is made in the abdomen, and the fallopian tubes are "tied off." Advantages include the opportunity to visually explore the abdomen for disease, a small incision and rapid recovery. However, unexpected findings or complications may necessitate conversion to laparotomy.
 

Hysteroscopic Sterilization

The Essure permanent birth control procedure is a minimally invasive hysteroscopy. A camera is inserted into the vagina, through the cervix into the uterus in order to visualize the opening of the fallopian tubes. A tiny coil mechanism is inserted into the fallopian tube hysteroscopically, under local anesthesia. The device appears to induce fibrosis, which closes the tubes over a three-month period. Patients must use alternative contraception until a hysterosalpingogram performed after three months confirms tubal occlusion.
 

Outcomes

Pregnancy is uncommon after tubal sterilization. The risk appears to be related to age and the type of procedure. If pregnancy does occur, there is increased risk that it will be ectopic.
 

Important Considerations

Informed Consent
A woman's decision to undergo sterilization must be voluntary and not coerced by her family, partner or health care provider. Complete, unbiased information about the procedure and alternatives to surgery help to reduce post sterilization regret. The woman's husband is not required to give consent; however, ideally both partners should have an understanding of the procedure as well as the benefits, alternatives and potential risks. This discussion should include:

• reasons for choosing sterilization

• a screening for risk indicators of regret

• an explanation of the details of the procedure, including anesthesia

• emphasis on the permanence of the procedure and information on reversal

• the causes and probability of sterilization failure, including the chance of ectopic pregnancy

• the need for condoms to protect against sexually transmitted diseases if the patient has multiple sex partners or a partner with other partners

• the impact, or lack thereof, on the menstrual cycle 

The patient should have an opportunity to ask questions and express any concerns following this discussion.

Women whose sterilization will be federally funded must sign a special consent document, be at least 21 years of age, and wait 30 days between signing the consent form and the procedure. Insurance coverage for the procedure and possible reversal should also be addressed.

Timing and Preparation
Sterilization can be performed postpartum, postabortion, as an interval procedure (unrelated to pregnancy), or in conjunction with another surgical procedure (e.g., gall bladder removal). Ideally, postpartum procedures are performed immediately after delivery or within 24 hours, but may be done up to seven days later. Further delay increases the risk of infection and difficulty due to uterine size decreasing.

Contraception should be used for at least one month before sterilization and continued until the next menstrual cycle to decrease the occurrence of pregnancy. Performance of the procedure postpartum or during menstruation reduces the chance of pregnancy at the time of the procedure. If this is not practical, a sensitive urine or blood test can be done on the day of the procedure to help detect an early pregnancy.