Tubal ligation (“getting your tubes tied”) literally means tying the fallopian tubes so that sperm cannot meet the egg. In practice, the tubes are usually cauterized with electrical current and cut, but they may be cut and tied or clamped to achieve the same objective.

Sterilization of women has been performed for centuries, and at one time or another the ovaries, uterus, and fallopian tubes have all been surgically altered or removed to control fertility. Nowadays tubal ligation is the preferred technique. It has even been used in Catholic hospitals, where sterilization is not permitted, to “isolate” the uterus and help avoid the spread of pelvic inflammatory disease.

In the past, tubal ligation was almost always performed in a hospital under general anesthesia. Today, newer tools and techniques have made the procedure shorter, so that it is often done in a surgicenter or the outpatient surgical unit of a hospital.

Is tubal ligation right for you?

If you do not wish to bear any children, or any more children, at any future time, and you do not want to put up with the inconveniences of other birth control methods, you might consider this procedure. However, when you chose tubal ligation, you should consider it irreversible. If you are not totally sure about never wanting another biological child, and in the back of your mind are thinking that you can always have the procedure reversed, you should not have a tubal ligation. Try long-term reversible contraception instead, perhaps Depo-Provera or Norplant. In my experience, women who choose tubal ligation because they do not want any children at all seldom seek to have the procedure reversed.

Rebecca is the eldest of eight children. She took care of her brothers and sisters from the time she was old enough to help her mother until she left home. When she got married, she already had many nieces and nephews whom she dearly loved, and she was sure she did not want to care for children of her own. Nor did her husband particularly want children. Rebecca had a tubal ligation after several years of marriage and remained content with that decision throughout her life.

If you already have children, you should ask yourself two important questions before going ahead with a tubal ligation. First, if you should lose a child, would you want to have another baby? Second, if something were to happen to your present marriage and you married again, would you want to have a child with your new husband? If you can without hesitation answer no to these questions, then a tubal ligation may well be appropriate for you. Some women are sure they do not want more children because they cannot face the discomforts of pregnancy again.

Emily has a daughter who is now 5 years old. Throughout her pregnancy she was miserable, so nauseated for so long that the thought of being pregnant again is simply more than she can bear. She has a tubal ligation and is happy with her choice.

You should also consider your surgical risks. You are at higher risk for complications during tubal ligation if you are obese or have scar tissue from previous abdominal surgery (for example, ovarian cysts) or a pelvic inflammation.

How is a tubal ligation performed?

There are two surgical approaches: a minilaparotomy and a laparoscopic procedure. Until about twenty-five years ago, minilaparotomy under general or spinal anesthesia was the standard way of performing a tubal ligation. The surgeon makes an incision about 1.5-2 inches wide in the abdomen, works down through the layers of skin, fat, and muscle, enters the pelvic cavity, picks up each fallopian tube, cuts apiece out of each, and ties off the ends. This procedure is still done today, though there are modern variations.

A different time-honored way to approach tubal ligation was through the vagina, a method not often used nowadays. In this procedure the surgeon made the incision in the vagina, reached upward, and drew each tube back down through the vaginal incision. The tubes were then cut and tied off. This procedure had a slightly higher rate of infection than the abdominal method, but women who absolutely did not want an abdominal scar chose this method anyway.

About twenty-five years ago the “belly button” or “band-aid” operation came into favor in this country and has since become the most commonly performed technique of tubal ligation. The surgeon makes a very small incision, maybe half an inch long, just under the belly button, through the abdominal wall. Through the incision the surgeon fills the belly with carbon dioxide, which moves the intestines out of the way, making it easier to find the fallopian tubes and less likely that the bowel or other organs will be injured during the procedure. Using a laparoscope, a long lighted fiber-optic tube, the surgeon looks inside the pelvis, moving the scope around until the fallopian tubes come into view. (In the old days we looked directly through the tube, but now we hook it up to a video camera, which projects the view onto a screen.)

Figure: In tubal ligation, the sperm cannot meet the egg when the tubes are interrupted by cauterizing or some other method

Figure: In tubal ligation, the sperm cannot meet the egg when the tubes are interrupted by cauterizing or some other method

The surgeon makes a second small incision in the pubic area, inserts special tweezer-like forceps, and grasps the fallopian tubes one at a time. With an electrocauterizing device, the surgeon passes an electric current through each tube in two or maybe three places, which makes them disintegrate. After both tubes have been cauterized, the surgeon removes the instruments and lets the gas out of the abdomen. The small incisions can be sewn up with a couple of dissolving stitches. Laparoscopic surgery is not riskier than regular abdominal surgery, but if injury should occur, the surgeon will have to make a regular abdominal incision to repair the damage.

Can a tubal ligation be performed under local anesthesia?

Usually in this country tubal ligations are done under general anesthesia, because whatever the approach, the surgeon must find the tubes in the pelvis and destroy them. Local anesthesia will deaden feeling in the skin, but it will not help with the nerve endings in the tubes themselves. Still, in countries such as India where tubal ligations are done in large numbers, local anesthesia is frequently used.

How long does it take to recover?

After a laparoscopic procedure you can usually leave the hospital or the surgicenter on the same day and resume your regular activities, including sexual intercourse, in a day or so. The incision site is tender for few days, and you may have some abdominal soreness as well. Many women experience pain from the gas that was pumped into the abdominal cavity. Some even feel shoulder pain, if a small pocket of gas gets under the diaphragm and stimulates a nerve that goes to the shoulder.

A minilaparotomy causes about the same level of postoperative discomfort and, again, you can resume your normal activities within one or two days. Shoulder pain is not an issue, because gas is not used in this procedure.

Joanne, an amateur race-car driver, decided to have a laparoscopic tubal ligation. She was scheduled for a Friday and wanted to know whether she would be in shape to race on Sunday. This was a request I had never encountered before, and while I would not have wanted Joanne out there on the track the very day her surgery was performed, a couple of days later seemed safe.

The surgery went very smoothly and Joanne felt fine almost immediately afterward. On Sunday she drove the best race of her life, came in first, and won a handsome trophy. On Monday she called, wondering whether I could tie her tubes another time, jokingly suggesting the surgery had somehow contributed to her victory!

How reliable is tubal ligation?

Tubal ligation is one of the most reliable forms of contraception, more than 99 percent effective both in theory and in actual use. It has a failure rate between 0.3 and 1 percent. That is, of every three hundred procedures one to three women will become pregnant. Failure does not necessarily mean that the surgery was performed incorrectly; it simply means that the ends of the tubes have somehow managed to find their way back together again. The failure rate is greater in women who are having their tubes tied after a cesarean section or after delivery. During pregnancy the blood vessels are dilated and have more blood flowing through them, so that tissue can rejoin more easily.

What should you do if your tubal ligation fails?

If you have had a tubal ligation and suspect you might be pregnant, call your doctor immediately. You could have an ectopic pregnancy, a fertilized egg that does not make it down the fallopian tube to the uterus but starts developing somewhere outside the uterus. Warning signs include bleeding, especially after a late or light menstrual period, and abdominal pain, which may be sharp and localized on one side of the body. An ectopic pregnancy can be life threatening, so don’t delay calling.

How long does it take for a tubal ligation to be effective?

Unlike a vasectomy, a tubal ligation is effective immediately. You may not feel like having intercourse for a day or so after the procedure, but you are protected from pregnancy if you do.

Should you have a tubal Heidi right after having a baby?

Some physicians recommend performing a tubal Heidi shortly after delivery, usually a day or two later, after you have recovered from the delivery. I strongly urge against it. For one thing, the first days and weeks are a vulnerable time in a baby’s life. I have seen two heartrending instances of babies who died shortly after their mother had a postpartum tubal Heidi.

In a minilaparotomy the incision, though not large, is a real incision and the procedure involves a certain amount of work inside the pelvic cavity. If you wait six or eight weeks, everything inside the pelvis will have gone back to its normal size. The uterus will have shrunk, the blood vessels will have returned to their prepregnant state, and the surrounding tissues (which get softer during pregnancy) will have returned to normal. The operation will be much easier to perform as a laparoscopy.

Finally, tubal ligations have the highest rate of failure if they are done right after delivery, whether the delivery was vaginal or via cesarean section.

So I urge new mothers to wait until their regular postpartum checkup to think about having a tubal Heidi, and then perhaps to choose a laparoscopic procedure.

What are the possible complications?

Tubal hgation is not a high-risk procedure; only about one in a thousand women who have it encounter significant complications. On the other hand, no surgery is trivial. You can minimize risk by choosing a surgeon who has done the procedure many times before. Don’t feel shy or awkward about asking.

Besides the usual hazards of any surgery — unexpected bleeding, infection, and difficulties with the anesthesia — there is a small risk of damage to the bowel, bladder, or blood vessels, because the fallopian tubes are crowded close to these structures in the pelvis.

Heidi, a nurse who worked in the labor room at the hospital where I practice, decided to have a tubal Heidi when she was in her mid-30s. An active woman who enjoyed horseback riding and other sports, she was in good physical condition. Heidi almost died during her tubal Heidi because she had a rare reaction to the anesthesia, and her heart stopped. Fortunately, we were able to save her.

Carole had a routine abdominal tubal Heidi when she was 35.1 was a first-year resident at the time and assisted the surgeon performing the tubal, which went very smoothly. Later I went around to check on Carole and found her sitting on the edge of her bed, blue in the face and wheezing. She couldn’t catch her breath. She had a blood clot in her lung, a pulmonary embolus which had formed in her legs or her pelvis and traveled to the lung. I ran to the nursing station, grabbed a syringe of heparin, an anticoagulant, injected it as quickly as I could, and gave her oxygen. When Carole could breathe again, we took her for diagnostic x-rays. Her blood clot was almost the size of a fifty-cent piece, so large that you could see it on the x-ray from across the room. On heparin, her clot dissolved and she recuperated well.

Although complications are rare, and serious complications even more so, these incidents did impress on me the potential hazards of a tubal ligation.

Can a tubal ligation pose long-term complications?

Some women, years after tubal ligation, notice heavier menstrual periods, more cramps, and menstrual irregularities. It is difficult to tell whether these difficulties came about simply because of increasing age or because of the tubal ligation. Furthermore, many women who have tubal Hgations formerly used birth control pills, which kept their periods light and comfortable. Sometimes I ask women who are using the pill to try a few months without it before having a tubal ligation, in order to see how their periods respond.

How much does a tubal ligation cost?

The cost of the surgeon, anesthesiologist, and operating room facility can come to about two thousand dollars, but your insurance will probably cover the procedure. In the past, insurance companies did not usually pay for tubal ligations, but eventually the insurers realized that sterilization is less expensive for them than a pregnancy.

Are tubal ligations ever reversible?

Although no one should have a tubal ligation who does not consider it permanent, some women do want their tubes connected again — usually because of major life changes. The surgery to repair the severed tubes is delicate and expensive, and succeeds only about 50 percent of the time. And often insurance will not pay for the procedure.

Alesse

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