Permanent Birth Control

Permanent birth control, also called tubal sterilization, may be an attractive option for women from Long Island and Queens who are certain they have completed their families. Tubal sterilization is a procedure in which the fallopian tubes are permanently sealed off in order to prevent pregnancy. Once the fallopian tubes are sealed, the sperm and egg cannot meet, and pregnancy does not occur. Tubal sterilization was first reported in 1880, and now used worldwide by more couples than any other method of contraception.

Advantages of Tubal Sterilization

Overall, the vast majority of patients are happy to have had their tubes “tied.” Tubal sterilization has many advantages for the right candidates, including:

  • It is extremely reliable. Failure rates well under 1% are expected with all types of tubal sterilization.
  • It requires no ongoing precautions. Once sterilized, there are no prescriptions to fill and no ongoing costs. Couples enjoy intimacy without awkward preparations or precautions for contraception. After sterilization, a couple will never have to worry about contraception again.
  • Laparoscopic tubal sterilization—for reasons that remain obscure—is associated with a substantial reduction in the risk of subsequent ovarian cancer.
  • There is no exposure to hormones contained in the Pill, the patch, or contraceptive injections that can affect a woman’s mood, her menstrual cycle, or her sexual response. Actually, some women report more satisfying sexual relations once their fear of pregnancy is removed.

Is it right for me?

Sterilization procedures are intended to be permanent. While it is true that modern reproductive techniques (like in vitro fertilization) can permit some women to achieve pregnancy after a sterilization procedure, the process is costly and complicated, and results are not guaranteed. If you’re not sure if you want children, or if you might change your mind in the future, you should not undergo a sterilization procedure.

About half of all tubal sterilization procedures are performed at or immediately after delivery: tubal ligation (“tying the tubes”) may be performed at the time of cesarean section, or through a small incision below the navel the day after a vaginal delivery. The remainder of sterilization procedures are not associated with delivery and are called “interval sterilizations.”

Laparoscopic Tubal Sterilization

While female sterilization (“tying the tubes”) was first performed over a century ago, innovation and technology popularized the technique in the 1970s. Since then, most interval sterilization procedures have been performed as an outpatient procedure using a laparoscopic technique. In recent years, new techniques have been introduced which permit sterilization to be accomplished through the vagina, with no incision at all. Now, about one third of married couples rely on sterilization for contraception.

How It Works

There are many techniques of laparoscopic tubal sterilization, but all of them are designed to “seal” the fallopian tubes so sperm and egg cannot meet. Some use specially designed clips or rubber bands to seal the tubes, while others rely on cautery. There are subtle differences between these techniques, but all provide reliable contraception after a brief, minimally invasive procedure. We generally use a bipolar cautery technique with a single ½” incision hidden in the navel; we find this technique more cosmetically appealing than the two-incision procedure favored by many other surgeons.

The Procedure

Laparoscopic tubal sterilization is performed in an operating room either in a surgicenter or in a hospital. The procedure typically takes just 15 to 20 minutes to perform, with women discharged home after a short period of observation in the recovery room.

Recovery

Recovery after laparoscopic tubal sterilization is not difficult, but it does typically take a few days for women to get back to their usual activities. In the first 24 to 48 hours, patients may notice some pain in the shoulders, chest, or neck; this comes from the gas we use to inflate the abdomen. Mild pain at the incision is also usual. We sometimes provide a prescription for a mild narcotic (e.g., Percocet) after laparoscopic procedures, but many women find they can get by with just ibuprofen. Most patients can return to work after 2 to 3 days.

Risks

Laparoscopic tubal sterilization is an extremely safe procedure, but rare complications have been reported:

  • Bleeding and infection are uncommon, but can occur, as with any surgical procedure.
  • Other complications, including but not limited to anesthetic complications, injuries to the bowel or to urinary structures, and blood clots have rarely been reported.
  • The risk of failure (i.e., pregnancy) after laparoscopic tubal sterilization is about 1 in 300; this makes laparoscopic sterilization more reliable than birth control pills, the patch, or the ring, and much more reliable than condoms, diaphragms, and “pulling out.”
Importantly, about half of the pregnancies that occur after laparoscopic sterilization are ectopic pregnancies (pregnancies in the fallopian tubes). Since this is a potentially life-threatening condition, women who think that they may be pregnant after a laparoscopic tubal sterilization should seek medical attention immediately.

Risk of Regret

Another important risk to consider is the risk of regret: Laparoscopic tubal sterilization is intended to produce permanent results. If you are not certain whether your family is complete, or you feel that you may change your mind at some point in the future, you definitely should not undergo a sterilization procedure.
While it is possible nowadays to achieve pregnancy after being sterilized by tubal ligation, it is definitely not easy to do so. Achieving a pregnancy after laparoscopic sterilization requires another operation (to re-connect the tubes) or in vitro fertilization, a highly specialized and expensive reproductive technique. Success in achieving a pregnancy is not guaranteed in either case. Women under 30 and women with unstable marriages are at particularly high risk of subsequent regret, and should carefully consider whether permanent sterilization is the right choice for them.

For the right patients, tubal ligation is a sensible, permanent method to prevent pregnancy. If you think that tubal ligation is right for you, we invite you to consult with us at The Woman’s Health Pavilion.

Essure®

In 2002, the FDA approved the Essure procedure as a new method of permanent tubal sterilization. The Essure procedure requires no incision at all. Instead, it relies on tiny micro-inserts that are placed in the fallopian tubes hysteroscopically: a narrow telescope is inserted into the uterus through the vagina, and the inserts are carefully placed into the tubal openings. Once in place, a filament inside the coils promotes the growth of tissue in the tubes, resulting in tubal occlusion (see illustration).

Sterilation
Sterilation

The Procedure

The Essure procedure takes just 10 minutes to perform. We generally perform Essure procedures in an operating room—either in a hospital or a surgicenter—with anesthesia to ensure that our patients our comfortable.

Recovery

Women are discharged after a short period of observation in the recovery room, and can easily return to work the next day. Unlike traditional laparoscopic sterilization, which requires a few days of recovery, women can easily return to work the day after an Essure procedure. Most women will not even need postoperative pain medication. Essure is a truly ambulatory procedure: Aside from some mild cramping, there is not much “recovery” to speak of.

There Is a Waiting Period

Importantly, women must use a backup method of contraception for three months after the Essure procedure: This allows tissue ingrowth around the micro-insert to completely seal off the tubes. At the end of three months, women must have a hysterosalpingogram (otherwise known as an HSG, a study performed in a radiologic facility) to confirm that both tubes are completely blocked. Once HSG confirms that both tubes are blocked, the risk of subsequent pregnancy is extremely low: Initial studies demonstrated not a single pregnancy among 664 women with 4 years of follow-up.

Risks

It is occasionally technically difficult to navigate the inserts into the tubal openings: In about 5% of procedures, the inserts cannot be acceptably placed in both tubes. We try to discuss this possibility with patients in advance of their planned procedure, since patients may elect to have us perform a laparoscopic sterilization immediately (i.e., while they are asleep) in the event that Essure placement is not successful. Other risks include perforation of the uterus, fluid overload, and risks relating to general anesthesia.

Timing of the Procedure

Both types of sterilization procedures should ideally be scheduled in the first two weeks of your menstrual cycle (i.e., right after your period) to reduce the possibility that you might be pregnant and not know it when the procedure is performed. If it is not possible to schedule your procedure during this time, make sure you use a reliable form of contraception in the weeks prior to your procedure date.

Think It Through

If you are considering a sterilization procedure, think carefully about your life circumstances, your relationship, and your family. Sterilization is sometimes a very sensible and convenient option, but this permanent option requires thoughtful consideration.

Tubal sterilization is the most popular method of contraception for women over 35 in this country. If you are certain that you have completed your family, contact us to schedule a consultation. Laparoscopic tubal sterilization or Essure may be right for you. The Woman’s Health Pavilion serves patients 7 days a week and offers same-day appointments for urgent conditions.