Tubal ligation and tubal implants

Surgery Overview

Tubal ligation , often referred to as "having your tubes tied," is a surgical procedure in which a woman's fallopian tubes are blocked, tied, or cut. Tubal implants are small metal springs that are placed in each fallopian tube in a nonsurgical procedure (no cutting is involved). Over time, scar tissue grows around each implant and permanently blocks the tubes. Either procedure stops eggs from traveling from the ovaries into the fallopian tubes, where the egg is normally fertilized by a sperm.

Tubal ligation and tubal implants are considered to be permanent methods of birth control for women. They are usually done by a gynecologist. They may also be done by a family medicine doctor or general surgeon.

Tubal ligation method

There are several different ways of closing the fallopian tubes , including clipping or banding them shut or cutting and stitching or burning them closed. Your surgeon will probably prefer one of the following methods. See a picture of tubal ligation methods .

A tubal ligation can be done in the following ways:

• Laparoscopy involves inserting a viewing instrument and surgical tools through small incisions made in the abdomen. See a picture of a laparoscopic procedure .
• Mini-laparotomy ("mini-lap") is done through an incision that is less than 2 in (5 cm) long. See a picture of a mini-laparotomy procedure .
• Postpartum tubal ligation is usually done as a mini-laparotomy after childbirth. The fallopian tubes are higher in the abdomen right after pregnancy, so the incision is made below the belly button (navel). The procedure is often done within 24 to 36 hours after the baby is delivered. See an illustration of a postpartum tubal ligation .

An open tubal ligation (laparotomy) is done through a larger incision in the abdomen. It may be recommended if you need abdominal surgery for other reasons (such as a cesarean section) or have had pelvic inflammatory disease (PID), endometriosis, or previous abdominal or pelvic surgery. These conditions often cause scarring or sticking together (adhesion) of tissue and organs in the abdomen. Scarring or adhesions can make one of the other types of tubal ligation more difficult and risky.

Laparoscopy is usually done with a general anesthetic. Laparotomy or mini-laparotomy can be done using general anesthesia or a regional anesthetic, also known as an epidural.

Reversing a tubal ligation is possible, but it is not highly successful. This is why tubal ligation is considered a permanent method of birth control.

Tubal implant method

Implants are inserted in the fallopian tubes without surgery or general anesthesia. The procedure is done in a doctor's office, an outpatient surgery center, or hospital and does not require an overnight stay. The implant procedure usually takes about 30 minutes.

• Before the procedure, your cervix is first opened (dilated) to reduce the risk of injury to the cervix. Your health professional will use a speculum and a dilating instrument to gradually open the cervix just before the procedure.
• For the procedure, you are positioned as you would be for a pelvic exam. Your health professional passes a thin tube (catheter) through your vagina and cervix, into the uterus, and then into a fallopian tube. The catheter is used to place an implant into a fallopian tube. An implant is then placed in the other fallopian tube the same way. You may have some menstrual-like cramping afterwards.

After the procedure, an X-ray is taken to make sure the implants are in place and the tubes are closed.

On occasion, a tubal implant can be difficult to insert. Should this happen, a second procedure is needed to completely block both tubes.

For the first 3 months after insertion, you must use another method of birth control. At 3 months, dye is injected into your uterus and an X-ray is taken (hysterosalpingography) to make sure that the implants are in place and the tubes are fully blocked by scar tissue. If they are, you will no longer have to use another method of birth control.

What To Expect After Surgery

Tubal ligation

After a tubal ligation, you will most likely go home the same day. Your surgeon will give you instructions on what to expect and when to call after the surgery.

• You may have some slight vaginal bleeding caused by the movement of your uterus during the surgery.
• If you had a laparoscopy, your stomach may be swollen (distended) from the gas that was used to lift your skin and muscles away from your abdominal organs so the surgeon could see them better. This should go away within a day or so but may last longer. You may also have some back or shoulder pain from the gas in your abdomen. This will go away as your body absorbs the gas.
• You can shower 24 hours after the surgery, but avoid rubbing or pulling on your incision for at least a week.
• You can have sexual intercourse as soon as you feel like it and it does not cause pain, which is usually 1 week after surgery.
• Be sure to rest for a few days (or at least 24 hours) before beginning to resume your normal activities. You should be able to resume all activities within a week.
• No backup method of birth control is needed after the surgery.

A follow-up exam in 2 weeks is usually scheduled.

Implants

• Most women can return to normal activities the same day as the procedure.
• Be sure to use another method of birth control for 3 months, until an X-ray confirms that the fallopian tubes are blocked.

Why It Is Done

A tubal ligation or tubal implant placement is a permanent method of birth control. Only consider this method when you are sure that you will not want to become pregnant in the future.

Permanent birth control is a reasonable option when you:

• Do not want to have children in the future, no matter how your life may change.
• Have a partner who also does not want children in the future but does not want to have a vasectomy (which is cheaper, has a lower risk, and possibly is more effective than tubal ligation¹).
• Have also considered other methods of birth control and do not want the side effects, risks, or costs of those methods.
• Have health problems that would be made worse by pregnancy.
• Have a hereditary condition that you do not want to pass on.
• Do not have any medical conditions that would make having surgery dangerous.

How Well It Works

Tubal ligation and tubal implants are not 100% effective at preventing pregnancy.

Tubal ligation

• There is a slight risk of becoming pregnant after tubal ligation. This happens to about 5 per 1,000 women after 1 year. After a total of 10 years following tubal ligation, about 18 per 1,000 women will have become pregnant.²
• Pregnancy may occur if:
  • The tubes grow back together or a new passage forms (recanalization) that allows an egg to be fertilized by sperm. Your health professional can discuss which method of ligation is more effective for preventing tubes from growing back together.
  • The surgery was not done correctly.
  • You were pregnant at the time of surgery.

Tubal implants

• Sterilization implants are a new birth control technology, so there are no long-term statistics. Studies so far show that over 2 years, fewer than 1 per 100 women got pregnant with implants.¹
• A tubal implant can be difficult to insert. Some women have to have a repeat procedure before both tubal implants are properly placed.

Call your health professional immediately if you have had tubal ligation or tubal implants and you have:

• Symptoms of pregnancy, such as a missed menstrual period, breast tenderness, and nausea.
• Pain on one side of your lower abdomen and you feel faint or dizzy.

It is important to be checked early if you have these signs of a tubal pregnancy.

Risks

Tubal ligation. Major complications of tubal ligation are not common.

• Minor complications include infection and wound separation. These affect about 11% of women after mini-laparotomy, and 6% of women after laparoscopy.³
• Major complications include heavy blood loss, general anesthesia problems, organ injury during surgery, and need for a larger laparotomy incision during surgery. These affect 1.5% of women after mini-laparotomy, and 0.9% of women after laparoscopy.

Although fewer complications occur with laparoscopy than with other kinds of tubal ligation surgery, these complications can be more serious. For example, on rare occasions, the bowel or bladder is injured when the laparoscope is inserted.

The general risks of surgery are greater if you have diabetes, are overweight, smoke, or have a heart condition.

Tubal implants. There are rare reports of implants causing pelvic pain that doesn't go away. In these cases, the implants were removed 6 weeks after they were placed in the fallopian tubes.⁴ The risk of pelvic infection is greater with tubal implants. Before you receive implants, you will be tested to make sure that you do not have a vaginal infection or a sexually transmitted disease (STD).

Ectopic pregnancy risk

If a tubal ligation or implant fails and you become pregnant, you have an increased risk of having an ectopic pregnancy. Ectopic pregnancies can occur years after the tubal ligation and are most likely 3 or more years after the procedure.⁵ For more information, see the topic Ectopic Pregnancy.

What To Think About

Tubal ligation and tubal implants do not change your monthly menstrual cycle. You will still release an egg each month (ovulate) and have menstrual periods. You will go through menopause at the same time that you would have if you had not had the surgery. Your sexual desires will not change, although you may feel more relaxed about having sex because you don't have to worry about becoming pregnant.

Advantages

Tubal ligation and tubal implants are permanent methods of birth control and allow you to be sexually active without worrying about becoming pregnant.

Although tubal ligation and tubal implants are expensive, it is a one-time cost. These procedures are usually covered by medical insurance, and there are no costs after the surgery is done. The cost of other birth control methods, such as pills or condoms and spermicide, may be greater over time.

Disadvantages

Tubal ligation and tubal implants do not protect against sexually transmitted diseases (STDs), including infection with the human immunodeficiency virus (HIV). To help protect yourself and your partner from possible STD infection, use a condom every time you have sex.

You must use another form of birth control for 3 months after receiving tubal implants.

Other considerations

Reversing tubal ligation requires reconnecting the fallopian tubes, and success rates for reconnecting are very low. If you are considering tubal ligation, be absolutely certain you will never want to have a biological child in the future. You should be able to say that this will be true even if one of the following happens:

• One of your living children dies (if you are a mother).
• You divorce and lose custody of your children.
• You have a new partner who wants children.
• Your financial situation improves and you can afford another child.
• Your children grow up and leave home.

Women who are probably not good candidates for tubal ligation include those who:

• Are younger than age 30, especially if they have never had a child. Women who have a tubal ligation in their 20s are more likely to want to reverse it later.
• Are having a problem pregnancy. Women who decide to have a tubal ligation during the stress of a difficult pregnancy are likely to regret the decision later.
• Are not currently in a stable relationship but might be in the future.
• Count on being able to reverse the tubal ligation later if they change their minds.
• Are being pressured to have the surgery by their partners, family, or other people.
• Are “giving up” on finding another method of birth control they can use successfully.

If you are married, you do not need the consent of your husband to have tubal ligation.

In the 1970s, women's and ethnic advocacy groups became concerned about the possibility of sterilization abuse. This concern led to regulations and practices that protect women who might feel pressured into having this surgery against their will.

• Health insurance coverage may require a waiting period from 48 hours to 30 days under most circumstances.
• Some health professionals advise a waiting period between the time a woman requests a tubal ligation and the time the surgery is performed. This waiting period allows you to be certain about your decision.

Complete the surgery information form (PDF) (What is a PDF document?) to help you prepare for this surgery.

Author:	Bets Davis, MFA	Last Updated: May 22, 2008
Medical Review:	Joy Melnikow, MD, MPH - Family Medicine Kirtly Jones, MD - Obstetrics and Gynecology
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