Tubal ligation

Female sterilization through tubal ligation is primarily used to permanently prevent a patient from having a spontaneous pregnancy (as opposed to pregnancy via in vitro fertilization) in the future. While both hysterectomy (the removal of the uterus) or bilateral oophorectomy (the removal of both ovaries) can also accomplish this goal, these surgeries carry generally greater health risks than tubal ligation procedures. Less commonly, tubal ligation procedures may also be performed for patients who are known to be carriers of mutations in genes that increase the risk of ovarian and fallopian tube cancer, such as BRCA1 and BRCA2. While the procedure for these patients still results in sterilization, the procedure is chosen preferentially among these patients who have completed childbearing, with or without a simultaneous oophorectomy. Benefits and advantages for use as contraception High effectiveness Most methods of female sterilization are approximately 99% effective or greater in preventing pregnancy. These rates are roughly equivalent to the effectiveness of long-acting reversible contraceptives such as intrauterine devices and contraceptive implants, and slightly less effective than permanent male sterilization through vasectomy. Avoidance of hormonal medications Many forms of female-controlled contraception rely on suppression of the menstrual cycle using progesterones and/or estrogens. For patients who wish to avoid hormonal medications because of personal medical contraindications such as breast cancer, unacceptable side effects, or personal preference, tubal ligation offers highly effective birth control without the use of hormones. Reduction of pelvic inflammatory disease risk Occluding or removing both fallopian tubes decreases the likelihood that a sexually transmitted infection can ascend from the vagina to the abdominal cavity, causing pelvic inflammatory disease (PID) or a tubo-ovarian abscess. == Risks and complications ==

Risks associated with surgery and anesthesia Most tubal ligation procedures involve accessing the abdominal cavity through incisions in the abdominal wall and require some form of anesthesia. Major complications from laparoscopic surgery may include need for blood transfusion, infection, conversion to open surgery, or unplanned additional major surgery, while complications from anesthesia itself may include hypoventilation and cardiac arrest. Several factors influence the likelihood of failure: increased time since sterilization, younger age at the time of sterilization, and certain methods of sterilization are all associated with increased risk of failure. However, if patients do have a pregnancy after tubal ligation, a greater percentage of these will be ectopic; approximately one third of pregnancies that occur after a tubal ligation will be ectopic pregnancies. patients who are unmarried at the time of sterilization, non-white patients, patients with public insurance such as Medicaid, or patients who undergo sterilization soon after the birth of a child. Regret has not been found to be associated with the number of children a person has at the time of sterilization. Evidence does not indicate a strong association between tubal ligation and earlier onset of menopause. Sexual function Sexual function appears unchanged or improved after female sterilization compared with non-sterilized females. Hysterectomy Patients who had tubal occlusion surgeries have been found to be four to five times more likely to undergo hysterectomy later in life than those whose partners underwent vasectomy. == Contraindications ==

Given its permanent nature, tubal ligation is contraindicated in patients who desire future pregnancy or who want to have the option of future pregnancy. In such cases, reversible methods of contraception are recommended. Since most forms of tubal ligation require abdominal surgery under regional or general anesthesia, tubal ligation is also relatively contraindicated in patients for whom the risks of surgery and/or anesthesia are unacceptably high considering their other medical issues. == Procedure technique ==

Tubal ligation through blocking or removing the tubes may be accomplished through an open abdominal surgery, a laparoscopic approach, or a hysteroscopic approach. Depending on the approach chosen, the patient will need to undergo local, general, or spinal (regional) anesthesia. The procedure may be performed either immediately after the end of a pregnancy, termed a "postpartum" or "postabortion tubal ligation", or more than six weeks after the end of a pregnancy, termed an "interval tubal ligation". and Adiana systems were previously used for hysteroscopic sterilization, and research trials are investigating new hysteroscopic approaches. ==Tubal ligation methods==

There are a number of methods of removing or occluding the fallopian tubes, some of which rely on medical implants and devices. Postpartum tubal ligation Performed immediately after a delivery, this method removes a segment, or all, of both fallopian tubes. The most common techniques for partial bilateral salpingectomy are the Pomeroy or Parkland procedures. The ten year pregnancy rate is estimated at 7.5 pregnancies per 1000 procedures performed, and the ectopic pregnancy rate is estimated at 1.5 per 1000 procedures performed. Some large medical systems such as Kaiser Permanente Northern California have endorsed complete bilateral salpingectomy as the preferred means of female sterilization and professional medical societies such as the Society of Gynecologic Oncology and the American College of Obstetricians and Gynecologists (ACOG) recommend discussing the benefits of salpingectomy during counseling for sterilization. While complete bilateral salpingectomy theoretically should have an efficacy rate that approaches 100 percent and eliminates the risk of tubal ectopic pregnancy, there is not high quality data available comparing this method to older methods. Bipolar coagulation This method uses electric current to cauterize sections of the fallopian tube, with or without subsequent division of the tube. The ten year pregnancy rate is estimated at 6.3 to 24.8 pregnancies per 1000 procedures performed, and the ectopic pregnancy rate is estimated at 17.1 per 1000 procedures performed. The ten year pregnancy rate is estimated at 36.5 pregnancies per 1000 procedures performed, and the ectopic pregnancy rate is estimated at 8.5 per 1000 procedures performed. The ten year pregnancy rate is estimated at 17.7 pregnancies per 1000 procedures performed, and the ectopic pregnancy rate is estimated at 8.5 per 1000 procedures performed. Uchida tubal ligation This method involves dissecting the fallopian tube from the overlying connective tissue (serosa), placing two ligatures and excising a segment of the tube, then buries the end of the fallopian tube closest to the uterus underneath the serosa. Dr. Uchida reported no failures among 20,000 procedures. Essure tubal ligation This method closed the fallopian tubes through a hysteroscopic approach by placing two small metal and fiber coils in the fallopian tubes through the fallopian ostia. After insertion, scar tissue forms around the coils, blocking off the fallopian tubes and preventing sperm from reaching the egg. It was removed from the US market in 2019. It was removed from the US market in 2012. == Reversal or in vitro fertilization after tubal ligation ==

All tubal ligation procedures are considered permanent and are not reliably reversible forms of birth control. Patients who wish to have the option of future pregnancy should ideally be directed towards effective but reversible forms of birth control, rather than sterilization procedures. Examples of this include intrauterine devices. However, patients who desire pregnancy after having undergone a female sterilization procedure have two options. Tubal reversal is a type of microsurgery to repair the fallopian tube after a tubal ligation procedure. Successful pregnancy rates after reversal surgery are 42-69%, depending on the sterilization technique that was used. Alternatively, in vitro fertilization (IVF) may allow patients with absent or occluded fallopian tubes to successfully carry a pregnancy. The choice of whether to attempt tubal reversal or move straight to IVF depends on individual patient factors, including the likelihood of successful tubal reversal surgery and the age of the patient. == Recovery and rehabilitation ==

Most laparoscopic methods of interval tubal ligation are outpatient surgeries and do not require hospitalization overnight. Patients are counseled to expect some soreness but to expect to be ready to perform daily activities 1–2 days after surgery. Patients undergoing postpartum tubal ligations will not be delayed in their discharge from the hospital after birth, and recovery is not significantly different from normal postpartum recovery. == History ==

The first modern female sterilization procedure was performed in 1880 by Dr. Samuel Lungren of Toledo, Ohio, in the United States. Hysteroscopic tubal ligation was developed later by Mikulicz-Radecki and Freund. Given this history of human rights abuses, current sterilization policy in the United States requires a mandatory waiting period for tubal sterilization on Medicaid beneficiaries. This waiting period is not required for private insurance beneficiaries, which has the effect of selectively restricting low-income women's access to tubal sterilization. == Society and culture ==

Prevalence Of the 64% of married or in-union women worldwide using some form of contraception, approximately one fifth (19% of all women) used female sterilization as their contraception, making it the most common contraceptive method globally. The percentage of women using female sterilization varies significantly between different regions of the world. Rates are highest in Asia, Latin America and the Caribbean, North America, Oceania, and selected countries in Western Europe, where rates of sterilization are often greater than 40%; rates in Africa, the Middle East, and parts of Eastern Europe, however, are significantly lower, sometimes less than 2%. An estimated 180 million women worldwide have undergone surgical sterilization, compared to approximately 42.5 million men who have undergone vasectomy. Slightly more than 8.2 million women in the US use tubal ligation as their main form of contraception, ==See also==