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Tubal ligation

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Surgeries and procedures

Tubal ligation, also called getting one's tubes tied, and sometimes used to mean a bilateral salpingectomy (destroying both fallopian tubes), is a form of sterilization. Any method of tubal ligation works by stopping the path the egg cell would travel through the fallopian tube to the uterus. For people who have a uterus, this procedure is meant to make it permanently virtually impossible for them to get pregnant. There are several methods of tubal ligation, but bilateral salpingectomy has come to be the preferred standard of care, because it is the most effective.[1] For some transgender and nonbinary people, if their only concern about their uterus is that a risk of pregnancy is a source of distress and body dissonance (called gender dysphoria), this is an alternative to removing the uterus (called hysterectomy).[2] Because this is not Wikipedia, this article should focus on common questions that transgender and nonbinary people have about this procedure, and should be written in simple English, so that people who are not doctors can easily understand it.

Tubal ligation has no effect on the person's menstrual flow, menstrual cycle, hormone balance, the ability to orgasm, vulnerability to sexually transmitted infections,[3] or when or how the person will go through menopause.[4] It does not elevate any cancer risks, and lowers ovarian cancer risk.[5][6] Sometimes a person can choose to have uterine ablation done at the same time as tubal ligation, which is supposed to stop menstrual flow. If someone chooses to get ablation, then they have to get a tubal ligation or some other kind of contraception too.[7]

There are various methods for tubal ligation, which can be considered either a laparoscopic surgery (meaning it is done by cutting only a few tiny holes on the lower belly, and putting long thin laparoscope tools through them to do the work), or a procedure (meaning it can be done without cutting into the body). The fallopian tubes (which connect the ovary to the uterus) can be blocked off by a variety of different methods. The tubes can be tied and cut (ligation), clipped, pinched off in a loop with a band, burned (cauterization), blocked with scar tissue or an implant (tubal occlusion), or completely destroyed (salpingectomy). Any of these methods can be called tubal ligation on paperwork and health insurance. Cutting or tying the tubes has the most risk of still being able to get pregnant, whereas destroying the tubes is the most effective at preventing pregnancy. Blocking the tubes with an implant can be done by putting it in through the vagina, without cutting into the body, which is safer,[7] but an implant has the risk of later traveling into parts of the body where it is not supposed to be, which can be harmful.

Process

 
A diagram of the parts of an adult person's uterus, before any surgery.
 
A diagram of some-- but not all-- methods of tubal ligation.

Some regions have laws that make it so that a person has to be certain age before they are allowed to get a tubal ligation.[citation needed] Tubal ligation is done by written informed consent from the patient, without needing a diagnosis of any health problem.

Anyone seeking sterilization will encounter sexist discrimination. Doctors, local laws, and health insurance companies put many more obstacles in the way of sterilization for people who they perceive as female, because of a widespread misconception that everyone who was born with a uterus will want to get pregnant someday. By comparison, doctors are much more willing and cooperative about giving the equivalent sterilization procedure to people who have testicles (a vasectomy). A doctor will only let a patient sign the consent forms for tubal ligation in the first place if the doctor is satisfied with how the patient answers a long series of intentionally offensive questions. Doctors intentionally try to lead people into giving the "wrong" answers, and then refuse to let the patient sign the consent forms. A survey found that male and female doctors are equally reluctant to let a "young" person (in their 20s or 30s) get a tubal ligation. Looking too youthful or whimsical can be enough for the doctor to decide you don't look like you can consider this decision, so dress maturely for this appointment.[8] See sterilization for more details on what the doctor wants to hear. There is also racist discrimination involved: doctors make sterilization relatively obtainable for people of color, or even push it on people of color who don't want it, but make sterilization almost impossible to obtain for people who are white. The motivation behind this racist discrimination is eugenics. After signing these consent forms, the patient may be required to wait a certain number of days before being allowed to have surgery, according to local laws or the person's health insurance. The wait is to give the patient time to make sure it's what they really want. This is also sexist discrimination, because people seeking a vasectomy are not forced to wait.[3][9][10] Even after submitting the consent forms, the doctors usually continue to create obstacles, such as deciding that the consent forms need to be redone because the doctor didn't print their name below their signature, or canceling the surgery at the last minute because the patient didn't call to confirm that they still wanted it.

A tubal ligation is done by a gynecologist, family medicine doctor, or general surgeon in a medical office, hospital, or clinic.[3] Tubal ligation is done in one stage. Although many sources refer to it being done under local or regional anesthesia,[11] typically it is done under general anesthesia. The patient goes home the same day.

During laparoscopic surgery, the surgeons put carbon dioxide gas into the abdominal cavity. This is to lift organs apart so that the surgeon can see what they're doing as they work. This is called insufflation of the abdomen. After surgery, the person's belly will still temporarily look enlarged (distended). This is the only particularly uncomfortable part of tubal ligation. During recovery, the person may feel pain in their shoulders, because the distended abdomen puts pressure on the muscles inside the top of the abdomen (the diaphragm), and the nerves refer that sensation to the shoulders.[12] The gas slowly goes away by being absorbed into the body, so in a few days, the belly will no longer look distended.

Costs and health insurance

Out of pocket, a tubal ligation may cost between USD$1,500 and USD$6,000.[3] Most health insurance companies cover it, especially if they otherwise cover contraception. If cost is a obstacle, you may be able to lower it to suit your income level through a state program or a Planned Parenthood health center.[3] If a complication happens, it could cost much more. See also: Saving up for transition expenses.

Complications and risks

Statistics show that sterilization by tubal ligation is safer than giving birth.[13] Since tubal ligation is a surgery done under general anesthesia, it has the same risks of any such surgery, plus a few of its own distinctive risks, depending on the method used. Like any surgery, the most common serious risks are from infection, complications from the anesthesia, and bleeding too much (hemorrhage).[13] Systemic infection (sepsis) is an extremely rare complication. Death from tubal ligation is extremely rare, and is usually caused by a reaction to anesthesia.[3]

During the surgery, there is a low risk that a bubble of air might get into a blood vessel (an embolism), which can cause the heart to stop (cardiac arrest). That can cause the patient to die on the operating table, but usually surgeons can restart the heart and resuscitate the patient.[14][15]

Tubal ligation does not increase the risk of cancer, not even hormone-sensitive types of breast cancer.[5] Tubal ligation correlates with a much lower rate of ovarian cancer.[5][16]

Effectiveness and pregnancy risks

 
Some types of ectopic pregnancies in a uterus that hasn't had tubal ligation.

Most methods of tubal ligation are about 99% effective or greater in preventing pregnancy.[17] A pregnancy can happen if the fallopian tubes weren't fully cut, tied, blocked, or destroyed, or if the tubes later reconnected (recanalization), so that there was enough of an opening in the tube for an egg or sperm to pass through. If someone does get pregnant after a tubal ligation, then the embryo might implant somewhere wrong. This is called an ectopic pregnancy. Whether the embryo implants in the ovary (an ovarian pregnancy) or in the fallopian tube (a tubal pregnancy), the embryo generally can't survive,[18] For the pregnant person, an ectopic pregnancy is a life-threatening emergency that can only be fixed by removing the embryo (an abortion), which can sometimes only be done by surgery.[19] Worldwide, pregnancy happens after the cutting, tying, or blocking methods of tubal ligation in 1 in 200 cases; of those pregnancies, 1 in 10 of them were ectopic pregnancies.[20] However, the preferred method, salpingectomy, destroys the whole fallopian tubes, which makes it far safer for preventing pregnancies (ectopic or otherwise) than tubal ligation methods that only cut, tie, or block the tubes. There have only been two reported cases worldwide of any kind of pregnancy happening after bilateral salpingectomy.[21]

See also

References

  1. ↑ ACOG Committee Opinion No. 774: Opportunistic Salpingectomy as a Strategy for Epithelial Ovarian Cancer Prevention, Obstetrics & Gynecology: April 2019 - Volume 133 - Issue 4 - p e279-e284 doi: 10.1097/AOG.0000000000003164 Full text: https://journals.lww.com/greenjournal/Fulltext/2019/04000/ACOG_Committee_Opinion_No__774__Opportunistic.59.aspx
  2. ↑ Laura Erickson-Schroth, ed. Trans Bodies, Trans Selves: A Resource for the Transgender Community. Oxford University Press, 2014. Pp. 236, 267-268.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 "Sterilization." Planned Parenthood. Retrieved July 9, 2020. https://www.plannedparenthood.org/learn/birth-control/sterilization
  4. ↑ Deborah B. Nelson; Mary D. Sammel; Ellen W. Freeman; Clarisa R. Gracia; Li Liu; Elizabeth Langan (2005). "Tubal ligation does not affect hormonal changes during the early menopausal transition." Contraception, 71(2), 0–110. doi:10.1016/j.contraception.2004.09.008 https://www.sciencedirect.com/science/article/abs/pii/S0010782404002756
  5. ↑ 5.0 5.1 5.2 Brinton LA, Gammon MD, Coates RJ, Hoover RN. “Tubal ligation and risk of breast cancer.” British Journal of Cancer 2000 May; 82(9), 1600–1604. doi:10.1054/bjoc.1999.1182
  6. ↑ Lyn Turney (1993). "Risk and contraception: What women are not told about tubal ligation." Women's Studies Int. Forum, 16(5), 471–486. doi:10.1016/0277-5395(93)90097-s
  7. ↑ 7.0 7.1 A.C. Donnadieu; X. Deffieux; A. Gervaise; E. Faivre; R. Frydman; H. Fernandez (2007). "Essure® sterilization associated with endometrial ablation." International Journal of Gynecology and Obstetrics, 97(2), 0–142. doi:10.1016/j.ijgo.2007.02.009
  8. ↑ Misa, “How to get your tubes tied, even if you’re only 21.” Misa's Place (blog). Posted September 21, 2006. Accessed July 1, 2013. https://web.archive.org/web/20130701000000*/http://misasplace.blogspot.com/2006/09/how-to-get-your-tubes-tied-even-if.html
  9. ↑ Erin Gloria Ryan, “Getting your tubes tied is a giant pain in the ass.” Published July 9, 2012. Jezebel (magazine). http://jezebel.com/5924414/getting-your-tubes-tied-is-a-giant-pain-in-the-ass
  10. ↑ J. Lowder, “Sterilize me, please.” Slate (magazine). Posted July 9, 2012. Accessed May 4, 2012. http://www.slate.com/articles/double_x/doublex/2012/07/getting_your_tubes_tied_why_do_young_women_have_a_hard_time_getting_sterilized_.3.html
  11. ↑ Hatasaka HH, Sharp HT, Dowling DD, Teahon K, Peterson CM. Laparoscopic tubal ligation in a minimally invasive surgical unit under local anesthesia compared to a conventional operating room approach under general anesthesia. Journal of Laparoendoscopic & Advanced Surgical Techniques. 1997 Oct;7(5):295-9. doi: 10.1089/lap.1997.7.295. PMID: 9453874.
  12. ↑ "Diagnostic laparoscopy." MedLine Plus. Accessed May 4, 2022. http://www.nlm.nih.gov/medlineplus/ency/article/003918.htm
  13. ↑ 13.0 13.1 Strauss LT, Huezo CM, Kramer DG, Rochat RW, Senanayake P, Rubin GL. Sterilization-associated deaths: a global survey. International Journal of Gynaecology and Obstetrics. 1984 Feb;22(1):67-75. doi: 10.1016/0020-7292(84)90106-1. PMID: 6144595.
  14. ↑ Duncan C. Carbon dioxide embolism during laparoscopy: a case report. AANA Journal. 1992 Apr;60(2):139-44. PMID: 1414176.
  15. ↑ Ostman PL, Pantle-Fisher FH, Faure EA, Glosten B. Circulatory collapse during laparoscopy. Journal of Clinical Anesthesia. 1990 Mar-Apr;2(2):129-32. doi: 10.1016/0952-8180(90)90068-e. PMID: 2140690.
  16. ↑ Heidi L. Miracle-McMahill, Eugenia E. Calle, Andrzej S. Kosinski, Carmen Rodriguez, Phyllis A. Wingo, Michael J. Thun, Clark W. Heath, Jr., Tubal Ligation and Fatal Ovarian Cancer in a Large prospective Cohort Study, American Journal of Epidemiology, Volume 145, Issue 4, 15 February 1997, Pages 349–357, https://doi.org/10.1093/oxfordjournals.aje.a009112 Full text: https://academic.oup.com/aje/article/145/4/349/69111
  17. ↑ American College of Obstetricians Gynecologists' Committee on Practice Bulletins—Gynecology (March 2019). "ACOG Practice Bulletin No. 208: Benefits and Risks of Sterilization". Obstetrics & Gynecology. 133 (3): e194–e207. doi:10.1097/AOG.0000000000003111. ISSN 0029-7844. PMID 30640233. S2CID 58625472.
  18. ↑ Zhang J, Li F, Sheng Q (2008). "Full-term abdominal pregnancy: a case report and review of the literature". Gynecologic and Obstetric Investigation. 65 (2): 139–41. doi:10.1159/000110015. PMID 17957101. S2CID 35923100.
  19. ↑ Kirk E, Bottomley C, Bourne T (2014). "Diagnosing ectopic pregnancy and current concepts in the management of pregnancy of unknown location". Human Reproduction Update. 20 (2): 250–61. doi:10.1093/humupd/dmt047. PMID 24101604.
  20. ↑ Date, Shilpa Vishwas et al. “Female sterilization failure: Review over a decade and its clinicopathological correlation.” International journal of applied & basic medical research vol. 4,2 (2014): 81-5. doi:10.4103/2229-516X.136781 Full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4137647/
  21. ↑ Bollapragada, Shrikant S et al. “Spontaneous pregnancy after bilateral salpingectomy.” Fertility and sterility vol. 83,3 (2005): 767-8. doi:10.1016/j.fertnstert.2004.07.970 Full text: https://www.fertstert.org/article/S0015-0282(04)02993-0/fulltext
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