What Is Tubal Ligation?

Introduction

Tubal ligation, also known as tubal sterilisation, is a form of birth control that involves a surgical procedure where the fallopian tubes are cut, tied or blocked to prevent pregnancy permanently. The process prevents an egg from travelling from the ovaries down the fallopian tubes to the uterus. It also prevents the sperm from travelling from the tubes to the ovaries. Hence fertilisation and implantation cannot occur. It is commonly referred to as getting the tubes tied or female sterilisation.

Purpose of tubal ligation

Its sole aim is to prevent pregnancy permanently. At 99 per cent effectiveness, it is one of the most effective kinds of birth control. It is often recommended for adult females who are certain that they do not want any pregnancy in future. The procedure is known to be safe and effective and can be done at any point in time.

Procedure overview

The fallopian tubes are cut and closed with clips or bands or sealed by electrocautery during the procedure. 

It can be performed in one of three ways:¹

Laparoscopic

two incisions are made, one at the navel and one above the pelvic bone. A laparoscope, a thin tube, is inserted into the abdomen and the abdomen is inflated with carbon dioxide for better viewing of the internal organs. The surgical instruments are then inserted into the incision at the pelvic region to tie, cut or seal the fallopian tubes. This procedure is minimally invasive and, therefore, requires a short recovery time.

Laparotomy

Requires a larger abdominal incision where the fallopian tubes can then be pulled out to view before they are cut or tied off. This procedure is invasive and requires a longer time for recovery. 

Mini-laparotomy (also known as mini-lap)

This method uses a smaller incision and is typically done within 24 hours of vaginal birth where epidural has already been used or can be done under spinal anaesthesia. The fallopian tubes are then lifted to the incision site and cut or tied off. 

Effectiveness of tubal ligation

There are many advantages of tubal ligation: 

• High effectiveness and convenience – with a 99 per cent success rate and a failure rate of 0.5 per cent, it is highly effective in preventing pregnancy
•  Hormone-free birth control – some women believe hormone-free birth control is safer and better. Tubal ligation does not affect the hormones, therefore it does not affect the menstrual cycle or menopause
• Reduce disease risk – studies have shown that the risk of ovarian cancer can be reduced by approximately 40 per cent in women who have undergone tubal ligation¹

Considerations and eligibility

Tubal ligation is a simple surgery that can be done at any time, including immediately after childbirth. Most women opt for the procedure to be done during delivery, caesarean section or vaginal birth. It is only recommended for women who are sure they want to prevent pregnancy as a reversal of this procedure is highly unlikely to be successful.

People who were assigned female at birth, under the age of 30 and have never had children are strongly advised against tubal ligation as it is common for them to experience regret and dissatisfaction later in life.

Risks and complications

Although tubal ligation is a low-risk surgery, like any other surgical procedure, it comes with some risks. These include:

• Bleeding
• Infection
• Injury to organs or surrounding blood vessels
• Side effects caused by anaesthesia
• Difficult and expensive to reverse

The risk of having these side effects is higher if you have had previous abdominal surgery and if you have other underlying health conditions like obesity, diabetes, lung disease or pelvic inflammatory disease. If you experience any of the following symptoms after a tubal ligation, it is important to call your doctor or healthcare provider:

•  Continuous nausea and vomiting
• Temperature higher than 37.3 degrees Celsius for more than 24 hours
•  Swelling, redness or bleeding around the incision site
• Heavy bleeding with blood clots or rapidly soaking a pad within two hours or less

Long-term complications are rare but may still occur. These include: 

Post tubal ligation syndrome (PTLS)

PTLS is a condition that occurs when the blood vessels that supply the ovaries are damaged during the procedure. This results in a significant decrease in the production of oestrogen and progesterone. These hormones may trigger menopause-like symptoms.

These symptoms include heavy or irregular periods, hormonal imbalances, mood swings, hot flashes, anxiety and sleep problems. People who were assigned female at birth (PAFAB) in their 20s are known to be at a higher risk for this condition than older PAFAB.²

Future hysterectomy

There may be a connection between tubal ligation and the risk of having a hysterectomy in future. Many studies have tried to link tubal ligation to women needing hysterectomy but this was more prominent in the United States where hysterectomy rates are generally higher than in other parts of the world.³

Perceived risk of breast or ovarian cancer

Some PAFAB who choose permanent birth control such as tubal ligation are concerned about increasing their risk for breast and ovarian cancer. However, research shows a reduction in the incidence of these types of cancer in women who have undergone the procedure.⁴

Ectopic and unplanned pregnancies

PAFAB who have tied their tubes have a slightly higher risk of having ectopic pregnancies. Some studies have shown that one in 200 women will fall pregnant after undergoing tubal ligation. Less than seven out of 1000 of these pregnancies will be ectopic which is higher than the average in non-sterilised women. Women in their 20s have a higher rate of failure of the procedure.

Of all the side effects listed above, regret is often the most discussed among PAFAB intending to undergo the procedure. Life events, and pressure from spouses, family members, and doctors are known to be the major factors that contribute to the feeling of regret.

Alternatives to tubal ligation

• Vasectomy - permanent male birth control
• Essure - a non-surgical option where a flexible, soft object is placed into the two fallopian tubes. This device has been recalled by the manufacturers due to its serious side effects like chronic pain
• Other alternatives include long-acting, reversible methods of contraception like intrauterine devices (IUD), contraceptive implants placed under the skin of the arm and short-acting reversible types like oral birth control pills

Before choosing a desired method of birth control, counselling and education must be sought to determine which option best suits your body or your desired outcome. It is important to weigh all options before deciding on a permanent contraceptive like tubal ligation. If unsure, reversible forms are advised. 

Recovery and aftercare

After a tubal ligation, close monitoring during the recovery phase is essential. The type of ligation determines the length of stay in the hospital. If the procedure has been combined with childbirth, the patient will already have a planned hospital stay. Some of the advice that the healthcare provider will give includes:

• No heavy lifting for up to two weeks after the procedure. If combined with childbirth, it is recommended not to lift anything heavier than your baby for up to four weeks
• No alcohol consumption or driving for 24 hours
• No activities that involve immersion in water like swimming or taking baths for about two weeks. Only showers are advised
• Nausea is a common side effect, light meals especially on the day of surgery may help ease symptoms
• Vaginal bleeding for up to a month post-surgery is typical. Normal menstrual cycle might not resume for up to six weeks after surgery. Heavier than normal bleeding may be noticed when cycle resumes
• A swollen abdomen for several days post-surgery may be noticed

Over-the-counter or prescribed medication pain medication may provide relief.

FAQ's

Is tubal ligation very effective?

Yes, it is known to have 99% effectiveness and protects you for the rest of your life from falling pregnant.

Can tubal ligation be reversed?

Yes, but this is expensive and very rarely successful.

Does it affect the menstrual cycle?

No, it does not change your hormones, affect your menstrual cycle or cause menopause.

Summary

Tubal ligation is a permanent birth control method involving the surgical alteration of fallopian tubes to prevent pregnancy. The procedure, commonly known as getting the "tubes tied," has a 99% effectiveness rate and is hormone-free. It can be performed through various methods, including laparoscopy, laparotomy, and mini-laparotomy, each with different levels of invasiveness and recovery times.

The advantages of tubal ligation include its high effectiveness, hormone-free nature, and potential reduction in the risk of ovarian cancer. However, it is crucial to consider eligibility factors and potential risks. Tubal ligation is recommended for women certain about not wanting future pregnancies, as its reversal is expensive and with a low chance of success. Risks and complications associated with tubal ligation include exposure to sexually transmitted diseases, bleeding, infection, damage to organs, and difficulty in reversal. Long-term complications, while rare, may include Post Tubal Ligation Syndrome (PTLS), future hysterectomy, perceived cancer risks, and a slightly higher risk of ectopic pregnancies.

Regret is a common concern, often influenced by life events and external pressures. Alternatives to tubal ligation include permanent male birth control (vasectomy), Essure (recalled due to side effects), intrauterine devices (IUDs), contraceptive implants, and oral birth control pills.

Post-surgery, recovery involves close monitoring, with specific guidelines such as avoiding heavy lifting, refraining from alcohol, and driving initially, and limiting activities involving water immersion. Nausea, vaginal bleeding, and a swollen abdomen are common post-surgery experiences, with normal menstrual cycles resuming within six weeks. Before opting for tubal ligation, counselling and education are emphasised, encouraging individuals to weigh all contraceptive options. If unsure, reversible forms of birth control are recommended.