Procedure

Tubal Sterilization

Editors: Elliot M. Levine MD, FACOG; Allen Shaughnessy PharmD, M Med Ed, FCCP; Katharine DeGeorge MD, MS

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Background Information

Description

  • permanent contraceptive method which surgically interrupts the patency of the fallopian tubes
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    ,
    2

Also Called

  • tubal ligation
  • bilateral tubal ligation
  • tubal occlusion
  • "tubes tied"

Rates of Use

  • reported use in about 33% of women aged 35-44 years and < 1% of women aged 15-24 years
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    ,
    3
  • most common contraceptive method for married couples in United States (about 30% reported use)
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  • reported incidence of ambulatory interval sterilizations in United States 290,000 annually
    3
  • use of interval sterilizations appears to be decreasing in developed countries (likely due to delayed childbirth and increasing availability of long-acting reversible contraceptive methods)
    • in United States, reported number of procedures performed
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      ,
      3
      • 702,000 in 1977
      • 643,000 in 2006
    • in Belgium, reported number of procedures performed
      • 20,137 in 1999
      • 13,853 in 2008
      • Reference - Eur J Contracept Reprod Health Care 2010 Dec;15(6):385
  • rate of tubal sterilization reported to vary by race
    2
    • 21.3% of non-Hispanic Black women
    • 18.8% of Hispanic women
    • 14% of non-Hispanic White women
  • STUDY SUMMARY
    rural residence and low education level associated with higher prevalence of sterilization in women < 35 years old in the United States
    COHORT STUDY: Obstet Gynecol 2013 Aug;122(2 Pt 1):304

Indications and Contraindications

  • tubal sterilization indicated for well-informed women who request sterilization, and parity should not limit use
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    ,
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  • advise young women of permanence of procedure and alternative long-term forms of contraception, but young age should not be a barrier to use
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    ,
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  • contraindications
    • there are no absolute contraindications to tubal sterilization
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    • assess safety of sterilization procedure in context of patient's overall health
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      ,
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    • in women having transcervical sterilization procedure, only contraindication is hypersensitivity to use of local anesthetics (procedure no longer available in United States)
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      ,
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  • World Health Organization (WHO) Medical Eligibility Criteria for contraceptive use
    • conditions which require delay of sterilization procedure until condition is evaluated or corrected include (WHO Grade D)
      • postpartum/postabortion conditions, including
        • postpartum status 7-41 days
        • severe preeclampsia/eclampsia
        • prolonged rupture of membranes ≥ 24 hours
        • puerperal sepsis, maternal intrapartum fever, or puerperal fever
        • postabortal sepsis or fever
        • severe postabortal hemorrhage
        • severe antepartum or postpartum hemorrhage
        • severe vaginal/genital tear at delivery or abortion
        • acute hematometra
      • cardiovascular conditions, including
      • reproductive tract infections and/or disorders, including
        • unexplained vaginal bleeding (perform evaluation before sterilization procedure)
        • gestational trophoblastic disease with persistently elevated beta subunit-human chorionic gonadotropin (beta-hCG) levels or malignant disease
        • untreated cervical cancer (treatment typically results in sterility)
        • endometrial cancer (treatment typically results in sterility)
        • ovarian cancer (treatment typically results in sterility)
        • current pelvic inflammatory disease (PID)
        • current purulent cervicitis, chlamydial infection, or gonorrhea (if no symptoms following treatment, sterilization may be performed)
      • gastrointestinal conditions, including
        • current, symptomatic gall bladder disease
        • acute or flare viral hepatitis (appropriate infection-prevention procedures recommended)
      • iron deficiency anemia with hemoglobin (Hb) < 7 g/dL [70 g/L]
      • other conditions
        • local infection (may increase risk for postoperative infection)
        • acute respiratory disease (bronchitis or pneumonia)
        • systemic infection or gastroenteritis
        • sterilization concurrent with abdominal surgery, including
          • emergency (without previous counseling)
          • infectious condition
    • conditions requiring experienced surgeon/staff and access to equipment for general anesthesia and other back-up medical support as needed include (WHO Grade S)
      • uterine rupture or perforation (sterilization procedure may be performed concurrently in stable women having exploratory surgery or laparoscopy if no additional risks)
      • cardiovascular diseases, including
        • presence of multiple risk factors for arterial cardiovascular disease (such as older age, smoking, diabetes, and hypertension)
        • hypertension (control elevated blood pressure prior to sterilization procedure due to increased risk for complications), including
          • systolic blood pressure ≥ 160 mm Hg or diastolic blood pressure ≥ 100 mm Hg
          • vascular disease
        • deep vein thrombosis (DVT) and/or pulmonary embolism (PE) on anticoagulant therapy
        • complicated valvular heart disease in patients with
          • pulmonary hypertension
          • risk for atrial fibrillation
          • history of subacute bacterial endocarditis
      • systemic lupus erythematosus (SLE) in patients with
        • positive (or unknown) antiphospholipid antibodies
        • severe thrombocytopenia
        • immunosuppressive treatment
      • endometriosis
      • severe or advanced HIV clinical disease (WHO Stage 3 or 4) (AIDS-related illness may require delay of sterilization procedure)
      • pelvic tuberculosis
      • endocrine conditions, including
      • severe (decompensated) cirrhosis
      • other conditions
        • coagulation disorders
        • chronic respiratory disease (asthma, bronchitis, emphysema, or lung infection)
        • fixed uterus due to previous surgery or infection
        • abdominal wall hernia or umbilical hernia (perform abdominal wall repair and sterilization concurrently if possible)
    • Reference - World Health Organization (WHO) Medical Eligibility Criteria for contraceptive use (WHO 2015 PDF)

Timing

  • interval procedure
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    • may be performed any time in menstrual cycle
    • ideally performed between days 6 and 13 of menstrual cycle (may reduce likelihood of concurrent pregnancy and improve visualization of tubal ostia for hysteroscopic procedures)
    • perform urine pregnancy test prior to procedure (may not rule out luteal phase pregnancy)
  • postpartum procedure
    • obtain consent for postpartum procedure during prenatal care when patient may better make an informed decision
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    • postpartum procedure may be performed
      • at time of cesarean delivery
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      • within 24-48 hours of vaginal delivery
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        • enlarged postpartum uterus improves fallopian tube proximity to the umbilicus
        • small infra- or supraumbilical mini-laparotomy incision can be used to easily access the tube, rarely resulting in prolonged hospitalization
        • if performed shortly after delivery, epidural anesthesia placed during labor may be left in place for tubal procedure
    • in United States, > 50% of tubal sterilization procedures are performed in early postpartum period, and are performed in 8%-9% of all hospital deliveries
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  • postabortion procedure
    • may be performed immediately or within 1 week after uncomplicated spontaneous or induced abortion
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    • immediately after first or second trimester abortion, either laparoscopic or minilaparotomy procedure may be performed using single anesthetic for both abortion and sterilization
      1

Barriers

  • barriers to access to sterilization in the United States include
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    • federal consent requirements (surgical consent required ≥ 30 days before procedure, federal funds cannot be used for sterilization for women aged < 21 years)
    • unfulfilled postpartum sterilization requests (consent form may not be in chart by time of delivery, request may not be fulfilled if form was not signed 30 days before delivery)
    • refusal to provide sterilization at some faith-based hospitals
      • sterilization is against Catholic hospital policy, although this restriction is not uniformly enforced (Linacre Q 2013 Feb;80(1):32)
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