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Tubal Ligation



Tubal Ligation

Tubal ligation (or “tying the tubes”) is a surgery to close a woman’s fallopian tubes. These tubes connect the ovaries to the uterus. A woman who has this surgery can no longer get pregnant (sterile).

Tubal ligation is done in a hospital or outpatient clinic. You may receive general anesthesia. This will make you unconscious and unable to feel pain. Or, you may have local anesthesia or spinal anesthesia (awake but unable to feel pain). The procedure takes about 30 minutes.

Contents

Procedure
Effectiveness
Reversal
Risks
Assessment
Important Notes
Alternative Names
Video
References

Procedure

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There are mainly four occlusion methods for tubal ligation, typically carried out on the isthmic portion of the fallopian tube, that is, the thin portion of the tube closest to the uterus:

  • Partial salpingectomy, being the most common occlusion method. The fallopian tubes are cut and realigned by suture in a way not allowing free passage. The Pomeroy technique, is a widely used version of partial salpingectomy, involving tying a small loop of the tube by suture and cutting off the top segment of the loop. It can easily be applied via laparoscopy. Partial salpingectomy is considered safe, effective and easy to learn. It does not require any special equipment to perform; it can be done with only scissors and suture. Partial salpingectomy is not generally used with laparoscopy.
  • Clips: Clips clamp the tubes and inhibits blood flow to the portion, causing a small amount of scarring or fibrosis, in turn, preventing fertilization. The most commonly used clips are the Filshie clip, made of titanium, and the Wolf clip (or “Hulka clip”), made of plastic. Clips are simple to insert, but require a special tool to put in place.
  • Silicone rings: Tubal rings, similarly to clips, block the tubes mechanically. It encircles a small loop of the fallopian tube, blocking blood supply to that small loop, resulting in scarring that blocks passage of the sperm or egg. A commonly used type of ring is the Yoon Ring, made of silicone.
  • Electrocoagulation or cauterization: Electric current coagulates or burns a small portion of each fallopian tube. It mostly uses bipolar coagulation, where electric current enters and leaves through two ends of a forceps applied to the tubes. Bipolar coagulation is safer, but slightly less effective than unipolar coagulation, which involves the current leaving through an electrode placed under the thigh. It is usually done via laparoscopy.

Interval tubal ligation is not done after a recent delivery, in contrast to postpartum tubal ligation.

In addition, a bilateral salpingectomy is effective as a tubal ligation procedure. A tubal ligation can be performed as a secondary procedure when a laparotomy is done; i.e. a cesarean section. Any of these procedures may be referred to as having one’s “tubes tied.”

Tubal ligation can be performed under either general anesthesia or local anesthesia (spinal or epidural, often supplemented with a tranquilizer to calm the patient during the procedure). The default in tubal ligations following on from cesarean birth is usually spinal/epidural, while the default in non-childbirth related situations may be general anesthesia as a matter of doctor preference. However, tubal ligations under local anesthesia, either inpatient or outpatient, may be performed under patient request.

Entry to the site of tubal ligation can be done in many forms; through a vaginal approach, through laparoscopy, a minilaparotomy (“minilap”), or through regular laparotomy.

Another form of permanent birth control is the non-surgical Essure procedure that has been in use since 2002. In this procedure, Micro-inserts are placed into the fallopian tubes by a catheter passed from the vagina through the cervix and uterus. Once in place, the device is designed to elicit tissue growth (scarring) in and around the micro-insert to form over a period of 3 months. There would be an occlusion or blockage in the fallopian tubes; the tissue barrier formed prevents sperm from reaching an egg.

Effectiveness

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It was noted in the past that a tubal ligation is approximately 99% effective in the first year following the procedure. In the following years the effectiveness may be reduced slightly since the fallopian tubes can, in some cases, reform or reconnect which can cause unwanted pregnancy.

Tubal Ligation was intended to be a form of “permanent” female sterilization, however, with the advancement of science. Even this method can be override by skilled surgeons.

Reversal

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Generally tubal ligation procedures are done with the intention to be permanent, and most patients are satisfied with their sterilizations. Tubal reversal is microsurgery to repair the fallopian tube after a tubal ligation procedure.

Usually there are two remaining fallopian tube segments—the proximal tubal segment that emerges from the uterus and the distal tubal segment that ends with the fimbria next to the ovary. The procedure that connects these separated fallopian tube is called tubal reversal or microsurgical tubotubal anastomosis.

In a small percentage of cases, a tubal ligation procedure leaves only the distal portion of the fallopian tube and no proximal tubal opening into the uterus. This may occur when monopolar tubal coagulation has been applied to the isthmic segment of the fallopian tube as it emerges from the uterus. In this situation, a new opening can be created through the uterine muscle and the remaining tubal segment inserted into the uterine cavity. This microsurgical procedure is called tubal implantation, tubouterine implantation, or uterotubal implantation. (see Tubal Reversal for more info)

IVF in vitro fertilization may overcome fertility problems in patients not suited to a tubal reversal.

Risks

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Risks for any surgery are:

  • Bleeding
  • Infection

Risks for any anesthesia are:

  • Allergic reactions to medicines
  • Breathing problems or pneumonia
  • Heart problems

Risks for tubal ligation are:

  • Incomplete closing of the tubes, which could make pregnancy still possible. About 1 out of 200 women who have had tubal ligation get pregnant later (even without tubal reversal).
  • Increased risk of a tubal (ectopic) pregnancy if pregnancy occurs after a tubal ligation.
  • Injury to nearby organs or tissues from surgical instruments.

Assessment

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Before the procedure, ask the patient what drugs they are taking, even drugs, herbs, or supplements they bought without a prescription.

Important Notes

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During the days before surgery:

Intake of aspirin, ibuprofen (Advil, Motrin), warfarin (Coumadin), and any other drugs that make it hard for blood to clot must be stopped.

Patient smoking should also be stopped.

On the day of surgery:

Tell patient not to drink or eat anything after midnight – the night before the surgery, or 8 hours before the time of the surgery.

Doctor prescribed drugs could be taken with a small sip of water.

Tell the patient when to arrive at the hospital or clinic.

Alternative Names

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Sterilization surgery – female; Tubal sterilization; Tube tying; Tying the tubes

Video

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Laparoscopic Tubal Ligation with Filshie Clips. Courtesy of www.elitesurg.org


References

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1. Mishell DR Jr. Family planning: contraception, sterilization, and pregnancy termination. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007:chap 14.

2. American College of Obstetricians and Gynecologists. Sterilization by laparoscopy. ACOG Education Pamphlet AP035. February 2003. Accessed February 19, 2009.

3. “MedlinePlus Medical Encyclopedia, Tubal Ligation

4. Female Sterilization Occlusion Techniques Sarah Keller. Network Vol. 18, No. 1, Fall 1997.

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