Tubal Ligation Procedure – Should You Get Your Tubes Tied?

Tubal ligation, commonly referred to as tubectomy, is a surgical procedure intended for permanent female sterilization. Getting your tubes tied involves being protected against an unintended pregnancy. It has some associated side effects, even though recovery is expected to occur in about one week. Although it is not always successful, women wishing to have a baby after tying their tubes can do so through tubal ligation reversal.

The history of tubectomy takes us back to the 1960s, when female sterilization was indicated only for medical reasons. During the same decade, with the development of surgical advances, non-invasive methods appeared. The fact that insurance companies began to cover female sterilization procedures boosted the popularity of this technique.

What does it mean?

Bilateral tubal ligation is the medical term for having the tubes tied or tying the tubes. Also known as tubectomy, it is a non-hormonal permanent birth control method which is done through surgery, often referred to as tubectomy operation.

It is always a bilateral procedure, as women have two Fallopian tubes. This means it is always necessary to cut or tie both of them in order for a pregnancy to be successfully prevented in the future.

The following are the most common cases in which a patient might need a tubal ligation:

• You are an adult woman, preferably already on motherhood
• You are in a stable relationship
• Pregnancy may be a health risk
• You or your partner has a genetic disorder

A woman may choose to have a tubal ligation performed for the purpose of blocking the tubes, so that the sperm cannot reach the egg and fertilize it. If egg insemination does not take place, pregnancy cannot occur.

Advantages and disadvantages

For many women, permanent sterilization is an ideal choice for continuing with an active sex life while removing the risk for an unintended pregnancy.

These are the main characteristics which turn it into an advantageous sterilization method:

• Permanent birth control
• Immediate effectiveness
• Highly effective protection
• Few side effects
• Cost-effective in a long term
• No daily attention is required unless the patient notices unexpected symptoms

On the other hand, tubectomy has also some risk and complications are likely to appear after surgery. The most obvious disadvantage is that it does not offer any protection against sexually transmitted diseases (STDs), so a barrier method such as the condom should be used.

For more information on contraceptive methods, please visit the following guide: What are the most common birth control methods?

Surgical procedure by laparoscopy

Getting your Fallopian tubes tied involves closing them by means of either tubal clips or rings. Then, the remaining part of the tube between them is cut or burned. It is usually done in the hospital or in an outpatient surgical clinic.

Surgery for tubal sterilization

Surgery is generally done under general anesthesia, that is, being asleep. However, local anesthesia can be used as well, depending on the case. In most cases, women can go home on the day of surgery.

It is advised not to undergo this operation if the patient currently has or has had a history of bladder cancer, as there is some risk of injuring the bladder, bowel or major blood vessels.

The procedure is done in both Fallopian tubes, so that the sperms are unable to reach the oocyte. This means, egg insemination, that is, the egg-sperm binding cannot take place. The process can be done in two different ways:

• By laparoscopy: Also known as keyhole surgery, operations are performed through small incisions by means of a laparoscope.
• By laparotomy: It is an open procedure which involves making a large incision through the abdominal wall.

Normally, tubal ligation is done by laparoscopy. It consists in doing a small incision and inserting a tube with a tiny camera on the end through the pelvic area. A tubectomy takes around 30 minutes.

In general, laparoscopic procedures can be done through any of the following techniques:

With hulka or filshie clips

This type is the most easily reversed, as the tubes are just clamped or clipped. Also, thanks to their design, these are the clips that fit best in the mid-isthmic portion of the tube, which eliminates any chance of error in placement.

Hulka clip tubal ligation

With fallope rings or rubber bands

Reversal is only possible if one ring per side is placed. Rubber bands are more likely to damage the isthmic portion of the tubes than the clips, as the process involves bringing a loop of tube into the band.

Fallope ring tubal ligation

Monopolar & bipolar cauterization

Monopolar cauterization is the most commonly used because of its effectiveness and versatility. One or more adjoining segments of the tube are cut, thereby causing interruption.

On the other hand, bipolar cauterization, also called bipolar tubal coagulation, involves using a bipolar coagulator to grasp the Fallopian tube between two poles of electrical conducting forceps. Electrical current passes through the tube between both ends of the forceps. Commonly, only 2 or 3 adjacent sites are burned.

Bipolar and monopolar tubal coagulation

Fimbriectomy

The fimbria or distal end as well as the infundibilar portions of the tube located next to the ovary are removed. By doing this, we leave behind one tubal segment attached to the uterus.

Tubal reversal is generally not possible because the fimbrial and infundibular end of the tube contains the tubal cilia, which promotes egg transportation down to the tube.

Tubal ligation by fimbriectomy

Laparotomy or open tubal ligation

Open tubal ligation or laparotomy is another method of permanent birth control. In contrast to commonly performed laparoscopic procedures, this one is done immediately after or before another type of open abdominal surgery.

In most cases, it is carried out when a woman is having a C-section (i.e. cesarean section) delivery. It is a way for patients to take advantage of the surgery for having their abdomen open. It takes only a few extra minutes, as it is carried out when the woman is still under epidural anesthesia.

In pomeroy or modified pomeroy tubectomy procedures, also referred to as post-partum tubal ligation, the surgeon holds a loop of Fallopian tube with special tubal forceps. Then, a 2-4 cm loop is made in order for the tube to be tied with suture. Usually, the intervening segment of tube is cut, although some specialists prefer to burn the ends.

Tubal ligation during C-section

A laparotomy can also be recommended if the patient has or has had:

• Pelvic Inflammatory Disease (PID)
• Abdominal or pelvic surgery
• Endometriosis

This type of surgery becomes necessary in these cases because these conditions often cause abdominal tissue and/or organs to stick together (i.e. adhesion) or scar. Being significantly overweight, smoking, having diabetes or a heart condition are also reasons why a laparotomy may be less risky.

Effectiveness and failure rate

Surgery for tubal ligation makes it effective immediately, so women are protected against an unplanned pregnancy right after having their tubes tied. Sexual activity, however, can start again as soon as the woman feels comfortable—which usually occurs after a week.

Tubal ligation procedures are not 100% effective at preventing a pregnancy, although they are expected to be 99.5% accurate. There is a slight risk of having an unplanned pregnancy even after tubal ligation. The likelihood of falling pregnant increases over time as one can see below:

• After 1 year: 5 out of 1,000 women will fall pregnant
• After 5 years: 13 out of 1,000 women will fall pregnant
• After 8-10 years: 18 out of 1,000 women will fall pregnant

Pregnancy rates after tubal ligation

Also, these rates depend on the age of the woman. In patients younger than age 28, the rate of pregnancy reaches 5%, while it drops to 2 percent in women between ages 28 and 33. It is as low as 1 percent in women older than age 34.

Although permanent sterilization is not totally guaranteed, some techniques may have a higher failure rate than others. For example, if not performed properly, Fallope rings can fall off or clamps can get loose, which can result in the continuity of the Fallopian tubes.

Fistula formation or spontaneous reanastomosis in the cut ends of the tube can make them grown back together if the gap between them is not large enough, so in this sense the chances of success depend on the expertise of the surgeon as well.

Signs of failure are those related to early pregnancy symptoms. If a tubal ligation has gone wrong, women are likely to miss a period, followed by breast tenderness, food cravings, unexplained fatigue, frequent urination, etc.

Side effects, risks and recovery time

During the recovery time, women usually come back to their normal lifestyle with no problems. If it was done during a C-section delivery, that is, by laparotomy, the hospital stay will not be prolonged for longer than a normal recovery period after a cesarian section. Doctors normally recommend to take a day off of work to rest.

As any other surgical intervention, patients are expected to experience some post-surgery symptoms. Although it is not a dangerous or painful procedure, your doctor will give you instructions on what to expect after having your tubes tied.

Most common side effects include:

• Slight vaginal bleeding: As a consequence of the movement of the uterus during the surgery.
• Distended stomach: Pain and stomach swelling are common as a consequence of the gas used to lift the skin and muscles away from the patient's organs to make it easier for the surgeon to see them.
• Back or shoulder pain: As a result of the gas in your abdomen as well. It should go away within a day or so, once your body absorbs the gas.

Try not to touch the incision site for at least 1 week after surgery. By doing this, you will help healing and avoid infection of the incision site. Laparoscopic tubal ligation is likely to leave small scars on the area where the incision was made.

Some studies have shown that gynecologic surgery, both tubal ligation and hysterectomy, may reduce the chances of developing ovarian cancer. Still, experts insist on the fact that they should only be done for valid medical reasons, and not because of their effects on ovarian cancer risk.

Also, there exist certain long-term complications and/or risks associated with tubal ligation procedures that should be considered, even though they occur rarely. The most common is the post-sterilization or post tubal ligation syndrome (PTLS or PTS), which will be explained hereunder:

Post-sterilization syndrome

The post-sterilization syndrome is a consequence of a rapid decline of estrogen/progesterone hormone levels. It is considered a doctor-caused complication as it is the result of the blood supply being damaged to the ovaries during the tubal ligation surgery.

Women who suffer from PTLS experience a series of moderate-to-severe symptoms which are often associated with menopause, hormonal imbalances (estrogen/progesterone changes) and hormone shock in general:

• Irregular periods: either heavier, shorter, or lighter
• Ectopic pregnancy
• Hot flashes
• Irritability and/or mood swings
• Loss of libido
• Joint pain
• Weight gain or loss
• Hair loss or thinning (head, pubic, whole body), or even increase in facial hair
• Symptoms of yeast infection with absence of yeast
• Depression
• Ovarian/tubal cysts

Recent studies have suggested tubal ligation reversal surgery for the treatment of women with PTLS symptoms. A recent study of 91 women experiencing these side effects have confirmed that 90% saw an improvement after undergoing surgery for tubal reversal, while the rest indicated either no change or an increase in symptoms.

Tubal ligation reversal

The first thing a woman willing to have her tubes tied should know is that it is a permanent birth control method. Although it can be reversed, it is estimated that only 50-80% of women will be able to become pregnant after getting their Fallopian tubes untied, reopened or reconnected.

Before being considered a good candidate for tubal ligation reversal, your doctor will consider several factors such as:

• Age: Women of advanced maternal age are not recommended to undergo this procedure, as their natural chances for a pregnancy may be too low.
• Type of surgery done: Tubectomy done with hulka or filshie clips is the most easily reversed. Conversely, bipolar and monopolar cauterization procedures are only reversible in a few cases.
• Overall health
• Health of the ovaries and uterus
• Length of the Fallopian tubes

If the surgeon considers you meet all these requirements and decides it is okay to proceed with the reversal, the procedure is done by means of surgery. It involves making a small surgical cut known as "bikini cut", as it is near the pubic hair. Then, aided by a laparoscope, he will remove the clips or rings that were used to block the tubes, and reconnect the ends to the uterus using tiny stitches. It takes around 2-3 hours.

Other contraceptive options

In addition to tubectomy, Fallopian implants or hysteroscopic sterilization is a non-surgical method for female sterilization. Its main advantage is, in fact, that cuts in the abdominal area are not required for it to be made. It just involves passing a narrow tube with a telescope through the vagina and cervix. In the United Kingdom, the brand name for this technique is Essure.

Salpingectomy, that is, Fallopian tube removal is an option when blocking the Fallopian tubes has failed. However, less invasive tubal occlusion procedures are more advisable. Moreover, it is recommended for ovarian cancer prevention.

There exist many non-permanent birth control methods for women, too. While nowadays new options are continuously entering into the market, such wide range of options may turn out to be confusing for some women.

The following are the most commonly used birth control methods:

• Natural family planning
• Barrier methods: male and female condom
• Intrauterine devices (IUD or coil)
• Hormonal contraception: combined oral contraceptive pill (COCP) or vaginal ring

Variety of contraceptive methods

There exists no permanent birth control that stops periods. However, some contraceptive pills such as Lybrel, Seasonable, Yaz, Yasmin or Seasonique help make them lighter or even non-existent. Patients who do not want to get pregnant can choose this birth control alternative instead of tubal ligation if the problem is related to the premenstrual syndrome (PMS) or any other symptom associated with menstruation.

The most adequate contraception for each woman should be chosen according to factors such as age, lifestyle, or whether she has a steady partner or not, among others. For further information on contraceptive methods, we recommend you to visit the following guide: Birth control methods.

Is pregnancy possible after tubal ligation?

There is an ongoing confusion about the effects that tubal ligation may have on female fertility. It should be noted that your ovaries will continue being functional. This means that some follicles will develop on a monthly basis until a mature egg is produced and released by the ovary.

Menstruation will continue to occur monthly, since the hypothalamo-pituitary-ovarian (HPO) axis is still working. Hormone levels make the mucus inner layer of the uterus or endometrium thicken. If pregnancy has not occurred, the endometrium sheds and is expelled as menstrual flow.

For all these reasons, when a woman chooses to undergo tubal ligation, she could have more children in the future by means of in vitro fertilization (IVF) if she wishes so. Pregnancy is possible, as she still produces eggs and the egg-sperm binding takes place in the laboratory—not inside the female reproductive system.

You should keep in mind that tubal ligation can increase a woman's risk for an ectopic pregnancy, in which the embryo attaches to the tubes instead of the uterine lining. This makes the miscarriage rate after a tubectomy slightly higher.

For more information, please visit the following post: Tubal ligation and pregnancy.

FAQs from users

Is tubal ligation dangerous for women?

Tubal ligation is a permanent method of contraception in which the fallopian tubes are cut, tied, or blocked to prevent pregnancy. The procedure itself has no consequences for the woman's menstrual cycle.

However, since tubal ligation is an operation under anesthesia that involves incision of the abdomen, there are some risks associated with the surgical intervention:

• Damage to intestines, bladder, or major blood vessels
• Reaction to anesthesia
• Inadequate wound healing or infection
• Continuous pelvic or abdominal pain
• Failure of the procedure, resulting in unwanted future pregnancy

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What possibilities does assisted reproduction offer to become a mother after a tubal ligation?

The best option to achieve a pregnancy after having had a tubal ligation is to resort to in vitro fertilization (IVF). Another possible option would be to try to repair the fallopian tubes by an operation called tubal reanastomosis, i.e. joining the ends of the cut tubes together again.
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How much does tubal ligation cost?

The cost of tubal ligation ranges from €1,000-€7,000. In comparison, the cost of a vasectomy is much less, so couples who agree to have no more kids are advised to consider the type of surgery they want to undergo taking this factor into account. Centers and hospitals carrying out this procedure may different different financing options for patients.

Is a tubal ligation less successful during a C-section?

Actually, there is no scientific research that confirms this theory. What has been shown, however, is that a woman is likely to get pregnant after having tubal ligation through laparotomy (during a C-section), vaginal delivery or laparoscopic surgery.

Can you get your tubes tied on the NHS?

Some patients may be referred for free sterilization on the NHS by their GP or another GP they have registered with for family planning services. Nevertheless, you should take into account that the waiting list on the NHS may be quite long, so you may consider getting private treatment—the cost is often more than £1,000.

Endometrial ablation (NovaSure), hysterectomy or tubal ligation, what's better?

Endometrial ablation means having your endometrial lining removed, while hysterectomy means having your uterus removed, so it should be clear that they are not a birth control methods. It is indicated in cases of women with heavy menstrual bleeding. If the purpose of considering these procedures is just being unable to conceive, we recommend you to go for tubal ligation, as it could be reversed in case you wanted to have a baby in the future.

Is it possible for me to get tubal ligation reversal insurance coverage somewhere?

In general, women will not get health insurance coverage if it is an elective tubal ligation reversal, and the same applies in case you want to have your Essure coil removed. On the other hand, you may find insurance coverage if it is medically necessary (e.g. it prevents or treats an injury, disease or the symptoms associated with a certain condition).

Can having your tubes tied cause early menopause?

Although tubal ligation does not stop periods, tubal ligation can make women experience some menopause-like symptoms. It actually leads to premature menopause rarely.

Can you get your tubes tied without having a baby?

The truth is, most doctors are not willing to perform a tubectomy on women under 32 with less than 3 children as a general rule. Take into account that you can change your mind when you turn 35 and regret the choice you made at 26, for example.

Does having your tubes tied while breastfeeding affect your milk supply?

No, tubal ligation procedures are fully compatible with breastfeeding. However, medications prescribed during the tubectomy procedure may cause a temporary effect on it.

Is there any type of tubal ligation which is temporary?

No, tubal ligation procedures are meant to be permanent, that is why it is considered to be a permanent birth control method. If you want to be protected against an unplanned pregnancy during a particular period of time, you should consider using a non-permanent birth control method, including the birth control pill or the vaginal ring.