Tubal ligation

Tubal ligation (informally known as getting one's "tubes tied") is a permanent form of female sterilization, in which the fallopian tubes are severed and sealed or "pinched shut", in order to prevent fertilization. Hormone production, libido, and the menstrual cycle can be affected by a tubal ligation.

Procedure
A tubal ligation surgery can be done in many forms; through a vaginal approach, through laparoscopy, a minilaparotomy ("minilap"), or through regular laparotomy. Also, a distinction is made between postpartum tubal ligation and interval tubal ligation, the latter not being done after a recent delivery. There are a variety of tubal ligation techniques; the most noteworthy are the Pomeroy type that was described by Ralph Pomeroy in 1930, the Falope ring that can easily be applied via laparoscopy, and tubal cauterization done usually via laparoscopy. 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.

Less commonly performed is the Essure procedure, in use since 2002. In this procedure micro-inserts are placed within the fallopian tubes by means of catheter and Hysteroscopy. The micro-inserts produce eventual occlusion of the fallopian tubes by causing the in-growth of tissue.

Effectiveness
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. Method failure is difficult to detect, except by subsequent pregnancy, unlike with vasectomy or IUD. If pregnancy does occur it carries a 33% chance of being an ectopic pregnancy.

Reversal
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 parts of the 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. Tubal reversal, if done by a specialist microsurgeon, has a high success rate and few complications. Successful repair of the fallopian tubes is now possible in 98% of women who have had a tubal ligation, regardless of the type of sterilization procedure.

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

Prevalence
Worldwide, female sterilization is used by 33% of married women using contraception, making it the most common contraceptive method.

Access
In developing countries, tubal ligation is generally a popular form of birth control, and is widely available, although some Muslim countries (e.g. Egypt and Indonesia) do not permit it. Faith-based medical institutions in developed countries will sometimes refuse to perform tubal ligations, and where long waiting times persist, there is a worrying risk of pregnancy or complications due to alternative contraception. Because of the permanent nature of the operation, women under 30 without children are often denied access to tubal ligation, even if they express a determined desire not to have children.

Advantages and disadvantages
Tubal ligation is a more major surgery than vasectomy, and carries greater risks. Postoperative complications are more likely than with vasectomy, and more costly. For instance, in industrialized nations, mortality is 4 per 100,000 tubal ligations, versus 0.1 per 100,000 vasectomies.

Tubal ligation has a larger initial cost than other contraceptive methods. Typically vasectomies are more cost-effective than tubal ligation because they are less expensive. It may take more than a decade of use for tubal ligation to become as cost-effective as other highly effective, long term methods like IUD or implant. Continued method costs or costs from unintended pregnancies make many other methods as or more costly than tubal ligation if used for several years. The cost of tubal ligation is reduced if it is performed during a cesarean section since the tubes are already exposed during the laparotomy.