Female Sterilization (Tubal ligation)
DR. S. Kalaichandran, MBBS, MD, FRCSC,FSOGC (Canada), FRCOG
Female sterilization is the most widely used method of permanent contraception. This may be carried out at the time of caesarean section, soon after a normal childbirth or as an interval procedure.
At the time of caesarean section, the tubes may be occluded by applying a clip across the fallopian tube or by ligating and excising a portion of the tube. Soon after the childbirth, when the uterine fundus is at the level of the umbilicus, sterilization can be performed in a similar fashion after entering the peritoneal cavity through a small infra-umbilical incision. Sterilization as an interval procedure may be carried out, using the same methods, through a short vertical or transverse mini laparotomy incision in the lower abdomen.
The most common method of female sterilization is laparoscope’s sterilization. The procedure entails introduction of a telescope into the peritoneal cavity through a small umbilical incision, filling the cavity with carbon dioxide to elevate the abdominal wall for visualization and occluding the tubes using unipolar or bipolar current, Silastic band or various clips. Unipolar current is associated with unacceptable risk for bowel damage and has been abandoned. The following video shows video laparoscopic tubal ligation using the Filshie clip. *Video
The failure rate of all forms of tubal ligation performed by a properly trained physician will be in the order of 1to 2 per 1000 procedures.
Counselling is very important before a sterilization procedure. In the days of paternalistic gynaecology, the gynaecologist decided what is the best method of contraception for a patient and the patient agreed. Often the criteria applied for sterilization were: women in their late 30’s, married for several years with three or more children with at least one of each sex. Today, one cannot apply these criteria, although the regret rate and request for reversal will be very low if one applied these criteria. The gynaecologist is a councillor who explains the various contraceptive options and risk/benefit. The patient/client makes an informed choice. They should be aware of the various reversible methods of contraception and vasectomy as an option for the male. Tubal ligation is meant to be a permanent and irreversible with occasional failure. When tubal ligation fails there is an increased risk of tubal pregnancy. The surgical procedure itself is associated with a small risk related to the general anaesthesia, risk of bleeding and infection and trauma to bladder and bowel.
About 1% of those who undergo tubal ligation regret it and request reversal. Tubal ligation using the clip gives the best chance for reversal, as this is associated with minimal tubal loss and damage. Reversal of sterilization is not an insured service in Ontario. It is very expensive and success is not guaranteed. Again tubal pregnancy is associated with reversal procedures.